Salmon Creek Post Acute & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Vancouver, Washington.
- Location
- 2811 Ne 139th Street, Vancouver, Washington 98686
- CMS Provider Number
- 505522
- Inspections on file
- 37
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 31
Citation history
Health deficiencies cited at Salmon Creek Post Acute & Rehabilitation during CMS and state inspections, most recent first.
Surveyors found that staff did not complete or individualize multiple care plan segments for four residents, leaving key areas such as communication impairment, fall risk, anticoagulant use, diuretic and opioid use, vision impairment, rehab needs, ADL assistance, and constipation risk without resident-specific causes or related diagnoses. These residents had conditions including spinal stenosis, osteoarthritis, an artificial knee joint, hypertension, chronic heart failure, type 2 DM with vision issues, moderate cognitive impairment with ambulation needs, and a traumatic subdural hemorrhage. The DON reported that unit managers are responsible for developing the comprehensive nursing care plans and acknowledged that these sections should have been fully completed.
Surveyors found recurring medication administration errors and omissions when several cognitively intact residents with complex conditions (including PTSD, CKD, COPD, chronic pain, DM2, psychotic disorder, and traumatic subdural hemorrhage) did not receive ordered medications and treatments as prescribed. MAR and TAR reviews showed omitted evening doses of inhalers, psychotropics, wound care treatments, anticoagulant monitoring, and multiple supplements, as well as numerous instances where analgesics, antihypertensives, diuretics, anticoagulants, psychotropics, insulin, thyroid medication, lipid-lowering agents, and laxatives were administered outside the accepted 2-hour nursing administration window. An RN leader confirmed that blank MAR/TAR entries reflected omissions and that many doses were given outside the permitted timeframe, and the issue was cited as a recurring deficiency under state regulation.
A resident with ESRD and severe cognitive impairment who depended on hemodialysis did not consistently receive ordered pre- and post-dialysis assessments or required documentation, and the care plan did not address these assessments or communication with the dialysis provider. EMR review showed multiple incomplete or blank pre/post HD assessments, and the MAR revealed that ordered Norco premedication before dialysis was not consistently documented or supported by progress notes. Dialysis staff reported the resident frequently arrived in pain, without the communication binder, and often without food, dentures, blanket, or appropriate clothing, and records showed the resident missed at least one scheduled dialysis treatment.
The facility did not follow its own policy to provide at least two baths or showers per week for residents dependent on staff for ADLs. One resident with ESRD, incontinence, and moderate cognitive impairment missed multiple scheduled showers because bathing was routinely scheduled at the same times the resident was out of the facility for dialysis, and the TAR showed many of these showers were not provided. Another resident with cancer, severe cognitive impairment, and reduced mobility missed a scheduled shower with no explanation documented in the progress notes, despite the DON’s expectation that missed baths be documented.
Surveyors found that staff failed to follow prescriber orders and facility policy for two residents when multiple medications and treatments were omitted and not documented on the MAR/TAR. For one resident with metastatic cancer, chronic respiratory failure, and severe cognitive impairment, catheter care, urinary output documentation, bladder scans with straight catheterization, weekly skin observations, barrier cream applications, and heel boot use were not carried out or recorded as ordered. For another resident with metabolic encephalopathy, a UTI, and severely impaired cognition, ordered doses of levothyroxine and acetaminophen, orthostatic BP checks, weekly weights, barrier cream to the coccyx, and elevation of the head of the bed for SOB prevention were also missed or undocumented. The RN Director of Resident Services confirmed that blank MAR/TAR entries meant the interventions were not done or not documented.
A resident with moderate cognitive impairment and a history of rhabdomyolysis was discharged with medications that did not match the reconciled list in the discharge summary. The resident later discovered, with a case worker, that one of the four medications they were taking at home had another person’s name on the container, even though the MAR showed only three medications were ordered to be sent home. The DON confirmed that an incorrect medication belonging to another resident had been provided at discharge, indicating a failure to ensure accurate medication reconciliation and prescriptions at discharge.
A resident with diabetes and peripheral vascular disease, who had multiple open wounds, did not receive prescribed wound care treatments on several occasions. The MAR and TAR lacked documentation for these missed treatments, and progress notes did not explain the omissions, except for one instance where care was provided by an outside provider but not recorded. Facility policy required treatments to be administered and documented as ordered, but this was not followed.
A resident with acute kidney failure and pancreatitis experienced a significant episode of hypotension, but there was no documented notification to the physician about this change. Facility policy required such notification, and the DON confirmed that nurses are expected to inform the doctor of new or concerning symptoms, which did not occur in this case.
A resident with multiple acute medical conditions did not receive scheduled bathing assistance as required by facility policy, with documentation showing missed bathing opportunities and staff confirming that showers were not consistently provided according to the established schedule.
A resident with multiple medical conditions had an open coccyx wound documented on admission, but subsequent weekly skin assessments and progress notes failed to consistently address or document the wound's status. Despite facility policy requiring weekly documentation by a licensed nurse, several entries indicated no skin concerns, and there was no record of the wound's healing. The DON confirmed that ongoing documentation should have occurred.
A resident with multiple medical conditions did not receive several prescribed medications and treatments as ordered, including missed doses of psychiatric, cardiac, respiratory, and pain medications, as well as omitted catheter care and bladder scans. Facility policy requires administration and documentation of medications per provider orders, but this was not followed, as confirmed by the DON.
The facility failed to obtain informed consent before administering psychotropic medications to two residents. One resident received Wellbutrin for depression without being informed of the risks and benefits, while another was given Prochlorperazine Maleate for nausea related to end-stage renal disease without a signed consent. Staff acknowledged the oversight, highlighting a lapse in ensuring residents were fully informed about their treatment.
A resident with severe malnutrition and diabetes experienced significant weight loss, but the facility failed to accurately document and monitor this change. Despite a care plan and directives for weekly weight monitoring, weights were not recorded due to an order entry error, leaving the RD unable to review the resident's nutritional status.
