Sequim Bay Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Sequim, Washington.
- Location
- 650 West Hemlock St, Sequim, Washington 98382
- CMS Provider Number
- 505128
- Inspections on file
- 48
- Latest survey
- April 28, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Sequim Bay Post Acute during CMS and state inspections, most recent first.
A resident admitted after a hip fracture with peripheral vascular disease and no pressure injuries on admission developed a right heel Stage 2 pressure ulcer that progressed to an unstageable wound with necrotic tissue and infection after staff failed to consistently implement ordered offloading and wound care. Physician and consultant orders for AFO use, heel booties in bed, heel protectors, floating the heel at all times, and increased dressing-change frequency were not reliably followed, as shown by TAR documentation and repeated observations of the resident without heel protectors while devices lay on the floor. The resident and POA reported that heel protectors were supposed to be worn at all times but were frequently not applied, and several RNs and the DON acknowledged they had not seen the wound, were unaware of some orders, or could not explain why the daily dressing-change and offloading orders were not implemented.
A resident, cognitively intact and desiring family involvement in care decisions, developed a Stage 2 pressure injury on the heel that was documented on an incident report but not communicated to the resident’s POA, despite facility policy requiring notification of significant changes in condition. The POA only learned of the wound during an orthopedic appointment, while records showed that the POA/family was notified for other incidents such as falls. Staff interviews confirmed that representatives should be notified of new Stage 2 pressure injuries, though one RN indicated they might not notify if the resident was alert and oriented, leading to a cited deficiency under F686 and WAC 388-97-0320.
A resident admitted for post-hip fracture care with peripheral vascular disease was identified as at risk for pressure injury, but the facility did not include pressure injury risk or prevention interventions on the initial care plan. Despite physician orders for bilateral AFOs during transfers and heel booties with continuous offloading after a Stage 2 heel ulcer developed, TAR documentation showed frequent missed opportunities where AFOs and heel protectors were not in use. The resident and POA reported that heel protectors were often not applied, and surveyor observations repeatedly found the resident without heel protectors while they lay on the floor. Nursing staff and RNs gave conflicting explanations about when heel protectors should be used, and nursing leadership confirmed that pressure prevention interventions were not added to the care plan until after the ulcer was discovered.
A resident with moderate cognitive impairment and dependence on staff for ADLs, who required corrective lenses, had their eyeglasses go missing during their stay. The caregiver and a case manager reported the missing glasses to nursing staff and Social Services on multiple occasions, but no grievance or stop-loss form was completed and the issue was not entered in the grievance log. Staff interviews revealed inconsistent practices and poor recall regarding the missing item, and the glasses were never found, leading to the resident incurring a co-pay for replacement. This constituted a failure to honor the resident’s right to voice grievances and to follow the facility’s grievance policy under WAC 388-97-0460.
A resident with moderate cognitive impairment and dependence in ADLs was care planned to progress from a Hoyer lift to a sit-to-stand lift to improve function before discharge home, with PT documenting completion of sit-to-stand training and recommending its use with two staff for transfers. Despite this, the care plan update was not consistently implemented: caregivers and a case manager repeatedly observed staff using a Hoyer lift, including on the day of discharge, and staff interviews showed confusion or lack of recall about the sit-to-stand requirement. Task records showed infrequent transfers and only a few entries suggesting sit-to-stand use, while documentation reflected almost no refusals of care, resulting in a failure to follow the resident’s updated care plan for transfers.
A resident was unable to receive Social Security benefits due to the facility's failure to maintain complete and accessible medical records after discharge. Despite requests from the resident and a DSHS case manager, staff could not access the necessary records to complete required SSA forms, resulting in delays and incomplete documentation.
A resident with a hip fracture reported being abused by staff, including being forced into bed and handled inappropriately. Despite the resident's claims and police involvement, the facility failed to report the incident to the state agency or log it in the mandated reporting log. Staff interviews revealed discrepancies in handling the incident, with management concluding the allegation was unfounded and not requiring reporting.
The facility failed to provide routine cleaning services for two residents, leading to a lack of cleanliness in their rooms. Despite expectations for weekly cleaning, interviews revealed inconsistencies in cleaning practices due to staffing and scheduling challenges. A family member of a resident reported having to clean the room themselves due to the absence of housekeeping services.
The facility failed to provide adequate nursing staff, resulting in delayed care for residents. A resident with severe cognitive impairment experienced a 47-minute delay in assistance, and interviews revealed consistent concerns about long wait times for call lights, especially during weekends and holidays. Staff interviews confirmed the inability to meet resident needs due to insufficient staffing, with some staff responsible for more residents than manageable.
The facility failed to conduct care conferences for five residents and did not ensure care plans were accurate for three residents. A resident using a pocket talker did not have this documented in their care plan, while two residents with osteomyelitis lacked care plans reflecting their IV antibiotic needs. Staff cited staffing challenges as a reason for these deficiencies.
