Shoreline Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Seattle, Washington.
- Location
- 2818 Northeast 145th Street, Seattle, Washington 98155
- CMS Provider Number
- 505262
- Inspections on file
- 29
- Latest survey
- March 24, 2026
- Citations (last 12 mo.)
- 55
Citation history
Health deficiencies cited at Shoreline Health And Rehabilitation during CMS and state inspections, most recent first.
Failure to provide an ongoing activity program for multiple residents. Residents with mobility needs and mild cognitive impairment were repeatedly observed in bed while group activities were occurring, and they stated they were not offered activities. One resident had no activity calendar posted and limited activity documentation, while another resident’s music preference was not supported because the portable stereo was not initially in place, plugged in, or reachable.
Food safety and hand hygiene practices were not followed during kitchen storage and meal delivery. Mold-like growth was observed on grapes stored in the walk-in refrigerator, and an RT delivered meal trays to residents without performing hand hygiene before or after the deliveries. The DON stated staff were expected to perform hand hygiene before and after delivering meal trays.
The facility failed to fully implement its infection prevention and control program. The water management program did not include an Infection Preventionist on the risk team and listed the wrong health department for legionella outbreak reporting. Staff were observed failing to disinfect a Hoyer lift after use, failing to perform hand hygiene after handling soiled linens, and an RN failed to perform hand hygiene before and after medication administration for two residents. The Second Floor medication room also lacked readily accessible hand hygiene supplies, with the soap dispenser blocked and no paper towels, wastebasket, or ABHR dispenser available.
Resident rooms were not maintained in good repair in two rooms reviewed. One resident's room had a wall by the sink with unpainted patch marks from prior repairs, and the resident said the wall had looked that way since move-in. Another resident's room had cracked, chipped, and missing laminate flooring with sections lifting from the subfloor; maintenance staff said they were unaware of one room's repair needs and that the wall patching and flooring repair were still incomplete.
Inaccurate MDS Weight Assessment: A resident’s MDS recorded the same weight on two assessments even though the documented weight was not within 30 days of either ARD. The MDS Coordinator confirmed the weight used was from months earlier, acknowledged the weight section should have been dashed, and stated the assessments were not accurate. The DON stated MDSs were expected to be completed timely and accurately.
Failure to obtain a PASRR Level II report for a resident with bipolar disorder and documented mental health needs. The resident’s PASRR notice indicated the resident met NF LOC and may benefit from specialized behavioral health services, but the EHR contained no Level II PASRR report. The SS supervisor confirmed the report was not in the clinical record, and the Administrator stated staff were expected to follow the facility PASRR policy and obtain the report.
Failure to complete PASRR Level II referral for a resident with depression and a Level I PASRR marked yes for SMI. The resident’s record showed no Level II evaluation was indicated due to exempted hospital discharge, but staff later confirmed no Level II referral had been made and stated the Level II evaluation should have been completed within 30 days if discharge did not occur.
A resident with drug induced subacute dyskinesia and antipsychotic use had quarterly AIMS scores that increased to 11, but the care plan still reflected an older AIMS score of 6 and had not been revised to match the updated assessments. Staff observations noted abnormal involuntary movements of the mouth and hands, and the RCM and DON both stated the care plan should have been updated based on the AIMS results.
A resident with sleep apnea had a physician order to wear CPAP while sleeping with 2 L of O2, but the order did not include CPAP pressure settings. The resident’s care plan also had no CPAP care plan. An LPN, the RCM, and the DON all stated CPAP pressure settings should have been in the order and that a CPAP care plan should have been in place when the resident started CPAP on admission.
Controlled drugs in an East 2 med cart were not accurately reconciled. An LPN signed the shift-change log without verifying the controlled drug book against the physical stock, and a review found one 5 mg oxycodone tablet listed for a resident in the logbook but missing from the box. The DON stated controlled meds must be recorded in the logbook and validated during shift-change counts.
A resident’s metoprolol was administered despite a physician order to hold the medication when systolic BP was below 110. Review of the MAR showed multiple doses were given when the resident’s systolic BP was under the ordered parameter, and an LPN acknowledged the medication should have been held; the DON stated staff were expected to follow the BP parameters and notify the provider.
Improper storage and altered manufacturer instructions for lorazepam. An unopened bottle of lorazepam oral concentrate for a resident was found stored at room temperature on the medication cart, despite the manufacturer’s directions for cold-temperature/refrigerated storage. The LPN and DON gave conflicting explanations about storage requirements, and the facility’s copy of the manufacturer instructions included an added discard statement that was not on the actual document.
