Shuksan Rehabilitation And Health Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Bellingham, Washington.
- Location
- 1530 James Street, Bellingham, Washington 98225
- CMS Provider Number
- 505098
- Inspections on file
- 37
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Shuksan Rehabilitation And Health Care during CMS and state inspections, most recent first.
Surveyors found that the facility’s use of a broad flex-time medication pass system led to multiple residents receiving APAP, levetiracetam, carvedilol, carbidopa-levodopa, and fosfomycin at times that did not comply with prescriber orders, manufacturer guidelines, or the facility’s own one-hour-before/after policy. One resident’s seizure and pain medications were repeatedly given late or at inconsistent intervals; another resident’s Parkinson’s medication was not coordinated with meals as ordered and APAP doses were given too close together; and a third resident’s APAP and carvedilol were scheduled and administered without regard to ordered meal timing, with some APAP doses only minutes apart and an antibiotic order left unclear between “evening” and “with breakfast.” Staff interviews showed reliance on wide flex-time windows, lack of clear documentation of exact administration times on the MAR, and inconsistent understanding of how to space BID and TID medications, contributing to the cited deficiency for pharmaceutical services.
Surveyors identified that the facility lacked an effective medication administration system, resulting in missed doses, poor adherence to provider orders, and failure to follow the facility’s stated ten rights of medication administration. One resident on prophylactic Fosfomycin Tromethamine for UTI prevention had a 20‑day gap between documented doses, with no evidence the scheduled intermediate dose was given. During observed med passes, an LPN did not check medication expiration dates, did not knock before entering rooms, failed to verify resident identity, misidentified or failed to identify medications when questioned by residents, and only told residents, “this is your medication.” Multiple nurses could not accurately state the ten rights of medication administration. MAR reviews for several residents showed no documentation that scheduled evening or HS medications, including psychotropics, cardiovascular agents, pain medications, bladder medications, glaucoma drops, antivirals, and blood sugar monitoring, were administered, while the DON who worked that shift believed the medications had been given.
Surveyors found that a treatment cart on one unit was left unlocked while an LPN was away at another medication cart, with open Derma Fungal cream, an odor eliminator, and other treatments easily accessible in its drawers despite facility policy requiring carts to remain locked. On another unit, an open tube of Refresh eye drops was left in a medication cup on top of a medication cart while an RN was several feet away at a different cart, after a resident had refused the drops. The Administrator and DON later acknowledged that carts should not be left unlocked and medications should not be left unattended on top of carts.
Staff failed to consistently follow infection control practices, including hand hygiene, PPE use, and cleaning of resident care equipment. An LPN prepared and administered medications to a resident without performing hand hygiene before or after handling medication cups, then documented and moved on to another resident still without hand hygiene. For a resident on precautions, the same LPN checked blood glucose, left the room wearing PPE, handled a glucometer and medication cart in the hallway, removed PPE there, and continued care activities without performing hand hygiene or disinfecting the glucometer or vital sign cart. The glucometer was returned to its storage bag and cart drawer without cleaning, despite manufacturer instructions and facility handouts requiring cleaning and hand hygiene as part of standard infection prevention procedures.
The facility did not conduct comprehensive investigations into allegations of abuse and neglect involving two residents—one who reported delayed pain medication and verbal mistreatment by a nurse, and another who experienced a prolonged wait for incontinence care due to caregiver availability. Key investigative steps, such as interviewing involved staff and reviewing medical records, were omitted, and the needs of other residents with similar care preferences were not assessed.
The facility did not include agency staff hours in its PBJ submission, resulting in a significant underreporting of total staffing hours and failure to meet the required HPRD for the quarter. This led to inaccurate staffing data being reported to CMS.
Facility administration did not ensure timely payment to vendors, leading to the discontinuation of laboratory services and missed critical lab tests for several residents, including drug level monitoring and metabolic testing. Staff confirmed that unpaid bills caused the service disruption, and there was no alternative lab available for the required tests. The facility also experienced delayed payroll, affecting staff benefits and care continuity.