A facility failed to follow PASARR Level II recommendations for a resident with Alzheimer dementia and major depression. The resident's cognition was not assessed, and the necessary Level II assessment by a mental health professional was not documented in the medical record. Although a request was sent to the evaluator, the facility did not follow up to ensure services were initiated.
The facility failed to initiate timely baseline care plans for two residents, one with fall risks and another with communication needs, within 48 hours of admission. A resident with cognitive impairment experienced multiple falls before a care plan was developed, and another resident with limited English proficiency had delayed communication support.
The facility failed to complete neurological assessments for a resident after an unwitnessed fall, did not manage weight monitoring for two residents with CHF, and did not initiate bowel protocols for two residents experiencing prolonged periods without bowel movements. Additionally, the facility did not coordinate dental services for a resident needing dentures.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices or wounds, as staff only used gloves and did not wear gowns during care. Observations showed a lack of EBP signage and PPE at room entrances. Interviews revealed staff confusion about EBP requirements, contributing to the deficiency.
A resident tested positive for COVID-19, but the facility failed to notify the resident or their representative in a timely manner, as required by their policy. The resident was informed of the positive result three days later by a doctor. Staff acknowledged the oversight and stated that the notification should have occurred within 24 hours.
The facility failed to create comprehensive and individualized care plans for six residents, resulting in incomplete and non-specific plans. These deficiencies involved residents with various medical conditions, such as congestive heart failure, diabetes, and multiple sclerosis. The care plans lacked specific interventions and goals, leaving critical areas like ADLs, pain management, and discharge planning unspecified, placing residents at risk for unmet care needs.
A facility failed to administer medications as ordered for four residents, leading to significant medication errors. One resident with congestive heart failure and other conditions missed doses of Atorvastatin and Levo-T. Another resident with severe cognitive impairment and diabetes missed multiple medications after a hospital visit. A third resident did not receive prescribed Hydrocortisone cream, and a fourth resident's daily weight was not monitored as ordered. The DON acknowledged the omissions and noted that the MAR should indicate reasons for missed medications.
A resident at risk for falls due to impaired balance and cognitive deficits fell from bed because fall mats were not placed as required by the care plan. Staff confirmed the absence of fall mats at the time of the incident, contrary to the intervention initiated in the care plan.
Incomplete and Non-Individualized Care Plans for Multiple Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, individualized care plans with complete, resident-specific information for four of seven sampled residents. For a cognitively intact resident with spinal stenosis, osteoarthritis, and an artificial knee joint, the care plan initiated in early February 2026 contained incomplete segments for communication impairment, fall risk, and anticoagulant use, with the sections intended to describe the underlying causes or related diagnoses left blank. Another resident with severe cognitive impairment, hypertension, and chronic heart failure had an admission care plan with incomplete segments related to diuretic and opioid use, where the diagnoses or conditions necessitating these medications were not documented. A resident with type 2 diabetes mellitus and moderate cognitive impairment, who required moderate assistance with ambulation, had a care plan segment for vision impairment that lacked individualized information about the cause of the impairment. A cognitively intact resident admitted with a traumatic subdural hemorrhage had multiple incomplete care plan segments, including fall risk, need for rehabilitation and assistance with activities of daily living, and risk for constipation, all missing the specific related causes or diagnoses. The DON stated that unit managers are responsible for writing the comprehensive nursing care plans and acknowledged that the incomplete segments for these residents should have been completed.
Recurring Medication Administration Errors and Omissions
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors by not administering medications in accordance with prescriber orders and within the facility’s stated administration time parameters. The facility’s policy, dated January 2023, required medications to be administered according to written prescriber orders, documented on the MAR immediately after administration, and given within 60 minutes of the scheduled time. Surveyors’ review of MARs, TARs, and medication administration audit reports for multiple residents showed omitted doses and frequent administration of medications outside the accepted nursing standard of practice window of one hour before to one hour after the ordered time. For one cognitively intact resident with diagnoses including spinal stenosis, PTSD, and chronic kidney disease, the February MAR and TAR showed several omitted evening medications and treatments on a specific date, including ketoconazole cream for wound care, monitoring of bruised areas on multiple body sites, sedative/hypnotic monitoring for insomnia, and anticoagulant medication monitoring. The medication administration audit for this resident over a defined period showed numerous medications given outside the two-hour administration window, including acetaminophen, estradiol, fluticasone propionate, furosemide, heparin, hydromorphone, ketoconazole, losartan, phentermine, prazosin, rosuvastatin, senna, sertraline, and topiramate, with multiple late or early administrations documented for many of these drugs. For a second cognitively intact resident with COPD, chronic pain syndrome, type 2 diabetes mellitus, and a psychotic disorder, review of the January MAR and TAR showed that on one evening multiple scheduled medications and supplements were omitted, including Arnuity Ellipta, Cymbalta, melatonin, olanzapine, omega-3, vitamin C, Zetia, zinc, and potassium chloride. The audit report for this resident over another specified period showed repeated administration of several medications outside the two-hour window, including Arnuity Ellipta, Cymbalta, furosemide, Incruse Ellipta, insulin glargine, levothyroxine, melatonin, olanzapine, omega-3, potassium chloride, vitamin C, Zetia, and zinc. For a third cognitively intact resident admitted with a traumatic subdural hemorrhage, the medication administration audit over a defined period showed multiple medications administered outside the two-hour window. These included acetaminophen, amlodipine, aspirin for CVA prevention, atorvastatin, donepezil, levetiracetam, lisinopril, multivitamins, senna, and zinc, each with one or more instances of administration outside the permitted timeframe. During an interview, the RN/Director of Resident Services confirmed that blank spots on the MAR or TAR indicated medications or treatments were omitted or not charted and acknowledged that the identified administration times were outside the permitted two-hour timeframe. The deficiency was cited under WAC 388.97.1060(3)(k)(iii) and noted as a recurring deficiency previously cited on three earlier survey dates.