The facility failed to consistently provide restorative services to four residents, leading to potential avoidable decline. A resident with cerebral infarction and hemiplegia received range of motion therapy on only 8 of 31 days, while another resident with limited mobility received therapy on 10 of 31 days. Two other residents with moderate cognitive impairment also experienced inconsistent therapy. Staff frequently pulled restorative aids to work the floor, impacting the delivery of necessary services.
The facility failed to adhere to professional standards and facility policy for IV therapy for two residents. One resident's PICC line orders lacked necessary maintenance and monitoring directions, while another resident's central line assessments and documentation were incomplete. The ADON acknowledged these deficiencies.
The facility failed to follow the prescribed menu for residents on mechanical soft or pureed diets, using incorrect scoop sizes for serving meals. This was observed during a tray line inspection, where dietary staff used a #8 scoop instead of the specified sizes for pureed chicken, brussels sprouts, and dinner rolls. The Dietary Manager confirmed the error and corrected the staff, highlighting a risk of unmet nutritional needs for the residents.
The facility failed to ensure meals were served at appropriate temperatures and with good presentation, leading to resident dissatisfaction. Meal trays were left out for extended periods, resulting in improper food temperatures. Additionally, staff did not follow recipes for pureed meals, affecting consistency and nutritional value. Residents reported dissatisfaction with food quality and temperature, and there were complaints about the lack of snacks after kitchen hours.
A resident with moderate cognitive impairment and depressive disorder was administered antidepressant medications duloxetine and bupropion without prior informed consent. The facility's DON acknowledged the oversight in obtaining consent before medication administration.
The facility failed to notify the State Ombudsman of two residents' unplanned transfers to a hospital, as required. The Social Services Director confirmed the absence of notifications for these transfers, despite having a system to email discharge notifications monthly. This oversight risked inappropriate discharges and hindered advocacy efforts.
The facility did not provide a bed hold notice to a resident or their representative during an unplanned hospital transfer, as required. The resident's electronic health record lacked documentation of the notice, which was confirmed by the DON.
The facility failed to accurately assess two residents, leading to deficiencies in care. One resident's MDS did not reflect their active diagnosis of osteomyelitis or IV antibiotic therapy, despite documentation in the MAR. Another resident was not given a BIMS assessment, although staff confirmed the resident could communicate effectively. The MDS Coordinator acknowledged these assessment inaccuracies.
The facility failed to meet professional standards for three residents, leading to potential medication errors and health risks. A resident's CPAP machine was not present, yet tasks were signed off as completed. Another resident had incomplete PICC line orders and missed medication for constipation. A third resident's enteral pump was not programmed correctly, but staff inaccurately documented water flushes as administered.
A facility failed to administer enteral nutrition according to physician's orders, leading to discrepancies in the recorded amounts of formula and water flushes for a resident. Observations showed incorrect pump settings and incomplete MAR instructions, resulting in inaccurate recording of infused amounts. Staff interviews confirmed that nurses were not zeroing the pump at shift changes, causing incorrect totals to be recorded.
A facility failed to ensure staff compliance with PPE protocols for a resident on Enhanced Barrier Precautions (EBP) due to an indwelling catheter. Staff were observed not wearing gowns during high-contact activities, such as changing briefs and transferring the resident, contrary to facility policy. This non-compliance was confirmed by the Infection Preventionist and Resident Care Manager, highlighting a risk of cross-contamination and disease transmission.
A resident reported being stuck in a mechanical lift twice, but the facility failed to initiate a grievance process. Despite the resident's cognitive intactness and reporting the issue during care conferences, the grievance was not logged or resolved. Staff interviews revealed inconsistencies in handling the grievance, with the Social Service Director claiming to have submitted a form that was never found. The Administrator and Assistant Administrator acknowledged the issue but did not ensure proper follow-up, and the Director of Nursing Services was unaware of the grievance.
A resident with severe back pain and spondylosis experienced prolonged pain and limited mobility due to the facility's failure to act timely on physician orders for an MRI and spine specialist referral. Despite multiple provider notes and interdisciplinary team documentation, the facility delayed scheduling the necessary appointments for over three weeks.
A facility failed to prevent a UTI and ensure adequate hydration for a resident by improperly implementing an external urinary catheter system without proper assessment, staff training, or care planning. The resident's fluid intake was significantly below the required amount, leading to dehydration and hospitalization with acute UTI and kidney injury.