Antibiotic stewardship was not consistently maintained, and standardized criteria such as Loeb Minimum Criteria were not used for antibiotic initiation. One resident received Macrobid for UTI despite an infection surveillance form showing symptoms but no qualifying microbiologic criteria, and another resident received nitrofurantoin for UTI even though the urine culture colony count did not meet McGeer criteria. The DON stated McGeer criteria were used for both starting antibiotics and infection surveillance, and that SBAR and Loeb’s criteria were not used.
The facility failed to provide a homelike dining environment by serving meals on trays in the dining room, a practice that began during the COVID-19 pandemic. Staff confirmed this as the current process, which deviates from the facility's policy of creating a homelike environment.
The facility failed to properly store drugs and biologicals, with expired supplies found in two medication rooms and an unlabeled capsule in a medication cart. Staff acknowledged the issues, which violated the facility's storage policy.
The facility failed to follow food safety standards, with unlabeled cereal in storage and uncovered food items during meal delivery. Staff interviews confirmed expectations for labeling and covering food, but these practices were not consistently followed.
The facility failed to follow Contact Precautions for a resident with MRSA, as an Activities Assistant entered the room without proper PPE. Additionally, a Housekeeping Staff member did not perform hand hygiene after handling soiled laundry and before touching clean linens, and their gown was not properly tied. These actions were contrary to the facility's infection control policies.
A resident was not informed about the bed hold option during a hospital transfer, contrary to facility policy. The resident, who was their own financial responsible party, was not given the opportunity to make an informed decision, leading to a change in room upon their return. The facility contacted the resident's emergency contact instead, resulting in confusion and frustration for the resident.
A facility failed to accurately assess a resident's preferences for daily routines and activities, as required by the RAI manual. The resident, who had dementia and was non-verbal, did not have family interviews conducted to gather preference information. MDS assessments were incomplete, with sections either coded as non-responsive or left dashed. Staff confirmed that family interviews were not conducted, despite expectations, leading to inaccurate MDS documentation.
A facility failed to implement the activity care plan for a resident with dementia, as observations showed no one-on-one in-room activities were provided. The Activities Supervisor could not provide documentation, and the EHR lacked records of activity participation. The Resident Care Manager and Administrator confirmed the absence of documentation, leading to the deficiency.
The facility failed to update care plans for three residents, leading to potential risks. Two residents required medication administration during meals for compliance, but this was not initially reflected in their care plans. Another resident self-administered higher oxygen levels than prescribed, a behavior not documented in their care plan. Staff interviews confirmed the need for earlier revisions.
Two residents experienced medication administration errors in an LTC facility. One resident received oxycodone despite a pain level below the prescribed threshold, while another resident refused an anticoagulant injection for seven days without provider notification. Staff interviews revealed a lack of adherence to physician orders and facility policies.
A resident with dementia did not receive an individualized activity program as outlined in their care plan, which included one-on-one activities like story time and music. Observations showed a lack of these activities, and staff interviews revealed inadequate documentation and implementation. The facility's activity department failed to provide the necessary support, leading to a deficiency in meeting the resident's needs.
A facility failed to implement a bowel management protocol for a resident, leading to multiple five-day periods without documented bowel movements. Despite the care plan's requirement to monitor and document bowel movements, no PRN medications were administered, and there was no documentation of assessments or physician notifications. Interviews with staff revealed inconsistencies in following the protocol, highlighting a deficiency in providing care according to professional standards.
The facility failed to adhere to professional standards for respiratory care for three residents. A resident with COPD was observed receiving incorrect oxygen levels, with staff unaware of the resident's behavior of adjusting the flow. Another resident's nebulizer mask was improperly stored, risking contamination. A third resident's nasal cannula and portable oxygen tank were not stored according to policy, posing safety risks. Staff interviews confirmed these deficiencies in care and equipment management.
A resident's medical records were found to be inaccurate, with a discharge notice incorrectly documented as given to a non-existent daughter and a misdiagnosis of paranoid schizophrenia instead of bipolar disorder. The facility's policies require accurate documentation, but errors were acknowledged by the DON and Social Services staff.
Failure to Provide Ongoing Resident Activities
Penalty
Summary
The facility failed to provide an ongoing program of activities for 3 of 4 residents reviewed for activities: Residents 8, 55, and 71. The facility policy stated that activities were to be available to meet resident needs and interests and support physical, mental, and psychosocial well-being. The cited regulation was WAC 388-97-0940(1)(2). Resident 8 was admitted with diagnoses including walking difficulty and need for assistance with personal care. The quarterly MDS showed mild cognitive impairment and that it was somewhat important for the resident to do things with groups of people and favorite activities. The care plan directed staff to invite and encourage activities in a low stimulation environment and noted an updated activity calendar in the room. However, on multiple observations the resident was in bed while activity programs were occurring, stated they were not offered activities, and on one occasion said the TV remote was missing. The room did not have an activity calendar posted, and review of the January through March 2026 activity documentation showed only a few recorded activities and no documented refusals. Resident 55 was admitted with diagnoses including difficulty walking and need for assistance with personal care. The quarterly MDS showed mild cognitive impairment and dependence on staff for transfers and dressing. The quarterly activity evaluation stated that activities would continue to meet with the resident on a regular basis and that an updated activity calendar was in the room. On observation, the resident was repeatedly found in bed while activity programs were underway and stated they were not offered activities. Review of the January through March 2026 activity documentation showed very limited recorded activities and no documented refusals. Resident 71’s admission activity evaluation showed a preference for listening to classical music, and the activity care plan directed staff to offer a personal stereo. The resident was observed awake in bed without a personal stereo in the room, later received a portable stereo, and then stated it was not plugged in and was out of reach. Staff later plugged it in after observing it was not connected.