Failure to Complete Dialysis Assessments and Follow Dialysis-Related Physician Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide safe and appropriate dialysis-related care and to follow physician orders for a resident with end stage renal disease (ESRD) who was dependent on hemodialysis. The resident had severe cognitive impairment and required hemodialysis three times weekly. The facility had a service agreement with the dialysis provider requiring interchange of necessary information and ensuring appropriate information accompanied the resident at transfer. Physician orders directed staff to complete a Pre HD Assessment in the EMR before transport, provide a copy to the transport/dialysis center, and complete a Post HD Assessment upon the resident’s return, including updating the resident’s weight. Record review showed multiple dates on which the Pre and/or Post HD Assessments were incomplete or blank, and the resident’s care plan did not address pre/post dialysis assessments or ongoing communication and coordination with the dialysis provider after each treatment. The facility also failed to follow specific physician orders related to premedication and other dialysis-related needs. Orders dated 02/05/2026 required staff to premedicate the resident with Norco prior to dialysis, ensure dentures were in place, and send a donut seat and blanket with the resident. Additional orders required daily weights. Review of the MAR showed that Norco was not consistently documented as given prior to dialysis on several treatment days, with blank entries and “9 – see progress notes” not supported by any corresponding progress note documentation. Dialysis facility notes documented that the resident reported severe pain and stated he was not receiving pain medication at the SNF, and dialysis staff confirmed with the SNF RN that pain medication was available but not being given, and that dialysis patients were often premedicated but this was not occurring for this resident. Further, the facility did not consistently ensure that the resident was sent to dialysis with required items and appropriate clothing, nor did it consistently send the communication binder. Dialysis staff documented that the resident often arrived in pain, without the communication binder, not properly clothed, and frequently without food, dentures, or a blanket. On one occasion, dialysis notes indicated the resident was visibly cold and had been sent without a blanket, jacket, or shoes, and that this was at least the second time the dialysis staff had called the facility about the need for warm clothes and having the resident’s teeth in. The resident also missed a scheduled dialysis treatment on one date. In interview, the DON acknowledged that blank MAR entries indicated medication omissions or lack of charting, and that information from the communication binder should have been entered into the pre and post dialysis assessments, which were found to be incomplete or blank on multiple dates.
Failure to Provide Scheduled Bathing Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide required bathing assistance to residents dependent on staff for activities of daily living, specifically bathing, in accordance with its policy requiring at least two full baths or showers per week. One resident with end stage renal disease, weakness, reduced mobility, moderate cognitive impairment, and frequent bowel and bladder incontinence was care planned as dependent on staff for personal hygiene and bathing. Review of this resident’s Treatment Administration Records (TARs) for October and November 2025 showed that bathing was scheduled on specific days of the week but was only provided for a portion of the scheduled times. The TARs also showed the resident was routinely out of the facility three days per week for dialysis, and showers were scheduled on days and times that conflicted with these dialysis appointments, resulting in multiple missed showers. The resident reported frequently not being assisted with bathing because they were at their regularly scheduled dialysis appointments. Another resident with cancer, reduced mobility, weakness, severe cognitive impairment, and dependence on staff for bathing assistance was also care planned to require help with personal hygiene. Review of this resident’s October 2025 TAR showed they did not receive a scheduled shower on one date, and review of the progress notes for the same month showed no documentation explaining why the scheduled shower was not provided. During an interview, the DON stated that residents were scheduled for bathing assistance twice per week and that nurses were expected to document in the progress notes if a resident did not receive a scheduled bath. The DON acknowledged that the first resident’s bathing schedule had been set for the same days of the week as their dialysis appointments.
Failure to Administer and Document Ordered Medications and Treatments
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications and treatments were administered and documented in accordance with prescriber orders and facility policy, resulting in multiple omissions for two residents. The facility’s medication administration policy dated January 2023 required that medications be administered per written prescriber orders and that the individual administering the medication immediately record the administration on the MAR. During review of October and November 2025 MARs and TARs, surveyors identified numerous blank entries, which the Director of Resident Services confirmed meant the medications or treatments were not done or not documented, and stated those areas should not be blank. For one resident with metastatic cancer, chronic respiratory failure, hypertension, reduced mobility, weakness, and severe cognitive impairment, the October and November 2025 MAR/TAR showed multiple omitted treatments and monitoring tasks. These included missed catheter care and failure to document urinary output on several shifts, missed weekly skin observations, and omitted application of Triad barrier cream and other barrier creams to the buttocks and posterior thighs for skin breakdown and redness. Additional omissions included ordered bladder scans every six hours with straight catheterization for post-void residuals greater than 350 cc at several scheduled times, and failure to ensure bilateral heel boots were in place while the resident was in bed. For another resident with metabolic encephalopathy, a UTI, and severely impaired cognition, the October and November 2025 MAR/TAR also showed omitted medications and treatments. These included missed doses of levothyroxine and acetaminophen at scheduled administration times, as well as failure to complete ordered orthostatic blood pressure measurements and weekly weights. The records further showed omissions in applying barrier cream to the coccyx every shift and as needed for redness, and failure to elevate the head of the bed every shift as ordered to alleviate or prevent shortness of breath while lying flat. The Director of Resident Services confirmed that the blank MAR/TAR entries for these residents indicated the orders were not carried out or not documented.