Failure to Consistently Implement Offloading and Wound Care Orders for Heel Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to consistently implement pressure offloading interventions and ordered wound care for a resident who was admitted after a hip fracture with peripheral vascular disease and no pressure injuries on admission. The admission MDS documented the resident as cognitively intact and at risk for pressure injury. A physician’s order directed that bilateral AFOs be worn during all transfers and when out of bed, but the January Treatment Administration Record (TAR) showed the AFOs were not in use for 14 of 38 charted opportunities. On a later date in January, staff discovered a clear fluid-filled blister on the resident’s right heel, assessed as a Stage 2 pressure injury measuring 4 cm x 5 cm, and the incident report attributed the blister to the use of bilateral AFOs. Following identification of the heel pressure injury, a physician ordered heel booties to both feet whenever the resident was in bed, but the January TAR showed heel booties documented in place for only 7 of 17 charted opportunities. A wound care provider note documented a new Stage 2 right heel pressure injury with orders for dressing changes three times weekly and recommendations to offload at all times, yet a weekly skin assessment completed the next day documented no identified skin concerns. Subsequent wound care notes showed the wound deteriorated to Stage 3 with 95% necrotic tissue, and an outside provider later ordered daily dressing changes and for the heel to be floated at all times. The February TAR showed these daily dressing change and offloading orders were not implemented, and heel protectors were documented in place for only 17 of 56 opportunities. By late February and early March, wound care notes documented further deterioration, including 100% necrotic tissue, macerated wound edges, and eventual classification as unstageable. Throughout this period, documentation in March continued to show inconsistent use of heel protectors, with only 19 of 62 opportunities charted. An outside wound clinic provider noted the right heel wound was of mixed etiology, including pressure, and ordered offloading of the posterior heel at all times, including floating heels in bed and wearing heel protectors if possible. The resident and the POA reported that heel protectors were supposed to be worn at all times but were often not in place, with the POA stating that during frequent visits the resident was usually not wearing heel protectors and that they had to request a different wound care professional and a wound culture. Surveyor observations on multiple dates found the resident in a wheelchair with a dressing on the right foot but without heel protectors, while heel protectors were seen on the floor. Nursing staff, including RNs and the DON, reported they had not seen the wound, were unaware of certain wound care orders, or did not know why the increased dressing change and offloading orders were not implemented, and the RCM and DON acknowledged that heel protectors and specific offloading orders were not consistently carried out as ordered.
Failure to Notify Resident Representative of New Stage 2 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of a significant change in condition related to the development of a Stage 2 pressure injury. The facility’s policy, “Change in Condition and Notification Policy” dated 06/01/2025, required that notifications regarding a resident’s condition be made to the resident and resident representative based on the resident’s clinical status, decision-making capacity, and preference. The resident in question was admitted after a hip fracture with diagnoses including peripheral vascular disease, and the admission MDS documented that the resident was cognitively intact and felt it was very important to have family and close friends involved in discussions about their care. An incident report dated 01/23/2026 showed that staff discovered a clear fluid-filled blister on the resident’s right heel, measuring 4 cm by 5 cm and assessed as a Stage 2 pressure injury, but the incident report did not indicate that the resident’s representative was informed of this new wound. Additional incident reports for subsequent falls on 01/28/2026, 02/16/2026, 02/17/2026, and 02/23/2026 showed that the POA/family was notified either on the following shift or via phone call, demonstrating that the facility did notify the representative for other significant events. On 04/23/2026, the resident stated they would expect the facility to report the wound to their POA, and the POA reported that she was not made aware of the wound until she accompanied the resident to an orthopedic appointment on 02/09/2026. In interviews, the RCM/RN stated that resident representatives should be made aware of changes such as weight loss, medications, and wounds, and that representatives should be notified of a new Stage 2 pressure injury, although they added they might not notify if the resident was alert and oriented. Another staff member stated they would expect staff to notify the resident representative regarding a new Stage 2 pressure injury. The surveyors cited this as a failure to ensure notification of a significant change in condition, referencing F686 and WAC 388-97-0320(1)(a)-(d)(2)(a)(b).
Failure to Care Plan and Consistently Implement Pressure Injury Prevention and Heel Offloading
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive care plan with pressure injury prevention strategies for a newly admitted resident who was identified as at risk for pressure injury. The facility’s Comprehensive Care Planning Policy required a care plan to be developed upon admission based on clinical assessment and identified risk. The resident was admitted after a hip fracture with a diagnosis of peripheral vascular disease, had no pressure injuries on admission, and the admission MDS documented that the resident was cognitively intact and at risk for pressure injury. Despite this, the care plan initiated shortly after admission did not include a focus on pressure injury risk or any pressure prevention interventions until after a Stage 2 pressure injury was discovered on the resident’s right heel. Physician orders and subsequent documentation showed inconsistent implementation of ordered interventions intended to prevent and then treat the heel pressure injury. An order dated shortly after admission required the resident to wear bilateral AFOs during all transfers and when out of bed, but the January TAR showed the AFOs were not in use for 14 of 38 charted opportunities. After the Stage 2 pressure injury was identified, the care plan included an intervention to keep the heels off the bed, and a physician’s order directed the use of heel booties whenever the resident was in bed, with wound care provider recommendations to offload at all times. However, TAR documentation showed heel protectors in place only 7 of 17 opportunities in late January, 17 of 56 opportunities in February, and 19 of 62 opportunities in March, indicating that ordered offloading and heel protection were not consistently carried out. Interviews and observations further demonstrated inconsistent use of heel protectors and confusion among staff about the resident’s ordered interventions. The resident’s POA reported visiting multiple times per week and finding the resident without heel protectors nearly every visit, despite a belief that they should be worn at all times, and noted that a sign placed in the room about heel protectors led to a nurse’s criticism after a fall while the resident was wearing them. On multiple observations, the resident was seen in a wheelchair with a dressing on the right heel and heel protectors not in use, while two pairs of heel protectors lay on the floor. The resident stated she believed she was supposed to wear heel protectors at all times but that some staff removed them and she could not replace them independently. Nursing assistants and RNs gave differing accounts, with some stating heel protectors were used mainly at night or only in bed due to perceived fall risk, and key nursing leaders and care managers acknowledged that all residents were at risk for pressure injuries and that interventions such as heel offloading should be on the care plan, yet confirmed that no pressure prevention interventions were added to this resident’s care plan until after the Stage 2 pressure injury was discovered.