Multiple residents did not receive timely or complete laboratory testing as ordered, including missed urinalysis, Hemoglobin A1C, Depakote levels, CBC, and CMP tests. These failures were linked to a disruption in lab services caused by vendor non-payment, with staff interviews confirming missed draws and lack of follow-up or documentation.
A resident admitted with multiple pressure ulcers and at moderate risk for further skin breakdown did not receive a pressure offloading mattress in a timely manner. The care plan initially lacked pressure ulcer prevention interventions, and a low air loss mattress was not provided until about a month after the need was identified. This delay led to the development of a preventable stage 3 pressure ulcer on the coccyx, requiring advanced wound care and impacting the resident's rehabilitation.
The Governing Body did not ensure timely payment of vendor invoices, leading to discontinued lab services, missed essential lab tests for several residents, and threats of utility disconnection. Staff reported missed payroll and loss of benefits, while administration confirmed ongoing financial difficulties and delayed payments to vendors.
The facility did not conduct complete investigations into incidents involving falls, potential abuse or neglect, and medication errors. In several cases, investigations lacked necessary witness statements, omitted key details about the events, and failed to determine root causes or whether care plans were followed. For example, a resident with dementia was found with a head injury, but the investigation was missing staff statements and details about care provided prior to the fall. Another resident experienced multiple falls without thorough review of environmental factors or staff actions. Additionally, a medication error involving duplicate orders was not fully investigated, with missing verification from the pharmacy and no assessment of system failures.
The facility did not ensure timely and accurate completion of PASRR assessments for several residents with mental health diagnoses, including missing preadmission screenings, failure to update assessments when residents' conditions changed, and incomplete documentation of relevant psychiatric conditions. Staff responsible for PASRRs expressed uncertainty about the process, and required Level II evaluations were not initiated when indicated.
Nine CNAs worked with expired OBRA verifications, and the facility did not have a process to ensure active OBRA status prior to employment or scheduling. The Business Office Manager and Administrator confirmed that staff with expired verifications had been working and that OBRA documentation was not obtained for agency staff.
Surveyors found that the facility did not ensure complete and accurate medical records for several residents, with multiple omissions in MARs and TARs, including missing documentation of medication administration, monitoring, and assessments. In one case, a resident's record retained an incorrect mental health diagnosis despite a PASRR evaluator's correction, and staff were unaware of the error or lacked documentation audits.
A resident with cognitive impairment who required supervision for toileting was found on the floor with a significant head laceration after being left unsupervised, in violation of their care plan. The incident, which involved substantial injury and was not witnessed, was not reported to the state hotline as required by facility policy and state guidelines. Staff interviews confirmed the expectation to report such injuries, but the event was not documented as reported.
Two residents receiving psychotropic medications did not have their care plans revised to include current symptoms, resident goals, or non-pharmacological interventions. The care plans only addressed medication administration and monitoring for adverse effects, omitting key individualized information required for effective care planning.
Nursing staff administered cardiac medications to several residents despite physician orders to hold these medications for low blood pressure or heart rate. Medication administration records showed repeated instances where Amlodipine and Metoprolol were given when vital signs were below the specified parameters. Staff interviews confirmed awareness of the hold parameters, but the medications were still administered inappropriately.
A resident with severe cognitive impairment and a history of UTIs did not consistently receive adequate fluids, with daily intake falling short of the estimated requirement. Fluids were often not available or out of reach, and staff did not consistently assist or document hydration, despite the resident's need for extensive help and observed signs of dehydration.
A resident with mild cognitive impairment repeatedly reported significant pain, especially in the gluteal area, during daily care and repositioning. Staff did not consistently assess pain before or after administering scheduled pain medication, and pain assessments were only performed weekly. The provider was not notified of increased pain, and physical findings included red areas and an open wound. Staff interviews confirmed that pain complaints were not always followed by proper assessment or provider notification.