Incorrect Medication Sent Home at Discharge Due to Failed Medication Reconciliation
Penalty
Summary
Surveyors identified a deficiency in the facility’s discharge process related to medication reconciliation and accuracy of prescriptions provided at discharge. The facility’s own Discharge Planning policy, dated 10/01/2021, required that when discharge is anticipated, the facility prepare a discharge summary that includes reconciliation of all pre-discharge medications with the resident’s post-discharge medications. For one resident with a diagnosis including rhabdomyolysis and moderate cognitive impairment, the admission MDS dated 11/28/2025 documented this cognitive status. The resident reported that after discharge they were taking four medications daily, and later discovered with their case worker that one of the medications provided by the facility had another person’s name on the container. Record review of the resident’s December 2025 MAR showed only three prescribed medications ordered to be sent home at discharge, indicating a discrepancy between the reconciled medication list and what was actually provided. During an interview, the DON acknowledged the facility had been made aware that an incorrect medication, belonging to another resident, was sent home with this resident at discharge. The DON also stated that the nurse who provided the wrong medication had been identified. This sequence of events demonstrated that the prescriptions and medications supplied at discharge did not accurately reflect the reconciled medication list in the discharge summary for this resident.
Failure to Administer and Document Wound Care Treatments as Ordered
Penalty
Summary
The facility failed to ensure that medications and treatments were administered in accordance with provider orders for a resident with multiple chronic conditions, including Diabetes Mellitus II and Peripheral Vascular Disease. The resident had documented skin impairments, including open areas on the lower extremity, buttocks, and right heel, with care plan interventions specifying that wound care treatments be provided as ordered. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed that the resident did not receive prescribed wound care treatments on several specific dates. There was no documentation on the MAR/TAR or in the resident's progress notes explaining why the treatments were missed, except for one instance where wound care was provided by an outside provider but not recorded appropriately. Facility policy required that medications and treatments be administered according to prescriber orders and documented immediately after administration. The interim Director of Nursing confirmed that the expectation was for nurses to follow provider orders for medications and treatments. The lack of administration and documentation for the resident's wound care treatments constituted a medication and/or treatment error, as the facility did not follow its own policy or provider orders, and failed to document reasons for missed treatments.
Failure to Notify Physician of Significant Change in Condition
Penalty
Summary
The facility failed to notify a resident's physician about a significant change in the resident's physical condition. Specifically, a resident with a history of acute kidney failure and acute pancreatitis experienced a clinically significant episode of hypotension, with a recorded blood pressure of 73/48. Despite this event, there was no documented communication to or with the provider regarding the hypotensive episode, as confirmed by a review of the resident's progress notes and the electronic provider communication tool. The facility's policy requires nurses to notify the attending physician or practitioner when there is a significant change in a resident's physical, mental, or psychosocial status, including clinical complications. The care plan for the resident included monitoring for cardiac complications, but there was no evidence that the physician was informed of the low blood pressure event. The Director of Nursing stated that nurses are expected to assess and notify the doctor of any new or concerning symptoms, but this did not occur in this instance.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
The facility failed to provide adequate bathing assistance to a resident who was admitted with acute kidney failure, muscle weakness, and acute pancreatitis, and was assessed as cognitively intact. According to facility policy, residents are to be offered at least two full baths or showers per week, with refusals documented and reported to a licensed nurse. Review of the resident's records showed that bathing was not provided as scheduled, with only a few documented instances of bathing during the resident's stay. Staff interviews confirmed that showers were expected to be performed according to a set schedule, but this was not consistently followed for the resident in question.
Failure to Accurately Document and Assess Pressure Ulcer
Penalty
Summary
The facility failed to assess and accurately document a resident's wound, specifically a coccyx wound, for one of three residents sampled for wound care. According to the facility's policy, licensed nurses are required to conduct and document weekly skin observations, including the status of any pressure injuries. The resident in question was admitted with multiple diagnoses, including acute kidney failure, muscle weakness, and acute pancreatitis, and was cognitively intact. Medical records showed an order for weekly skin assessments, and initial documentation noted an open area on the coccyx. However, subsequent weekly skin observations and progress notes failed to consistently address the presence or status of the coccyx wound, with several entries indicating no skin concerns despite the initial finding. There was no documentation indicating that the coccyx wound had healed, and later observations described a red blanchable area and scar tissue at the same location. The Director of Nursing confirmed that nurses should have been documenting the wound each week or providing evidence of healing. This lack of consistent and accurate documentation regarding the resident's wound status constituted a failure to follow facility policy and placed residents at risk.
Failure to Administer Medications and Treatments as Ordered
Penalty
Summary
The facility failed to ensure that medications and treatments were administered in accordance with provider orders for one resident. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for this resident revealed multiple instances where prescribed medications and treatments were omitted or not administered as ordered. These included missed doses of Quetiapine Fumarate, Rosuvastatin Calcium, Vitamin C, Fluticasone Propionate, Spiriva Respimat, Metoprolol Succinate, Potassium Chloride, as well as missed daily weights, catheter care, hydromorphone for pain, and scheduled bladder scans. The facility's policy requires medications to be administered according to prescriber orders and documented immediately after administration, but this was not followed in these cases. The resident involved had diagnoses including acute kidney failure, chronic obstructive pulmonary disease, and acute pancreatitis, and was assessed as cognitively intact. The omissions were identified through review of the resident's records for April and May, which showed specific dates and times when medications and treatments were not given as ordered. During an interview, the DON confirmed that the expectation is for nurses to administer medications and treatments according to provider orders.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents were fully informed and provided with the necessary information to give informed consent before administering psychotropic medications. This deficiency was identified for two residents. Resident 32, who was admitted with a diagnosis of depression, received Wellbutrin, an antidepressant, on 10/25/2024, without having been informed of the risks and benefits, and without signing a consent form. Staff J, a Unit Manager and LPN, acknowledged that the medication was administered before obtaining the necessary consent. Similarly, Resident 78, who was alert and oriented, was prescribed Prochlorperazine Maleate, an antipsychotic, for nausea related to end-stage renal disease. The medication was administered without an informed consent form being signed. Staff B, the Director of Nursing Services and RN, confirmed that any use of psychotropic medication should have a consent form signed by the resident or their representative. These failures placed the residents at risk of not being fully informed about their care and treatment.