Food Storage and Hand Hygiene Deficiencies
Penalty
Summary
Food was not handled in accordance with professional food safety standards in the kitchen walk-in refrigerator and during meal tray delivery. During observation with the Dietary Supervisor, a clear bag of purple seedless grapes was found stored on a refrigerator shelf with a white hairy/fuzzy substance on the grapes, and the Dietary Supervisor stated the substance looked like mold and should not have been there. The facility's policy stated that food must be stored, prepared, distributed, and served in accordance with professional standards for food service safety and proper sanitation and food handling practices to prevent foodborne illness. Hand hygiene was not performed by Staff T while delivering meal trays to residents. During observation, Staff T pushed the meal cart from the nurses' station, delivered a tray to one room, exited without performing hand hygiene, then opened the cart again and delivered another tray to another room without performing hand hygiene before or after the deliveries. Staff T stated they should have performed hand hygiene between tray deliveries, and the DON stated staff were expected to perform hand hygiene before and after delivering meal trays to residents.
Infection Control Program Deficiencies
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program when its water management program did not include an Infection Preventionist on the risk management team and identified the wrong health department for reporting a legionella outbreak. The written water management document stated that legionella outbreaks or cases should be reported to the Snohomish County Health Department, while Staff A later stated it should have been the King County Department of Health. During interviews, Staff C and Staff N identified Staff B as part of the water management risk team, but Staff A stated Staff B was not a certified infection preventionist, and the record review showed the Infection Preventionist was not part of the team. The facility also failed to follow infection control practices for shared medical equipment. Staff I was observed moving a Hoyer lift out of a resident room and down the hallway without disinfecting or sanitizing it after use. Staff I later stated the lift should have been sanitized right away and acknowledged it was not done. Staff J stated staff were expected to wipe down the Hoyer lift before and after use with sanitizing wipes, and Staff G, Staff N, and Staff B all stated that resident equipment should be disinfected after use. Hand hygiene was also not performed as expected. Staff I was observed handling soiled linens, placing them in the soiled utility room, and then walking away without performing hand hygiene, despite a sanitizer dispenser being nearby. Staff I stated hand hygiene should have been done and was not. Staff S was observed preparing and administering medications to two residents without performing hand hygiene before or after medication administration, and also continued working at the medication cart without hand hygiene. In the Second Floor Medication Room, the soap dispenser was blocked by a small refrigerator, and the room lacked paper towels, a wastebasket, and/or an ABHR dispenser, while Staff H, Staff N, and Staff B stated that hand hygiene supplies should have been readily available.
Resident Rooms Not Maintained in Good Repair
Penalty
Summary
The facility failed to ensure resident rooms were maintained in good repair for 2 of 2 rooms reviewed, Rooms 218 and 223. In Room 218, observations on multiple dates showed the wall by the sink was painted reddish-brown with multiple white patches from previous repairs that remained unpainted. Resident 79 stated the wall had been like that since they moved in and that someone forgot to finish the job after patching it, adding that it would be nice if it was repaired. In Room 223, observations on multiple dates showed the laminate flooring by the resident's bed was cracked and chipped, had missing pieces, and part of the flooring was lifting off the subfloor. During a joint observation, Maintenance Supervisor Staff C and Maintenance Staff Staff K stated most repairs were completed immediately, but Staff K said they had only been notified about the flooring repair the day before and had repaired it, while Staff C and Staff K stated they were unaware of the repair needs in Room 218. Staff C also stated the wall patches in Room 218 still needed sanding and repainting, and that the missing section of flooring in Room 223 should have been repaired. The Administrator stated they expected all resident rooms to be maintained in good repair and was unaware of the floor issues in Room 223.