Failure to Follow Up and Document Grievance for Missing Eyeglasses
Penalty
Summary
The facility failed to follow up on and document a grievance regarding a resident’s missing eyeglasses. The resident, who had moderate cognitive impairment, was dependent on staff for ADLs, medically complex, and required corrective lenses, was admitted in early October 2025 and discharged in late December 2025. The admission MDS and care plan documented that the resident wore glasses, and the demographic record photo showed the resident wearing eyeglasses. The resident’s caregiver reported the glasses missing to facility staff on multiple occasions beginning in early December, and was referred to Social Services, where a search of a drawer did not locate the glasses. At discharge, the glasses were still not found, and the discharging nurse reportedly told the caregiver that because the glasses were not on the inventory list, “then it didn’t happen.” The facility’s grievance logs from October 1, 2025 through January 31, 2026 contained no entry for the missing glasses. Multiple staff interviews showed inconsistent understanding and implementation of the grievance and lost-item processes. A nursing assistant stated that when something was reported missing, he would notify Social Services, look for the item, and complete a grievance form. The Social Services assistant stated that a “stop loss” form should be completed when items are reported missing, but did not recall anything about the missing glasses; the Social Services director recalled hearing the glasses were missing and looking for them, but believed they had been found and acknowledged that no stop loss form was completed. An RN stated that if an item was reported missing and not found, a grievance form should be completed and forwarded to administration, but did not recall the glasses being reported missing. The case manager reported notifying nursing staff twice in December that the glasses were missing and that they were never found or replaced, resulting in the resident paying a $20 co-pay for a new pair. The LPN who completed the discharge summary recalled reviewing the inventory list but did not recall being informed of missing glasses, and the DON stated that missing items should trigger a grievance form and follow-up, but was unaware of this incident. The survey cited WAC 388-97-0460 regarding honoring residents’ right to voice grievances without discrimination or reprisal and the requirement to establish and follow a grievance policy.
Failure to Implement Updated Transfer Care Plan and Sit-to-Stand Training
Penalty
Summary
The deficiency involves the facility’s failure to promptly update and consistently implement care-planned transfer interventions for a resident admitted with moderate cognitive impairment, dependence in ADLs, and medically complex conditions. The admission MDS showed no prior use of a mechanical lift and no refusals of care. The resident’s care plan, initiated shortly after admission, included a goal to improve functional status, including transfers, and initially specified a two-person dependent assist using a Hoyer lift, later revised to a sit-to-stand lift. A Social Services care conference note documented that the resident had progressed from the Hoyer to the sit-to-stand lift, and a PT discharge note stated the resident had reached maximum potential, completed sit-to-stand training, and required two staff and a sit-to-stand lift for transfers. Despite these documented therapy recommendations and care plan revisions, multiple interviews and records indicated that staff continued to use the Hoyer lift rather than the sit-to-stand lift. The resident’s caregiver reported observing staff using the Hoyer lift several times in December and never seeing the sit-to-stand used, including on the day of discharge, and stated the resident had no idea how to use the sit-to-stand at home. A case manager also reported observing staff using the Hoyer lift on multiple visits, including a specific instance when staff transferred the resident out of bed with a Hoyer for an appointment, despite the expectation that the sit-to-stand be used in preparation for discharge home. Social Services staff acknowledged the concern, stated that therapy had cleared the resident for the sit-to-stand, and said staff were instructed to use the sit-to-stand, but believed staff may have continued using the Hoyer because it was easier. Nursing and therapy staff interviews and documentation further demonstrated inconsistency between the care plan and actual practice. The PT stated that at therapy discharge the recommendation was for sit-to-stand transfers and that they were unaware staff were still using a Hoyer or that the resident was refusing to get up; they would have expected a new PT referral if a decline or change in lift use occurred. Nursing assistants and an LPN recalled the resident as a Hoyer lift user and did not recall specific instructions to use the sit-to-stand prior to discharge. The DON and Resident Care Manager both described the resident as often not wanting to get out of bed and being transferred with a Hoyer when he allowed transfers, and the DON believed days without transfers reflected refusals. However, review of the task record for nearly a month before discharge showed the resident was transferred only 16 times, with only six entries indicating sit-to-stand mobility, and progress notes documented only one refusal (a declined shower), while the discharge MDS indicated the resident did not display rejection of care. This combination of documentation and interviews showed the facility did not consistently implement the updated care plan interventions to maintain the resident’s functional ability in preparation for discharge home.