Failure to Accurately Document Resident's Weight Loss
Penalty
Summary
The facility failed to accurately assess and document significant weight loss for a resident diagnosed with severe malnutrition and Diabetes Mellitus. The resident was admitted with a care plan goal to maintain stable weights within 3-5 pounds, with interventions including diet as ordered, weights per protocol, and supplements as ordered. However, a Nutrition/Dietary progress note documented a significant weight loss of 11.73% of total body weight, and a subsequent nutritional assessment recommended weekly weight monitoring. Despite these directives, the facility did not record the resident's weights as requested by the Registered Dietician (RD), due to an order not being correctly entered, which led to the absence of weight records for review. Staff interviews revealed that the weights were not recorded in the medical record as required, and the RD was unable to provide missing weights for the resident. The Director of Nursing Services confirmed the absence of recorded weights after a certain date. The facility's policy indicated that weight changes of 10% are significant, and greater than 10% are severe, necessitating accurate weight documentation to prevent, monitor, or intervene with undesirable weight changes. The failure to record and monitor the resident's weight placed them at risk for nutritional and functional decline.
Failure to Follow PASARR Level II Recommendations
Penalty
Summary
The facility failed to ensure the recommendations of the Preadmission Screen and Resident Review (PASARR) Level II were followed for a resident reviewed for PASARR. The resident was admitted with diagnoses including Alzheimer dementia and major depression. The Quarterly Minimum Data Set assessment indicated that the resident's cognition was not assessed. The PASARR Level I indicated the need for a Level II assessment by a licensed mental health professional or mental health agency for individual services. However, the PASARR Level II recommendations were not found in the resident's medical record. The facility had a fax confirmation for a PASARR Level II request sent to the evaluator, but did not follow up to ensure services were started.
Failure to Initiate Timely Baseline Care Plans for Fall Risk and Communication Needs
Penalty
Summary
The facility failed to develop a baseline care plan to address fall risks and communication needs for two residents within 48 hours of their admission, as required. Resident 66, who was severely cognitively impaired and had a history of cerebrovascular accident, experienced three falls after admission, with the first two occurring before a fall risk care plan was initiated. The care plan was only developed after the second fall, despite the resident being assessed for falls upon admission. The Director of Nursing Services acknowledged that the fall risk care plan should have been initiated at the time of admission. Similarly, Resident 82, who was alert and oriented but had limited English proficiency, did not have a communication needs care plan initiated until several days after admission. The resident was observed having difficulty communicating in English and requested assistance with a phone. Staff used a translator service to communicate with the resident, but the communication care plan was delayed. The Director of Nursing Services confirmed that the communication needs care plan should have been initiated upon admission.
Deficiencies in Neurological Assessments, Weight Management, Bowel Protocol, and Dental Services
Penalty
Summary
The facility failed to perform ongoing neurological assessments for a resident who experienced an unwitnessed fall. The resident, who was severely cognitively impaired and had a history of cerebrovascular accident, did not receive complete neurological checks as required. The Director of Nursing Services acknowledged that the neuro checks were incomplete, which was against the facility's expectations for handling unwitnessed falls. The facility also failed to manage weight monitoring for two residents with congestive heart failure. One resident had a physician's order for weekly weights, but several weekly weights were missing from the electronic health record. Another resident had an order for daily weights, but numerous daily weights were not recorded. Staff members, including the Unit Manager and Director of Nursing Services, recognized the lack of documentation and stated that it was expected for CNAs to weigh residents as ordered. Additionally, the facility did not initiate bowel protocols for two residents who experienced extended periods without bowel movements. Despite having physician orders for laxatives to be administered after specific durations without bowel movements, the medication administration records showed no interventions were initiated. Staff admitted that the bowel protocol was not followed, and there was inconsistency in documentation. Furthermore, the facility failed to coordinate dental services for a resident who expressed a need for dentures, with no documentation of attempts to address the resident's dental care needs.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for four out of five residents reviewed for infection prevention and control. These residents had indwelling medical devices or wounds, which required the use of gowns and gloves during high-contact care activities as per the facility's policy. Observations revealed that staff only used gloves and did not wear gowns when providing care to these residents. Additionally, there was no EBP signage or personal protective equipment (PPE) available at the entrances of the residents' rooms. Resident 62, who had an indwelling urinary catheter, was observed multiple times without EBP signage or PPE at their room entrance. Similarly, Resident 240, with an abdominal drain, and Resident 241, with a peripherally inserted central catheter (PICC line), reported that staff only used gloves during care, and no EBP signage or PPE was present at their room entrances. Resident 339, who used a suprapubic catheter, was also observed without EBP signage or PPE, and staff were seen entering and exiting the room without applying PPE. Interviews with staff, including the Infection Control Nurse and Director of Nursing Services, revealed a lack of understanding and implementation of EBP. Staff members incorrectly equated EBP with standard precautions and believed gowns were unnecessary unless an infection was present. The Infection Control Nurse stated that EBP should be initiated by the admission nurse and verified by the nurse manager, but this process was not effectively carried out, leading to the observed deficiencies.
Failure to Notify Resident of Positive COVID-19 Test
Penalty
Summary
The facility failed to notify a resident's family and/or representative of a positive COVID-19 test result, which was a requirement according to their policy. The policy, dated May 15, 2020, stated that the facility must inform residents, their representatives, and families by 5:00 p.m. the next calendar day following a confirmed COVID-19 infection. Resident 75, who was alert and oriented, tested positive for COVID-19 on September 27, 2024, as documented in their Treatment Administration Record. However, there was no documentation in the resident's Electronic Health Record indicating that the resident or their representative was informed of the positive result. Interviews with the resident and staff revealed that the resident was not notified of the positive COVID-19 test until about three days later, when a doctor mentioned it in passing. Staff D, the Infection Preventionist and RN, stated that the facility's practice was to notify residents and their representatives as soon as possible, ideally within 24 hours of the test. Staff B, the Director of Nursing Services and RN, acknowledged that the facility failed to notify Resident 75 as per the policy, admitting that they missed this notification.