Inaccurate MDS Weight Assessment
Penalty
Summary
The facility failed to ensure an accurate resident assessment for one of 13 residents reviewed, Resident 6, on the Minimum Data Set (MDS). The deficiency involved the weight entry in Section K of the MDS, where Resident 6’s weight was recorded as 219 lbs. on an annual MDS and again as 219 lbs. on a quarterly MDS. The Long-Term Care Resident Assessment Instrument (RAI) manual states that weight should be taken within 30 days of the Assessment Reference Date (ARD), or the item should be dashed if a resident cannot be weighed and the rationale documented. Resident 6’s weight records reviewed by surveyors showed a weight of 219 lbs. on 05/16/2025 and a later weight of 232 lbs. on 01/09/2026, with no other weights documented between those dates. During interview and record review, the MDS Coordinator stated the 219-lb. weight from May 2025 was used for both MDS assessments and acknowledged that it was not within 30 days of the ARD for either assessment. The MDS Coordinator stated the weight section should have been dashed and that the MDSs were not accurate. The DON stated that MDSs were expected to be completed timely and accurately.
Failure to Obtain PASRR Level II Report for Resident with Mental Health Needs
Penalty
Summary
The facility failed to ensure that a Preadmission Screen and Resident Review (PASRR) Level II report was obtained for one resident with bipolar disorder. The resident’s record included a PASRR Notice of Determination dated 08/26/2025 showing that the resident had a mental health diagnosis, met nursing facility level of care requirements because of current mental health needs, and may benefit from specialized behavioral health services. The notice also stated that the full PASRR Level II report would be sent to the nursing facility and become part of the medical record within 30 days. Review of the electronic health record from 08/01/2025 through 03/18/2026 showed no documentation of the resident’s Level II PASRR full report. During interviews and record review, the Social Services Supervisor stated that if a Level I PASRR was referred for Level II evaluation, it would be sent to the PASRR coordinator and followed up for results, and later stated there was no Level II PASRR in the clinical record for the resident. The Administrator stated staff were expected to follow the facility’s PASRR policy and to follow up and obtain Level II PASRR reports so recommendations could be carried forward.
Failure to Complete PASRR Level II Referral
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed as required for one resident who was reviewed for PASRR screening. The resident was admitted with a diagnosis that included depression. The resident’s PASRR Level I form dated 12/24/2025 indicated yes for SMI due to mood disorder depression and stated that the attending physician certified the individual was likely to require fewer than 30 days of nursing facility services. The form also stated that no Level II evaluation was indicated at that time due to exempted hospital discharge, with a note that Level II must be completed if scheduled discharge did not occur. During interview and record review, the Social Services Supervisor stated they were responsible for PASRR follow-up and would contact the PASRR coordinator by phone, email, or fax depending on what was marked on the Level I form. A later interview confirmed that no Level II PASRR referrals had been made for the resident, and the Social Services Supervisor stated that a PASRR Level I with Level II evaluation indication should have been completed no later than 30 days from admission. The Administrator stated they expected the resident’s PASRR to be completed accurately and for staff to follow the facility’s PASRR policy.
Care Plan Not Revised After Increased AIMS Scores
Penalty
Summary
The facility failed to ensure that Resident 43’s comprehensive care plan was reviewed and revised based on the resident’s assessment. Resident 43 was admitted with a diagnosis of drug induced subacute dyskinesia and was receiving antipsychotic medication. The facility’s policy stated that the resident’s comprehensive plan of care would be reviewed and/or revised by the IDT after each assessment, including comprehensive and quarterly review assessments. Record review showed quarterly AIMS assessments dated 07/25/2025, 10/23/2025, and 01/23/2026 with Resident 43 scoring 11, which was significantly increased from the 04/24/2025 assessment. However, the comprehensive care plan printed on 03/20/2026 still reflected an AIMS score of 6 and a revision date of 04/24/2025. Observations on 03/18/2026, 03/21/2026, and 03/23/2026 showed abnormal involuntary movements of the mouth and hands. Staff H, RCM, stated the care plan should have been updated based on the AIMS assessment, and Staff B, DON, stated the care plan should have been revised based on the resident’s AIMS assessment.
Missing CPAP Order Settings and Care Plan
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was deficient for Resident 30, who was admitted with a diagnosis of sleep apnea. Review of the physician orders printed on 03/19/2026 showed that the resident wore CPAP while sleeping with 2 liters of oxygen for sleep apnea, but the order did not include CPAP pressure settings. Review of the comprehensive care plan printed on the same date showed no care plan for CPAP usage for sleep apnea. During interviews and joint record reviews, Staff P, an LPN, stated that CPAP orders should include the prescribed pressure settings and that staff would check the physician orders, assist with applying the CPAP mask, and fill the machine with distilled water if required. Staff O, the Resident Care Manager, stated staff would know the resident’s CPAP pressure settings from the physician order and that if the resident used home settings, it would be stated in the orders; however, no order with CPAP pressure settings was found. Staff O also stated there should have been an order with the CPAP pressure settings on admission and expected a care plan for CPAP usage. Staff B, the DON, stated they expected physician orders for CPAP pressure settings and that the order and care plan should have been completed when the resident started CPAP on admission.