Failure to Maintain Complete and Accessible Medical Records
Penalty
Summary
The facility failed to maintain complete, accurate, and accessible medical records for a resident who had been discharged. The resident did not receive their Social Security benefits and, upon contacting the Social Security Administration (SSA), was informed that the cessation of payments was due to being incorrectly identified as still residing in the facility. The resident reached out to the facility's Business Office Manager, Administrator, and Social Services Director for assistance but did not receive a response. A DSHS case manager also contacted the Social Services Director to facilitate the completion of a required SSA form, but the form was left incomplete because the Social Services Director no longer had access to the resident's records after discharge. A review of the electronic health record (EHR) system showed no available record for the resident at the time of the request. The Medical Records staff indicated that records could only be obtained by requesting them from the previous facility ownership. The requested medical records were not received until two and a half days later. The incomplete documentation and lack of timely access to the resident's records resulted in the inability to complete necessary forms for the resident's Social Security benefits.
Failure to Report and Log Allegations of Abuse
Penalty
Summary
The facility failed to report and log allegations of abuse/mistreatment by staff within the required timeframe for one of the three residents reviewed for abuse and neglect. The guidelines, as outlined in the facility's policy and the Nursing Home Guidelines, require that any allegations of abuse be reported to the state agency within two hours if they involve abuse or serious bodily injury, and no later than 24 hours otherwise. However, the facility did not report the incident involving Resident 1, who alleged abuse by staff, to the state agency or log it in the mandated reporting log. Resident 1, admitted with a diagnosis of a left hip fracture, reported being abused and assaulted by staff, which included being aggressively forced into bed and handled inappropriately. The incident was initially reported by a family member to Staff C, an LPN, who then informed Staff B, the Director of Nursing. Despite the resident's claims and the involvement of law enforcement, the facility did not document the incident in the mandated reporting log, nor did they report it to the state agency as required. Staff interviews revealed discrepancies in the handling of the incident. Staff D, a CNA, assisted in the transfer of Resident 1 and was asked to fill out a witness statement, which was never collected by management. Staff C reported the incident to Staff B but was later asked to amend the incident note to be less detailed. Staff B concluded the allegation was unfounded and did not require reporting, while Staff A, the Administrator, was unaware of the abuse allegation, believing it was a call-out during care. This lack of proper documentation and reporting led to the deficiency identified by the surveyors.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide routine cleaning services to maintain a clean and homelike environment for two residents. Resident 1, who was cognitively intact and required substantial to maximal assistance for activities of daily living, reported that housekeeping had not cleaned their room in the previous 10 days, and their family had to clean the room instead. Similarly, Resident 2, who also required assistance, was affected by the lack of cleaning services. A review of the facility's housekeeping daily assignment sheets confirmed that no housekeeping was performed for the rooms of these residents over a 10-day period. Interviews with housekeeping staff and supervisors revealed inconsistencies in cleaning practices. Staff E and F indicated that rooms were cleaned based on a list, but not necessarily daily. The Housekeeping Supervisor, Staff D, admitted that rooms were cleaned once a week if possible, citing staffing and scheduling challenges as barriers. The Assistant Director of Nursing and the Director of Nursing both expected rooms to be cleaned weekly. A family member of Resident 1 corroborated the lack of cleaning, describing the room as dirty and noting the absence of disinfecting wipes. The facility's administrator also stated that resident rooms should be cleaned weekly, and family members should not be responsible for cleaning.
Insufficient Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient qualified nursing staff to meet the needs of residents, as evidenced by observations, interviews, and record reviews. Resident 67, who has severe cognitive impairment and is dependent on staff for activities of daily living, experienced a significant delay in receiving assistance. On one occasion, the resident's call light was activated for 47 minutes before being answered, and even then, the staff did not address the resident's need to be transferred back to bed. This delay was compounded by the fact that the staff member who eventually responded did not inquire about the resident's needs and instead attended to another room. Interviews with residents revealed consistent concerns about long wait times for call lights to be answered, with some residents reporting waits of up to 4-5 hours for assistance at night. Residents expressed that staffing was particularly inadequate during weekends and holidays, leading to rushed care and unmet needs. The Resident Council Meeting minutes from April to June 2024 also documented ongoing concerns about call lights being turned off before needs were met and insufficient staffing during night shifts. Staff interviews corroborated the residents' concerns, with several staff members indicating that they were responsible for more residents than they could adequately care for. Staff reported being unable to complete all assigned tasks, such as providing showers and performing wound care, due to insufficient staffing levels. The Director of Nursing Services acknowledged the staffing shortages, particularly in restorative services, and expressed that the expected response time for call lights was not being met, as evidenced by Resident 67's prolonged wait.