Annual staff performance reviews were not completed or properly documented for a nursing assistant certified, with missing signatures, dates, and incomplete evaluation forms. Only one page of a two-page evaluation was available, and no additional documentation was provided.
A resident with osteoporosis received duplicate weekly doses of Alendronate due to two active orders for the same medication on different days. Both doses were documented as administered over several weeks, and staff were unaware of the duplication until it was identified during review. The facility's medication error investigation did not fully clarify whether the pharmacy supplied extra medication or resolve inconsistencies in staff accounts.
A resident with osteoporosis received duplicate doses of Alendronate due to a duplicate order, and the error was not identified by the facility's medication management system or during monthly pharmacist reviews. Additionally, the resident's ongoing use of Enoxaparin lacked a documented stop date or treatment clarification, and these issues were not addressed in pharmacy reviews.
A NAC did not receive all required training in dementia care, abuse/neglect, communication, QAPI, and annual education. Review of training records showed only partial completion, and staff interviews revealed a lack of tracking for agency NAC training and unclear responsibilities for monitoring education requirements. This issue was previously cited.
A staff member worked as a NAC without an active certification after their credential expired. Employment and timecard records confirmed the individual continued to provide care while uncertified, and the lapse was not identified due to a missed follow-up in the facility's license audit process. Leadership confirmed that all NACs are expected to maintain current certification.
A resident with Alzheimer's disease eloped from the facility due to inadequate supervision and failure to follow the facility's wandering risk policy. The resident's assessments initially showed no elopement risk, and their care plan was resolved without proper documentation. Staff interviews revealed a lack of awareness and communication regarding the resident's risk status and procedures, contributing to the incident.
The facility failed to maintain a safe, sanitary, and homelike environment, with issues such as loose wallboard, broken ceiling tiles, and overgrown outdoor spaces. Additionally, hot water availability problems prevented residents from receiving showers, with water temperatures recorded as low as 61.9°F.
The facility failed to provide adequate supervision and update the care plan for a resident identified as a high fall risk, resulting in 11 falls and multiple injuries. Despite the resident's medical conditions and history of falls, the facility did not implement new interventions after each fall, leading to recurrent incidents and injuries.
The facility failed to complete required annual performance evaluations for three CNAs who had been employed for more than one year. This deficiency was confirmed during an interview with the Administrator, who acknowledged that the evaluations were not conducted, placing residents at risk for diminished quality of care.
The facility failed to maintain sanitary conditions in the kitchen, including issues with hot water supply, improper cooling of foods, and lapses in hand hygiene practices. These deficiencies placed residents at risk for foodborne illnesses.
The facility failed to ensure that three CNAs had the required 12 hours per year of in-service education and annual dementia training. The administrator acknowledged challenges in retrieving older training records and admitted that dementia training had not been conducted for a while, with no tracking of the required education hours.
The facility failed to honor a resident's choice regarding bathing frequency, resulting in the resident being bathed less often than desired. Documentation and staff interviews revealed a lack of follow-up when the resident refused a bath, and the resident reported missing a shower due to no hot water.
The facility failed to follow the PASRR process for two residents, resulting in incomplete documentation and unimplemented recommendations for their care. One resident's Level II PASRR report was not incorporated into their medical record, while another resident's Level II PASRR evaluation was not completed due to an administrative error.
The facility failed to fully develop baseline care plans and provide written summaries for three residents, leading to incomplete documentation on critical health information and potential unmet care needs. The residents had various diagnoses, including fractures, Alzheimer's, diabetes, hypertension, bipolar disorder, and schizoaffective disorder, but their care plans lacked essential details.
The facility failed to develop and implement a comprehensive care plan for a resident who required daily weights. Despite an order for daily weights, only one weight was documented from admission to over a month later. An LPN admitted to not always receiving or reviewing discharge summaries and did not notify the physician of the resident's refusals to be weighed. This issue was a repeat citation from previous surveys.