Controlled Drug Count Discrepancy in Medication Cart
Penalty
Summary
Controlled drugs were not accurately accounted for in the East 2 Medication Cart. During a review of the controlled drug logbook and the physical stock in the cart, Staff M, an LPN, stated they had counted the controlled drugs at the start of the shift and signed the shift-change log without verifying the drug book balance against the actual contents of the controlled drug box. The facility’s policy required nursing staff to count controlled medication inventory at the end of each shift, with the oncoming and off-going nurses counting together and documenting any discrepancies. A joint record review showed that Resident 56 had one 5 mg oxycodone tablet remaining in the controlled drug logbook, but a joint observation of the controlled drug box showed that one tablet was missing. When asked about the discrepancy, Staff M stated the night shift nurse may have administered the missing tablet without documenting it and acknowledged that the physical inventory should have been cross-referenced with the controlled drug book during the shift-change count. The DON stated that administered controlled drugs must be recorded in the logbook and validated during shift-change counts, and that all controlled medication records were expected to be accurate and regularly reconciled.
Failure to Hold Metoprolol When Blood Pressure Was Below Ordered Parameter
Penalty
Summary
The facility failed to follow a physician’s order for metoprolol for one resident reviewed for unnecessary medications. The order, printed on 03/19/2026, directed that metoprolol be given once daily and held if the resident’s systolic blood pressure was less than 110. Review of the March 2025 through March 2026 MAR showed that metoprolol was administered on multiple occasions when the resident’s systolic blood pressure was below that parameter, including readings of 108, 106, 108, 108, 108, 102, and 103. During a joint record review and interview on 03/22/2026, an LPN stated that blood pressure medication parameters should be followed and that medication should be held when blood pressures were outside parameters. The LPN acknowledged that metoprolol was given when it should have been held. The DON later stated that staff were expected to follow physician orders and blood pressure parameters, recheck, and notify the provider, and stated that metoprolol should have been held on the dates when the resident’s systolic blood pressure was below 110.
Improper Storage and Altered Manufacturer Instructions for Lorazepam
Penalty
Summary
The facility failed to ensure medication was stored in accordance with professional standards and manufacturer specifications for 1 of 2 medication carts reviewed, the East 2 Medication Cart. During observation, an unopened bottle of Lorazepam oral concentrate USP 2 mg/mL for Resident 76 was found stored at room temperature inside the cart, even though the manufacturer’s prescribing information stated the medication should be stored at cold temperature/refrigerated at 2 to 8 C and discarded 90 days after opening. Staff M, an LPN, stated the medication would require refrigeration after opening, then acknowledged the instructions did not say to store it in the fridge after opening and said they would need to consult a supervisor. The DON later stated the unopened bottle could be stored at room temperature for 90 days, then later said the pharmacist confirmed it could be stored at room temperature and discarded within 42 days. When the facility provided the manufacturer’s instructions, the version given to the surveyor contained an added statement that was not on the actual manufacturer document: “Once left at room temperature, discard within 42 days.” The DON stated they had printed the instructions from the manufacturer’s website and could not explain how the document was altered before it was provided.
Antibiotic Stewardship Program Not Consistently Followed
Penalty
Summary
The facility failed to consistently maintain its established Antibiotic Stewardship Program and did not consistently use standardized criteria, including Loeb Minimum Criteria, when evaluating residents for antibiotic treatment. The facility’s policy stated that the Antibiotic Stewardship Program was intended to promote appropriate antibiotic use and that residents would be assessed for infection using McGeer criteria. The infection control policy also stated that McGeer criteria were the nationally recognized surveillance criteria used to define infections. For Resident 63, the November 2025 MAR showed Macrobid was administered twice daily for five days for UTI. The infection surveillance document dated 11/06/2025 showed the resident had no indwelling catheter and had symptoms beginning on 11/05/2025. The form indicated two criteria 1 symptoms, dysuria and increased urinary urgency, but no qualified items were marked under criteria 2. The urine culture collected on 11/04/2025 did not meet McGeer criteria 2. During record review and interview, the DON stated that McGeer criteria were used for initiation of antibiotics, but also stated that for residents without an indwelling catheter, criteria 2 did not have to be met. For Resident 95, the February 2026 MAR showed nitrofurantoin was administered twice daily for five days for UTI. The infection surveillance document dated 02/17/2026 showed the resident had no indwelling catheter and had UTI symptoms beginning on 02/13/2026. The form listed four criteria 1 symptoms—dysuria, suprapubic pain, increased urinary urgency, and increased urinary frequency—but no qualified items under criteria 2. The urine culture from a clean catch specimen grew Enterobacter cloacae complex at 50,000 to 99,000 colony count, which did not meet the McGeer microbiologic criterion of more than 100,000 colony count. The DON stated that SBAR and Loeb’s criteria were not used because McGeer criteria had the same symptom check, and stated that McGeer criteria were used for starting antibiotics and for infection surveillance.