Deficiencies in Care Conferences and Care Plan Accuracy
Penalty
Summary
The facility failed to conduct care conferences for five residents, which are essential meetings where staff, residents, and families discuss the resident's care and make necessary adjustments. Residents 13, 17, 23, 28, and 44 did not have these conferences as expected. For instance, Resident 13, who is cognitively intact and values family involvement, had not had a quarterly care conference between the documented dates. Similarly, Resident 17, who is also cognitively intact and medically complex, reported not having a care conference since being off Medicare services. Staff acknowledged the lapse, attributing it to staffing challenges and time constraints. Additionally, the facility failed to ensure care plans were reviewed, revised, and accurately reflected the care needs of three residents. Resident 68, who is hard of hearing, was using a pocket talker, but this was not documented in their care plan, which only mentioned hearing aids. Resident 69, who has osteomyelitis and requires IV antibiotics, did not have their condition or treatment needs reflected in their care plan. Similarly, Resident 31, who also has osteomyelitis and a central line for antibiotic therapy, lacked a comprehensive care plan addressing these needs. These deficiencies indicate a failure to involve residents and their families in care planning and to maintain accurate and up-to-date care plans, potentially impacting the quality of care and life for the residents involved. The staff recognized these issues but cited workload and staffing challenges as contributing factors to the oversight.
Inconsistent Restorative Services Provided to Residents
Penalty
Summary
The facility failed to provide consistent restorative services for four residents, leading to a risk of avoidable decline and diminished quality of life. Resident 65, who was cognitively intact and required assistance with ADLs, had a care plan that included restorative interventions for transfers and range of motion. However, the resident received these services inconsistently, with documented minutes on only 8 of 31 days for range of motion and 17 of 31 days for transfers. Staff members reported that restorative aids were frequently pulled to work the floor, impacting the delivery of restorative therapy. Resident 17, who was cognitively intact and medically complex, required substantial assistance for ADLs and had a care plan for restorative services due to limited mobility. Despite the need for restorative interventions, the resident received services on only 10 of 31 days. The resident expressed frustration over the lack of consistent therapy, attributing it to staff shortages and the frequent reassignment of restorative aids to other duties. Resident 23, with moderate cognitive impairment, and Resident 28, also with moderate cognitive impairment, both required substantial assistance for ADLs and had care plans for restorative services. Resident 23 received services on 20 of 31 days, while Resident 28 received services on only 9 of 31 days. Both residents and staff noted that restorative aids were often reassigned to other tasks, negatively impacting the residents' ability to receive necessary therapy. Staff acknowledged that this practice could have adverse effects on residents' physical conditions.
Deficiency in IV Therapy Standards and Monitoring
Penalty
Summary
The facility failed to ensure that intravenous (IV) services were provided in accordance with professional standards of practice and facility policy for two residents receiving IV therapy. For Resident 69, the facility did not include necessary directions in the physician's orders for PICC maintenance and monitoring, such as obtaining initial and weekly external length or arm circumference measurements, performing weekly PICC dressing changes, monitoring the IV insertion site for signs of infection, changing needleless connector caps weekly and after blood draws, and specifying when and how to flush the PICC. The Assistant Director of Nursing (ADON) acknowledged that the IV orders were incomplete and that the facility nurses failed to identify and clarify these omissions. For Resident 31, the facility did not document assessments of the central line insertion site every two hours during continuous infusion, nor did they record the external length of the central line upon admission or weekly thereafter. The physician's orders lacked directions to monitor the IV insertion site for signs of infection and to change the needleless connector caps weekly. The ADON confirmed the absence of documentation for these required assessments and changes, indicating a failure to adhere to the facility's policy and professional standards for IV therapy.
Failure to Follow Prescribed Menu for Residents on Special Diets
Penalty
Summary
The facility failed to adhere to the prescribed menu for residents requiring mechanical soft or pureed diets, as observed during a tray line inspection. Specifically, the dietary staff used incorrect scoop sizes for serving pureed meals to four residents, which included pureed chicken, brussels sprouts, and dinner rolls. The menu specified that residents on D1 pureed diets should receive a #8 scoop of pureed chicken, a #12 scoop of pureed brussels sprouts, and a #16 scoop of pureed dinner roll. However, observations revealed that all items were served using a #8 scoop, which did not align with the menu's portion size requirements. The deficiency was identified during an observation of the steam table and tray line, where it was noted that the dietary staff consistently used the wrong scoop size for serving meals to residents on D1 and D2 diets. This error was confirmed by the Dietary Manager, who acknowledged the use of incorrect scoop sizes and subsequently corrected the staff. The failure to provide accurate portion sizes placed residents at risk of unmet nutritional needs and potential negative outcomes, as the facility did not follow the menu reviewed by a dietician, which is essential for meeting the nutritional needs of the residents.
Deficiencies in Meal Preparation and Service
Penalty
Summary
The facility failed to ensure that meals were prepared and served at appropriate temperatures, with good presentation, and were palatable for residents. On multiple occasions, meal trays were observed sitting out for extended periods without plate warmers, leading to food being served at improper temperatures. For instance, a cart with meal trays sat for 23 minutes before being transported to residents, resulting in hot foods being served at temperatures as low as 101 degrees Fahrenheit. Residents expressed dissatisfaction with the temperature and quality of the food, noting that hot foods were not hot enough and cold foods were not cold. Additionally, there were complaints about the lack of snacks available after the kitchen closed. The facility also failed to follow proper procedures for preparing pureed meals. Staff did not adhere to recipes when preparing pureed meals, as evidenced by a cook who admitted to not using a recipe for pureed chicken. This lack of adherence to recipes could affect the consistency and nutritional value of the meals. The dietary manager confirmed that recipes existed for pureed meals but were not being used. These deficiencies were noted during observations, resident interviews, and record reviews, highlighting ongoing issues with meal preparation and service in the facility.