Incomplete and Non-Specific Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive and individualized care plans for six residents, which resulted in incomplete and non-specific care plans. These deficiencies were identified during a review of the care plans for residents with various medical conditions, including congestive heart failure, diabetes mellitus, aortic valve stenosis, urinary tract infection, multiple sclerosis, and obesity. The care plans lacked specific interventions and goals tailored to each resident's needs, leaving critical areas such as assistance with activities of daily living (ADLs), pain management, mobility, cognitive function, and discharge planning unspecified. For instance, one resident with moderate cognitive impairment and mobility issues had a care plan that did not specify the level of assistance required for ambulation, toileting, and eating. Another resident with severe cognitive impairment and diabetes had a care plan that failed to detail pain management strategies and discharge arrangements. Similarly, a resident with aortic valve stenosis and muscle weakness had a care plan that omitted specific interventions for communication problems, behavior issues, and intravenous medication management. The lack of individualized care plans placed residents at risk for unmet care needs and diminished quality of life. The Director of Nursing Services acknowledged that the Resident Care Managers were responsible for writing these care plans and recognized the need for education to address the incomplete segments. However, the report does not detail any corrective actions taken to rectify the deficiencies.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as medications were not administered according to provider orders for four of the six sampled residents. Resident 1, who had diagnoses including congestive heart failure, hypothyroid, and hyperlipidemia, did not receive Atorvastatin Calcium and Levo-T as ordered. Resident 2, with severe cognitive impairment and conditions such as type 1 diabetes mellitus and hypertension, experienced a significant lapse in medication administration after returning from the hospital, missing multiple doses of critical medications including Losartan Potassium, Namenda, Basaglar KwikPen, and Humalog, among others. Resident 5, diagnosed with multiple sclerosis and paraplegia, did not receive Hydrocortisone External Cream as ordered for a facial rash. Resident 6, with congestive heart failure and class III obesity, did not have their daily weight monitored as ordered, which is crucial for managing their heart condition. The Director of Nursing Services acknowledged the omissions and indicated that the MAR should reflect valid reasons for any missed medications, which was not the case in these instances.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that fall mats were in place on either side of a resident's bed as directed in the comprehensive care plan. This deficiency was identified for a resident who was at risk for falls due to a history of falls, impaired balance, poor coordination, potential medication side effects, unsteady gait, and cognitive deficits. The resident's care plan, initiated in November 2020, included an intervention to place fall mats on either side of the bed at all times. However, during a facility investigation, it was found that on May 14, 2024, the resident fell from the bed onto the floor, and there were no fall mats present at the time of the fall. Staff members confirmed the absence of fall mats, which was contrary to the care plan requirements.
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Inaccurate PASARR screening affected two residents. One resident with vascular dementia, depression, and adjustment disorder had a PASARR level one that did not reflect mental health diagnoses, and staff stated it was inaccurate. Another resident with PTSD had a PASARR level one that did not include the PTSD diagnosis, with no additional PASARR level one or level two found in the EHR; staff stated the screening was not accurate and should have been repeated.
Undated open meds were found on 2 medication carts, including an open insulin vial and multiple open eye drop bottles with no dates. An LPN and an RN both stated the items should have been dated when opened, and the DON stated open multidose vials or bottles found without a date should be discarded immediately.
A resident with respiratory failure, HTN, and anxiety became SOB and diaphoretic, received a breathing tx, and was sent by EMS to the hospital. The facility could not locate the required SNF/NF to Hospital Transfer form or other transfer records showing what information was communicated to the receiving provider.
Care plans for two residents were not updated to match their current status and care needs. One resident had PTSD and generalized anxiety disorder and was receiving a psychotropic medication, but the care plan listed monitoring for antipsychotic and anticonvulsant meds that were not prescribed and did not include the anxiety diagnosis or related behaviors and interventions. Another resident had new upper and lower dentures, but the oral/dental care plan only noted edentulous status and difficulty chewing, with no mention of dentures or denture-related interventions.
Failure to Provide Individualized Activities: A resident with anxiety, depression, and weakness was cognitively intact but said they could not attend group activities because of leg problems and wanted more in-room activities. The resident mostly stayed in bed watching TV, and staff documentation showed only limited room visits with no consistent activity documentation despite a care plan goal for participation two to three times per week.
Failure to maintain heel offloading for a resident with a reopened DFU. A resident with dementia and dependence for mobility had a left heel wound that had healed and then reopened; the wound care provider recommended heel floating and pressure relieving boots at all times, but observations showed the resident in bed with heels on the mattress and later reclined in a wheelchair with the heel resting on the footrest strap and no boots in place. Staff stated the resident had not refused the boots or heel floating, and the care plan was not updated after the wound reopened.
Failure to Address Hearing and Vision Services for a Resident: A resident with dementia, bilateral hearing loss, and impaired vision was observed without eyeglasses or a hearing device, despite records showing admission with eyeglasses and a personal sound amplifier. The care plan addressed vision only and did not include hearing-related interventions, while staff interviews confirmed the resident’s hearing was strained and that the resident’s device use and vision needs were not fully reflected in the plan of care.
Respiratory care was not provided consistently for two residents receiving O2. One resident with COPD and chronic respiratory failure had an O2 order missing the indication for use and Sats parameters, no MAR documentation of O2 therapy, and inconsistent Sats charting. Another resident with respiratory failure was observed on continuous O2 via NC, but provider orders for O2 therapy and tubing changes were not present after readmission, despite the care plan stating the resident was dependent on O2.
A resident with dementia, hearing loss, and missing lower teeth had an MDS showing obvious or likely cavities or broken natural teeth, and the care plan identified oral/dental health problems with an intervention to coordinate dental care and transportation. Staff stated the resident’s dental needs were captured on the MDS, but no referral was made for dental services or follow-up with the dentist, and the DON said the lack of referral did not meet expectations.