Failure to Provide Homelike Dining Environment
Penalty
Summary
The facility failed to provide a homelike environment for residents during meal times in the Second Floor Dining Room. Observations revealed that residents were served their meals on trays, which were not removed from the tables, contrary to the facility's policy that emphasizes a homelike environment. This practice was observed on multiple occasions, involving several residents who were assisted by staff members to eat directly from their trays. Interviews with staff members, including a Restorative Nurse Assistant and a Resident Care Manager, confirmed that the use of meal trays in the dining room was a standard practice. The staff indicated that this practice began during the COVID-19 pandemic and has continued since then. The Director of Nursing also confirmed that the current process involves serving meals on trays in the dining room, which deviates from the facility's policy of creating a homelike environment.
Medication Storage Deficiencies in Facility
Penalty
Summary
The facility failed to appropriately store drugs and biologicals in two medication storage rooms and one medication cart, which placed residents at risk for receiving compromised and ineffective medications. In the West 1 Medication Storage Room, an expired Aquacel Advantage wound dressing was found, and in the Second Floor Medication Room, several expired SafeDay IV administration sets were discovered. Staff members acknowledged the presence of expired supplies and stated that they should have been disposed of. In the East 1 Medication Cart, an unpackaged and unlabeled red capsule, identified as a prescription antibiotic, was found in the top drawer. Staff confirmed that prescription medications should be packaged and labeled, and the presence of the loose capsule was not expected. The facility's policy requires that all drugs and biologicals be stored in a safe, secure, and orderly manner, which was not adhered to in these instances.
Deficiency in Food Safety Practices
Penalty
Summary
The facility failed to adhere to professional standards of food safety, as evidenced by improper food labeling and handling practices. During an observation, two unopened bags of cereal in the dry storage room were found unlabeled, which was confirmed by the Nutritional Services Manager, Staff C. Staff C mentioned that the cereal would be labeled once placed in bins, but admitted to not labeling them when taken out of the box. Interviews with Staff K, a Dietary Aide, and Staff A, the Administrator, revealed an expectation for food items to be labeled, although this was not consistently practiced. Additionally, the facility did not ensure that food items were covered during meal tray delivery, which was observed on multiple occasions. Staff members, including CNAs and other personnel, were seen delivering trays with uncovered food items such as blueberries, peaches, strawberries, salad, and grapes. Interviews with various staff, including Staff K and Staff T, a Registered Dietician, indicated that food should be covered during transport, especially when walking down hallways. However, this practice was not consistently followed, as confirmed by observations and staff interviews.
Infection Control Deficiencies in PPE Use and Hand Hygiene
Penalty
Summary
The facility failed to adhere to Contact Precautions for a resident diagnosed with MRSA in the right hip, as observed when an Activities Assistant entered the resident's room without donning the required gown and gloves. Despite the presence of signage indicating the need for such precautions, the staff member did not comply, which was acknowledged during an interview. The Infection Preventionist and Director of Nursing both confirmed the expectation for staff to wear appropriate PPE when entering rooms of residents on contact precautions. Additionally, the facility did not ensure proper use of PPE and hand hygiene in the laundry room. A Housekeeping Staff member was observed sorting soiled laundry with a gown that was not properly tied, leading to contamination of their clothing. After removing their PPE, the staff member failed to perform hand hygiene before handling clean linens. Interviews with the Infection Preventionist and Director of Nursing confirmed the expectation for staff to perform hand hygiene after glove removal and to ensure gowns are securely tied during use.
Failure to Provide Bed Hold Notice to Resident
Penalty
Summary
The facility failed to provide a bed hold notice to a resident, identified as Resident 65, during their transfer to a hospital. According to the facility's policy, residents or their representatives should be informed in writing about the bed hold provision upon admission and again before a transfer to a hospital. In the case of an emergency transfer, the notice should be provided within 24 hours. However, there was no documentation in the electronic health record or nursing progress notes indicating that Resident 65 was offered a bed hold notice for their hospital transfer. Resident 65, who was their own financial responsible party, was not informed about the bed hold option. Instead, the facility contacted the resident's emergency contact by phone, as indicated by Staff L, who was responsible for issuing bed hold notices. Staff L initially claimed that the notice was provided in person but later corrected this to indicate it was done over the phone. Despite this, there was no evidence that Resident 65 was directly informed or given the opportunity to make an informed decision regarding the bed hold. The oversight resulted in Resident 65 returning to the facility to find their private room had been changed to a shared room, causing frustration and confusion. The resident expressed a desire to have been informed about the bed hold option to make an informed decision, including understanding any associated costs. The facility's administrator, Staff A, acknowledged that the expectation was for staff to first discuss the bed hold notice with the resident if they were their own responsible party, which did not occur in this instance.