Failure to Obtain Informed Consent for Antidepressant Use
Penalty
Summary
The facility failed to inform a resident and/or their legal representative in advance about the risks and benefits associated with the use of psychotropic medications, specifically antidepressants, and did not obtain informed consent before administering these medications. This deficiency was identified for one resident who was admitted with moderate cognitive impairment and a diagnosis of depressive disorder. The resident had orders for duloxetine and bupropion, which were administered before informed consent was obtained. The facility's Director of Nursing Services acknowledged that consent should have been obtained prior to administering the medications but admitted that this was not done.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to ensure that the Office of the State Long-Term Care Ombudsman received the required resident discharge information for two residents who were transferred to an acute care hospital. Resident 43 had an unplanned transfer on April 30, 2024, and the facility did not provide the Ombudsman with a written notice detailing the reasons for the transfer. Staff D, the Social Services Director, confirmed that there was no record of notification for this transfer, despite having a system in place to email discharge notifications monthly. Similarly, Resident 31 experienced an unplanned transfer to a hospital on July 7, 2024, and there was no documentation indicating that the Ombudsman was notified. Staff D also confirmed the absence of notification for Resident 31's transfer. These oversights in communication with the Ombudsman placed residents at risk of being inappropriately discharged and hindered the Ombudsman's ability to advocate for the residents during the discharge process.
Failure to Provide Bed Hold Notice During Hospital Transfer
Penalty
Summary
The facility failed to provide a bed hold notice to a resident or their representative at the time of an unplanned hospital transfer, as required by regulations. This deficiency was identified during a review of Resident 43's case, who was admitted to the facility and later had an unplanned transfer to the hospital. The Discharge Minimum Data Set (MDS) indicated the transfer occurred on 04/30/2024. However, upon reviewing the resident's electronic health record, there was no documentation showing that a bed hold notice was provided. This was confirmed by the Director of Nursing Services, who acknowledged the absence of such documentation.
Inaccurate Resident Assessments in LTC Facility
Penalty
Summary
The facility failed to accurately assess two residents, leading to deficiencies in their care. Resident 69 was readmitted with a Peripherally Inserted Central Catheter (PICC) and orders for intravenous antibiotics, ceftriaxone and vancomycin, for osteomyelitis. However, the Minimum Data Set (MDS) assessment conducted on 07/18/2024 did not reflect the active diagnosis of osteomyelitis, the presence of IV access, or the administration of antibiotic therapy, despite these treatments being documented in the Medication Administration Record (MAR). Staff T, the MDS Coordinator, acknowledged the inaccuracies in the MDS coding. Resident 43 was admitted to the facility, and during the 06/14/2024 Quarterly MDS assessment, staff failed to conduct a Brief Interview for Mental Status (BIMS) as required. The staff documented that the interview should not be conducted due to the resident being rarely or never understood. However, subsequent interviews with staff revealed that Resident 43 was capable of communicating effectively through yes or no questions. Staff J, an LPN, and Staff C, the Assistant Director of Nursing, both confirmed the resident's ability to make their needs known. Staff T, the MDS Coordinator, admitted that the BIMS should have been conducted to assess the resident's cognitive patterns.
Deficiencies in Professional Standards and Medication Administration
Penalty
Summary
The facility failed to ensure services met professional standards for three residents, leading to potential risks for medication errors and other health complications. Resident 132 was admitted with orders to use a CPAP machine at night, but the machine was never brought to the facility. Despite this, nurses signed off on tasks related to the CPAP machine, such as validating settings and cleaning the mask and tubing, which were not completed. This discrepancy was confirmed by the facility's Administrator and Director of Nursing Services. Resident 69 was readmitted with a PICC line for IV antibiotics but had incomplete orders for PICC maintenance and monitoring. The facility staff did not clarify these orders, which included missing instructions for measurements, dressing changes, and site monitoring. Additionally, Resident 69 experienced constipation, but the as-needed medication was not administered as ordered. Resident 43, who was receiving enteral feeding, had an issue with the enteral pump not being programmed to deliver water flushes as ordered. Despite this, the nurse signed off on the MAR indicating that water flushes were administered, which was later acknowledged as an error by the Assistant Director of Nursing.
Failure to Administer Enteral Nutrition as Ordered
Penalty
Summary
The facility failed to administer enteral nutrition to a resident in accordance with physician's orders and professional standards of practice. Specifically, the facility did not accurately record the amount of enteral formula and water flushes administered to the resident, nor did they clarify incomplete enteral orders regarding the route of administration, method of delivery, and the timing of the enteral formula infusion. This oversight was observed in the case of a resident who was receiving enteral nutrition, where the facility's records showed discrepancies in the amounts of formula and water flushes administered compared to the physician's orders. Observations revealed that the resident's enteral feeding pump was not set correctly, resulting in incorrect delivery of water flushes. The facility's Medication Administration Records (MARs) lacked clear instructions for staff to total the amount of formula and water flushes delivered each day, leading to significant discrepancies in the recorded amounts. Staff interviews confirmed that nurses were inaccurately recording the amounts infused, as some were not zeroing the pump at the end of their shifts, causing subsequent nurses to record incorrect totals. This failure to adhere to proper procedures placed the resident at risk for inadequate nutrition and hydration.