Inaccurate Meal Intake Documentation: A resident with DM, dysphagia, and protein-calorie malnutrition was observed eating less than 25% of a meal, but the POC documented 76-100% intake. The CNA said the resident usually ate only 25-50% of meals and that intake was sometimes documented based on what a coworker reported. The LPN/RCM and DON stated meal intake should be documented accurately.
Inaccurate PASARR Screening for Two Residents
Penalty
Summary
The facility failed to ensure that two residents were screened for additional mental health supports through the PASARR process. Resident 97 was admitted with diagnoses including vascular dementia, depression, and adjustment disorder, and was able to make needs known. Review of the PASARR level one dated 04/10/2026 showed no mental health diagnoses and no need for a PASARR level two, even though the resident’s record included mental health diagnoses. During interview, the Regional Social Services staff and the Administrator stated the PASARR was inaccurate, needed modifications, and did not meet expectations. Resident 6 was admitted with diagnoses including heart failure, respiratory failure, and PTSD, and was able to make needs known. Review of the PASARR level one dated 03/30/2026 showed no serious mental illness indicators marked and no PASARR level two indicated, and the EHR contained no other documented PASARR level one or level two. The Social Services Director stated the hospital-provided PASARR was reviewed for accuracy and, if inaccurate, another level one would be completed, and stated this resident’s PASARR did not include PTSD and should have had another level one completed. The Administrator also stated the PASARR was not accurate and another level one needed to be conducted, but none could be located in the EHR.
Undated Open Medications on Medication Carts
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications for 2 of 3 sampled medication carts reviewed for medication storage and labeling, including carts on the 400 and 500 halls. On the 500 hall medication cart, an open vial of insulin and an open bottle of eye drops were observed with no dates. During interview, an LPN stated that when an insulin vial or bottle of eye drops is opened, it should be dated immediately and said both items should have been dated upon opening; the LPN stated they would dispose of the undated vial and bottle. On the 400 hall medication cart, two open bottles of eye drops were observed with no dates. During interview, an RN stated both bottles should have been dated as soon as they were opened and said they would get new eye drops and dispose of the undated bottles. The DNS/RN stated that if an eye drop was opened it should have been dated immediately and that any open multidose vial or bottle found without a date should be discarded immediately.
Missing Hospital Transfer Documentation
Penalty
Summary
The facility failed to ensure hospital transfer documentation was completed for one resident who was transferred to the hospital after complaining of not being able to breathe and appearing diaphoretic. The resident had diagnoses of respiratory failure, high blood pressure, and anxiety disorder, and was able to make needs known. A breathing treatment was provided, and the provider agreed to send the resident out for further evaluation, after which emergency transportation took the resident to the hospital. Record review found no documentation showing what information was provided or communicated to the receiving facility for the transfer. Staff stated that transfer documentation should have included a SNF/NF to Hospital Transfer form, the resident's face sheet, and the medication and treatment administration records, but they were unable to locate documentation showing these items were completed or sent for the resident's hospital transfer.
Care plans did not reflect current diagnoses, medications, or denture status
Penalty
Summary
The facility failed to ensure that care plans were revised and accurately reflected residents’ current status and care needs for 2 of 21 sampled residents. Resident 6 was admitted with diagnoses including heart failure, respiratory failure, and PTSD, and was able to make needs known. The EHR showed Resident 6 also had generalized anxiety disorder and was receiving a psychotropic medication, but the current care plan dated 05/05/2026 documented monitoring for side effects of antipsychotic and anticonvulsant medications even though Resident 6 was not prescribed those medications. The care plan also identified PTSD but did not include generalized anxiety disorder or behaviors to monitor and interventions related to PTSD or anxiety disorder. Staff F, LPN/CC, stated the care plan did not accurately reflect the resident’s current status or prescribed medications, and Staff B, DNS, stated it did not meet expectations because it did not address the anxiety disorder or target behaviors and interventions. Resident 71 was admitted with diagnoses including PTSD, high blood pressure, and depression and was able to make needs known. Observation on 05/06/2026 showed a denture cup by the sink with the resident’s name on the lid and new upper and lower dentures dated 01/12/26. The resident stated the lower dentures did not fit well and that denture adhesive had been provided, but the dentures still did not fit right and the resident had not told staff yet. The focused oral/dental care plan, initiated on 06/23/2026, identified the resident as edentulous and having difficulty chewing, but did not show that the resident had dentures or include interventions related to denture use or maintenance. Staff E, CNA, stated they had not seen the resident wear dentures and were unaware of the new dentures, Staff C, LPN/CC, stated the care plan should have been updated when the dentures were obtained, and Staff B, DNS, stated the care plan should have reflected the dentures and interventions.
Failure to Provide Individualized Activities
Penalty
Summary
The facility failed to provide individualized activities for Resident 5, who was admitted with diagnoses including anxiety disorder, depression, and weakness. The admission MDS dated 01/14/2026 showed the resident was cognitively intact. During interviews on 05/03/2026 and 05/06/2026, Resident 5 stated they could not attend in-person activities because of their legs, wanted more activities to occupy them, mostly stayed in bed watching TV, and did not remember the last time activities staff visited to offer activities. The resident also stated activities staff would need to offer something they were able to do because they had difficulty doing some activities. The activities care plan dated 12/26/2026 showed a goal for Resident 5 to participate in activities two to three times per week. Progress notes documented one visit on 12/22/2026 to provide a welcome packet and encourage participation in daily activities, but no further activity documentation was found in the progress notes. Staff H stated room visits should include puzzles, arts and crafts, visiting, and chatting, and that documentation was placed in tasks, but the task record showed no documentation of activities for the past 30 days. Staff J stated paper documentation existed for room visits and that Resident 5 was on a list for room visits every Monday and Wednesday, while the room visit documentation showed only four visits on 01/26/2026, 02/06/2026, 03/10/2026, and 04/08/2026.