Failure to Accurately Assess Resident Preferences
Penalty
Summary
The facility failed to accurately assess a resident's preferences for daily routines and activities, as required by the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual. The manual specifies that information regarding a resident's preferences should be obtained directly from the resident, or through family or significant other interviews if the resident cannot communicate. In this case, the facility did not conduct or attempt to conduct interviews with the family or significant others for a resident who was non-verbal and unable to communicate their preferences. The resident in question, who had a diagnosis of dementia, was admitted to the facility and had been discharged from hospice care services. The facility's Minimum Data Set (MDS) assessments for this resident showed that interviews for daily and activity preferences were not completed, and the sections were either coded as non-responsive or left dashed, indicating no information was gathered. Staff members involved in completing the MDS assessments confirmed that family interviews were not conducted, despite the expectation that they should have been. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing, revealed that the facility followed the RAI manual for coding accuracy but failed to adhere to the guidelines for conducting interviews with family members. The staff acknowledged that family interviews should have been completed to ensure accurate assessments of the resident's preferences, but these were not done, leading to incomplete and inaccurate MDS documentation.
Failure to Implement Activity Care Plan for Resident with Dementia
Penalty
Summary
The facility failed to implement the activity care plan for Resident 20, who was admitted with a diagnosis of dementia. The care plan, revised on 10/02/2024, included interventions such as offering in-room story time and frequent one-on-one visits. However, observations on multiple dates in December 2024 showed that Resident 20 did not receive these one-on-one in-room activities. Staff O, the Activities Supervisor, was unable to provide documentation of these activities in the resident's electronic health record (EHR) and admitted to discarding daily paper documentation. Further investigation revealed that Resident 20's EHR lacked documentation of one-on-one activity participation in various activities such as nail care, auditory stimulation, and family video calls over the last 30 days. Staff U, the Assistant Director of Nursing, confirmed that Resident 20 had been discharged from hospice services in August 2024, and there was an expectation for activity documentation when activities were provided. Staff D, the Resident Care Manager, acknowledged involvement in the care planning process but admitted that the care plan goal was not met due to the absence of documentation. The Administrator, Staff A, confirmed that there was no activity documentation for Resident 20 in the EHR and that the activity department was responsible for providing individualized activities. Staff A also stated that the MDS and care plans should support each other and that activities offered should be documented. The lack of documentation and implementation of the care plan interventions led to the deficiency, as the facility's policy required staff to implement the resident's individual care plan.
Failure to Revise Care Plans for Medication and Oxygen Administration
Penalty
Summary
The facility failed to revise comprehensive care plans for three residents, leading to potential risks for unmet care needs. For Resident 17, the care plan did not initially include the intervention to administer medications during meals, despite observations and staff interviews indicating that the resident was more compliant with medication intake during meal times. This intervention was only added to the care plan on December 16, 2024, after it was observed that the resident would spit out medications if not given with meals. Similarly, Resident 20's care plan lacked the intervention to administer medications during meals, even though staff noted that the resident, due to advanced dementia, was more likely to accept medications during meal times. This intervention was also added on December 16, 2024, after it was observed that the resident would refuse medications if not given with meals. Staff interviews confirmed that the care plans should have been updated earlier to reflect these needs. For Resident 6, there was a discrepancy between the care plan and the actual oxygen administration. The care plan indicated an oxygen setting of two to three liters continuously, but observations showed the resident self-administering five liters. Staff interviews revealed that the resident would increase the oxygen flow when frustrated, a behavior not documented in the care plan. The Director of Nursing acknowledged that the care plan should have been revised to match the physician's orders and the resident's behavior once it was known.
Medication Administration Errors and Lack of Provider Notification
Penalty
Summary
The facility failed to adhere to a physician's order for two residents, leading to medication administration errors. Resident 26 was prescribed oxycodone to be administered only when their pain level exceeded six out of ten. However, the medication was given on five out of eleven days when the resident's pain level was documented as less than six. This discrepancy was confirmed through interviews with the nursing staff, including a Registered Nurse and the Director of Nursing, who acknowledged that the physician's order was not followed as required. Resident 335, who was admitted with a diagnosis that included a closed fracture, refused their prescribed anticoagulant injection for seven consecutive days. Despite the refusals, there was no documentation indicating that the medical provider was notified of the resident's refusal, as required by facility policy. Interviews with nursing staff revealed a lack of awareness of the proper procedure for handling medication refusals, including the need to educate the resident and notify the provider. The Director of Nursing confirmed that providers should be notified after the first refusal, which did not occur in this case.