Non-compliance with PPE Protocols for Resident on EBP
Penalty
Summary
The facility failed to ensure staff compliance with infection control guidelines and standards of practice for donning personal protective equipment (PPE) for a resident under Enhanced Barrier Precautions (EBP). The facility's policy, dated August 2023, required the use of gowns and gloves during high-contact resident care activities to prevent the transfer of multidrug-resistant organisms (MDROs). Despite this policy, a Certified Nursing Assistant (CNA), identified as Staff O, was observed changing the brief of a resident with an indwelling catheter without wearing a gown. Additionally, both Staff O and another CNA, Staff N, were observed transferring the same resident using a Hoyer lift without wearing gowns. The resident involved, admitted to the facility in August 2021, was cognitively intact and had an indwelling catheter, necessitating the use of EBP. The facility's Infection Preventionist and Resident Care Manager confirmed that the expectation was for staff to wear gowns and gloves when performing activities such as changing briefs or transferring residents on EBP. The failure to adhere to these precautions placed residents at an increased risk for exposure to cross-contamination and disease transmission.
Failure to Address Resident Grievance Regarding Mechanical Lift
Penalty
Summary
The facility failed to initiate a resident grievance for a resident who experienced issues with a mechanical lift. The resident, who was cognitively intact and required assistance for transfers, reported being stuck in a sit-to-stand lift on two occasions. The first incident occurred in February, and the resident reported it during a care conference, expecting a grievance to be filed by the Social Service Director. However, no follow-up or investigation was conducted, and the grievance was not logged. The resident experienced a similar incident in April and inquired about the previous grievance, only to be informed that it was discarded as there was no injury. Interviews with staff revealed inconsistencies in handling the grievance process. The Social Service Director claimed to have filled out a grievance form and submitted it to the Assistant Administrator, but the form was not found, and the grievance was not logged. The Administrator and Assistant Administrator acknowledged the issue but did not ensure proper follow-up or resolution. The Director of Nursing Services was unaware of the grievance. The facility's grievance log did not reflect any grievances for the resident, indicating a failure to adhere to the established grievance policy.
Failure to Act Timely on Physician Orders for Diagnostic Testing and Specialist Referral
Penalty
Summary
The facility failed to ensure timely action on a physician's order for additional diagnostic testing and a referral to a spine specialist for a resident with spondylosis and severe back pain. The resident experienced a fall and reported increasing pain, which was not adequately managed despite adjustments in pain medication. An MRI and spine specialist referral were ordered on multiple occasions, but the facility did not act on these orders for over three weeks, leading to prolonged pain and limited mobility for the resident. The resident's pain was documented as worsening, impacting their ability to participate in physical therapy and daily activities. Despite multiple notes from providers and the interdisciplinary team highlighting the need for an MRI and specialist referral, the facility staff failed to schedule these appointments in a timely manner. The resident's condition continued to deteriorate, with severe pain limiting their mobility and quality of life. Interviews with staff revealed a lack of communication and follow-through on the ordered diagnostic tests and specialist referral. The facility's process for handling outside referrals was inadequate, with delays in scheduling and a lack of urgency in addressing the resident's needs. This deficiency in professional standards of practice placed the resident at risk for prolonged pain and decreased quality of life.
Failure to Prevent UTI and Ensure Adequate Hydration
Penalty
Summary
The facility failed to provide care and services to prevent a urinary tract infection (UTI) for a resident. The facility implemented an external urinary catheter system without assessing its appropriateness, training staff in its use, or including it in the care plan. Additionally, the facility did not ensure adequate hydration for the resident, who was frequently incontinent of bladder and occasionally incontinent of bowel. These failures placed the resident at risk for infection, dehydration, and medical complications. The resident was admitted to the facility and was documented as cognitively intact but medically complex, requiring substantial staff assistance for toileting. The care plan for bladder incontinence did not include the use of an external catheter device, and there was no physician's order for it. The resident's fluid intake was significantly below the estimated daily needs, and there were multiple instances where the resident refused fluids or had no fluid intake without proper nurse notification. The resident's condition deteriorated, showing signs of dehydration and confusion, and was eventually admitted to the hospital with diagnoses including acute UTI, acute kidney injury, and dehydration. Interviews with staff revealed a lack of training and familiarity with the external catheter system. Staff members were not aware of the proper use, placement, or removal of the device, and there was no additional guidance provided other than the package instructions. The facility's infection preventionist and staff development coordinator acknowledged that the facility did not use external catheter systems and that staff had not been educated on their use. The resident's family was expected to manage the device, which was deemed inappropriate by the infection preventionist. The lack of proper incontinence care, decreased fluid intake, and improper use of the external catheter system contributed to the resident's decline and subsequent hospitalization.
Latest citations in Washington
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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