Failure to Maintain Heel Offloading for Reopened DFU
Penalty
Summary
The facility failed to consistently implement pressure reducing strategies for a resident with a left heel diabetic foot ulcer that had reopened. The resident was admitted with diagnoses including left hip fracture with surgical repair, a blood clot of the left lower leg, and dementia, and was dependent on staff for mobility and unable to make needs known. The baseline care plan and care plan both included heel offloading interventions, and the wound care provider initially recommended heel floating with pillows or wedge and pressure relieving boots. The wound later resolved, but a weekly skin assessment documented that the left heel wound reopened and was very painful to touch. After the wound reopened, the contracted wound care provider documented that the DFU to the left heel had reopened and recommended the resident wear pressure relieving boots at all times. The current care plan reviewed after the wound reopened did not include new interventions related to the reopened wound. Observations showed the resident seated in a reclined wheelchair with the left foot/heel resting on the footrest strap and no pressure relieving boots in place, and later lying in bed with both heels directly on the mattress without being floated and without boots. Staff interviews indicated the resident had not refused the boots or heel floating, and the LPN/CC and DON stated the resident should have been assessed and the plan of care updated when the wound reopened.
Failure to Address Resident Hearing and Vision Needs
Penalty
Summary
The facility failed to address one resident’s hearing and vision needs. Resident 112 was admitted with diagnoses including a leg fracture, dementia, and hearing loss in both ears, and was able to make needs known. The record showed the resident lost their glasses and was given readers, but the resident did not wear them because they were concerned that wearing glasses that were not their prescription would further degrade their vision. Observation did not show glasses in the resident’s room, and the resident stated they did not use a hearing aid. The resident was observed to be hard of hearing, requiring an elevated voice and repeated questions to understand. The admission MDS dated [DATE] documented adequate hearing with hearing aid and adequate vision with corrective lenses, while the significant change MDS dated [DATE] documented moderate difficulty hearing without a hearing aid and impaired vision without corrective lenses. The care plan initiated 02/24/2026 addressed impaired vision with interventions to arrange consultation with eye care practitioners as needed and remind the resident to wear glasses, but it did not include a focus area or interventions for hearing loss or use of hearing aids. A resident clothing list showed the resident admitted with one pair of eyeglasses and one Super Ear headset personal sound amplifier, yet observation and interview showed the resident in bed without eyeglasses or a hearing device, with the amplifier stored in the bedside table drawer. Staff interviews confirmed the resident’s hearing was strained, that the hearing device and glasses were not being used, and that the resident’s hearing device use should have been included in the plan of care and the resident should have been referred for eye care assessment.
Respiratory Care Orders and Documentation Not Maintained
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for two residents receiving oxygen therapy. One resident with COPD and chronic respiratory failure with hypoxia was observed multiple times lying in bed receiving oxygen at 2 L via nasal cannula. The resident’s oxygen order, dated 02/15/2026, allowed 1 to 4 L per minute continuously via nasal cannula, but it did not include an indication for use or oxygen saturation parameters. The April and May 2026 MARs did not show documentation of oxygen therapy being provided, and the TARs showed only an order to change oxygen tubing if damaged or visibly soiled, not an order for oxygen therapy. Oxygen saturations were not documented consistently daily from 04/01/2026 through 05/04/2026. A second resident with respiratory failure, high blood pressure, and anxiety disorder was observed in the room receiving oxygen at 6 L via nasal cannula on multiple occasions. The resident stated they needed oxygen therapy to breathe, and the care plan identified the resident as dependent on oxygen and to receive oxygen per provider orders. However, provider orders reviewed on 05/04/2026 showed no orders for oxygen therapy or for changing oxygen tubing. Staff stated the oxygen and tubing-change orders had been discontinued when the resident went to the hospital and were not added back to the MAR or TAR when the resident readmitted to the facility.
Failure to Refer Resident With Identified Dental Needs
Penalty
Summary
The facility failed to ensure that Resident 112 received needed dental care. Resident 112 was admitted with diagnoses including a leg fracture, dementia, and hearing loss in both ears. Observation on 05/03/2026 showed the resident had missing lower teeth. The admission MDS, dated [DATE], documented obvious or likely cavities or broken natural teeth, and the care plan dated 02/24/2026 identified oral/dental health problems related to likely cavities or broken teeth with an intervention to coordinate dental care and provide transportation. During interviews, Staff G, Regional Social Services, stated Resident 112's dental needs were captured on the 02/24/2026 MDS and the resident was not referred for dental services. Staff M, Social Services Director, stated residents with dental needs should be referred to social services to be scheduled for assessment by a dental care practitioner, and that Resident 112 should have been referred after the MDS assessment. Staff B, DON, stated residents with identified dental needs should be referred for follow-up with a dentist and that Resident 112 should have been referred to the in-house dental provider; Staff B stated the lack of referral did not meet expectations.
Inaccurate Meal Intake Documentation
Penalty
Summary
The facility failed to accurately document the amount of food eaten for Resident 13, who was admitted with diagnoses including diabetes mellitus, dysphagia, and protein-calorie malnutrition. The quarterly MDS dated 02/12/2026 showed the resident was moderately cognitively impaired. During observation on 05/05/2026 at 12:09 PM, a meal tray was delivered to the resident’s room, set up on a bedside table, and the resident was observed eating slowly, eating less than 25% of the meal, then laying back in bed and closing their eyes while the tray remained in the room. Staff later removed the tray, but the POC documentation for lunch on 05/05/2026 recorded that Resident 13 ate 76-100% of the meal. During interview, the CNA stated the resident typically ate 25-50% of meals and never ate all of the food, and that if they did not pick up a tray they would ask a coworker what the resident ate before documenting it. The CNA stated they were told the resident ate 75-100% of lunch, so that is what was entered. The LPN/RCM stated staff should document meal intake accurately in POC, and the RN/DNS stated it was their expectation that all staff document meal intake accurately.
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