Failure to Implement Individualized Activity Program for Resident
Penalty
Summary
The facility failed to provide an individualized activity program for a resident, identified as Resident 20, who was reviewed for activities. Resident 20, who was admitted with a diagnosis of dementia, had been discharged from hospice care services and required a personalized activity plan to support their preferences and needs. The resident's care plan included interventions such as in-room story time and frequent one-on-one visits, with a goal to support end-of-life activities. However, observations over several days showed that the resident did not receive the planned one-on-one activities, and there was no documentation of such activities being provided. Interviews with facility staff revealed a lack of proper documentation and implementation of the resident's activity plan. The Activities Supervisor, Staff O, admitted to not knowing how to generate activity documentation from the electronic health record (EHR) and stated that daily paper documentation was discarded. A joint record review with the Assistant Director of Nursing, Staff U, confirmed the absence of activity documentation for Resident 20, despite the expectation that activities would be documented when provided. Additionally, the MDS Coordinator, Staff P, confirmed that family interviews were not conducted for the resident's significant change in status assessment, which was expected given the resident's inability to respond. The Director of Nursing, Staff B, and the Administrator, Staff A, acknowledged the lack of documentation and the failure to implement the resident's individualized care plan. The Administrator confirmed that the activity department was responsible for providing ongoing individualized activities and that the MDS and care plans should support each other. Despite these expectations, the facility did not document or provide the necessary activities for Resident 20, leading to a deficiency in meeting the resident's needs for activity pursuit and social engagement.
Failure to Implement Bowel Management Protocol
Penalty
Summary
The facility failed to implement a bowel management protocol for Resident 48, which is a deficiency in providing care according to professional standards. The facility's policy required accurate documentation of bowel movements for each resident per shift, and Resident 48's care plan included monitoring medications for constipation side effects and recording bowel movement patterns daily. However, documentation showed that Resident 48 did not have a bowel movement for multiple five-day periods in November and December 2024, and there was no record of any as-needed (PRN) medications being administered during these times. Interviews with staff revealed inconsistencies in following the bowel management protocol. Staff Z, an LPN, acknowledged that no PRN medications were given, and there was no documentation of abdominal assessments or physician notifications. Staff D, the Resident Care Manager, confirmed the lack of documentation and interventions for Resident 48 during the periods without bowel movements. The Director of Nursing, Staff B, stated that the protocol required PRN medication administration and documentation of assessments if a resident went three days without a bowel movement, which was not followed in this case.
Deficiencies in Respiratory Care and Equipment Storage
Penalty
Summary
The facility failed to provide respiratory care in accordance with accepted professional standards for three residents. Resident 6, diagnosed with Chronic Obstructive Pulmonary Disease (COPD), was observed receiving five liters of oxygen via nasal cannula, contrary to the physician's order of two liters per minute. Staff interviews revealed that Resident 6 sometimes increased the oxygen flow themselves, and there was a lack of documentation or care planning to address this behavior. The Director of Nursing was unaware of this behavior until informed by staff, indicating a communication gap regarding the resident's care needs. Resident 16, who was readmitted with pneumonia, had issues with the storage of their nebulizer mask. Observations showed that the nebulizer mask was not properly stored in a bag when not in use, as required by the facility's policy. Instead, it was found on top of a bedside table, covered by a white cloth and a book. Staff interviews confirmed that the nebulizer mask should have been stored in a bag to prevent contamination, but this practice was not followed. Resident 285, diagnosed with hypoxemia, had their nasal cannula improperly stored on a wheelchair cushion, and their portable oxygen tank was unsecured on a chair. Facility policy requires nasal cannulas to be stored in a plastic bag when not in use and portable oxygen tanks to be secured to a wheelchair or stored in the oxygen room. Staff interviews confirmed these storage practices were not adhered to, posing a risk of equipment contamination and safety hazards.
Inaccurate Medical Records and Diagnosis for a Resident
Penalty
Summary
The facility failed to ensure the accuracy of clinical records for a resident, which placed the resident at risk for unmet care needs and medical complications. The facility's policy on charting and documentation requires that medical records be objective, complete, and accurate. However, the Nursing Home Transfer or Discharge Notice form for the resident was inaccurately documented as being provided to the resident's daughter, despite the resident not having any children. The Director of Nursing acknowledged the error, stating that the notice should have been given to the resident or their power of attorney. Additionally, the resident's medical records inaccurately listed a diagnosis of paranoid schizophrenia, which was not supported by the resident's electronic health records or other medical documentation. Instead, the resident had an active diagnosis of bipolar disorder. The Social Services staff confirmed the discrepancy and acknowledged the error in the diagnosis. The Director of Nursing also confirmed that the diagnosis of paranoid schizophrenia was incorrect and should have been recorded as bipolar disorder.
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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