The facility failed to ensure the cleanliness of respiratory care tubing for three residents, leading to the use of potentially soiled equipment. Staff interviews confirmed the absence of specific orders and documentation for changing or cleaning the equipment, and the tubing was not dated.
The facility failed to ensure a resident was free from unnecessary psychotropic medications by not obtaining consent for an antianxiety medication and not conducting gradual dose reductions for antipsychotic and antidepressant medications. Despite staff indicating processes for audits and consents, the facility did not follow through, resulting in a repeat citation.
The facility failed to store medications in a safe place for a resident who had Lantus and Humalog insulin pens stored in their room. The insulins were observed on the resident's windowsill, and the DON was unable to explain why they were stored there. This placed residents at risk for compromised or ineffective medications and unintended access to drugs.
The facility failed to ensure complete and accurate clinical records for a resident with skin conditions. The resident, who was on a blood thinner medication, had bruising that was not documented in weekly skin assessments or monitored correctly in the Treatment Administration Record. Staff interviews confirmed the documentation lapses.
The facility failed to use adequate infection control practices during wound and incontinent care for a resident. Staff did not change gloves or perform necessary hand hygiene, leading to contamination of the resident's bedding, clothing, and light pull cord. This incident is a repeat citation from previous surveys.
Failure to Administer Medications per Orders and Standards Under Flex-Time System
Penalty
Summary
The deficiency involves the facility’s failure to consistently provide pharmaceutical services that ensured medications were acquired, scheduled, and administered in accordance with prescriber orders, manufacturer guidelines, and the facility’s own policies. The facility’s “Medication and Flexible Pass Time” policy allowed broad administration windows (AM 6:00–11:00, noon 11:00–2:00, evening 2:00–7:00, HS 7:00–10:00) and defined routine medications as time-specific orders that could be given one hour before or after the scheduled time. Surveyors found that, in practice, medications were not administered within these parameters and were not consistently spaced according to general medication guidelines. Staff interviews showed that nurses relied on the flex-time windows and did not always know or document the exact administration times on the MAR, requiring separate reports to determine when doses were actually given. For one resident receiving acetaminophen (APAP) 1000 mg three times daily for pain and levetiracetam 1000 mg twice daily for seizures, the MAR showed APAP scheduled at AM flex pass, 11:00, and 8:00 p.m., and levetiracetam at AM flex pass and 4:00 p.m. The Medication Administration Audit Report (MAAR) documented multiple late or irregular doses. On several dates, the 11:00 APAP dose was given significantly late (e.g., at 1:41 p.m. and 1:34 p.m.), outside the one-hour window after the scheduled time. Levetiracetam doses were also given late or too close together, including a 4:00 p.m. dose administered at 8:46 p.m. and another day when the two daily doses were only five hours and 24 minutes apart, deviating from consistent interval guidelines. For a second resident receiving APAP three times daily and multiple daily doses of carbidopa-levodopa for Parkinson’s disease, the MAAR showed that carbidopa-levodopa was not administered in accordance with orders specifying dosing one hour before breakfast and one hour before or after meals. Morning doses ordered one hour before breakfast were given around 5:00 a.m., while breakfast was served between 7:50 and 8:00 a.m. Midday doses ordered one hour before or after lunch were administered approximately one hour before the scheduled lunch time, and an afternoon dose scheduled at 3:30 p.m. was set two hours before dinner, contrary to the order to give one hour before or after the meal. Evening doses ordered one hour before or after a meal were given at various times not clearly aligned with meal times. This resident’s APAP doses were also administered with very short intervals between the morning and 11:00 doses, sometimes less than three hours apart. For a third resident receiving APAP 1000 mg three times daily and carvedilol 6.25 mg twice daily ordered after meals, the MAR scheduled APAP at AM flex pass, 11:00, and 8:00 p.m., and carvedilol at AM flex pass and 4:00 p.m., without aligning carvedilol with meals as ordered. The MAAR showed instances where APAP doses were given late or too close together, including one day when the AM dose was given at 11:32 and the 11:00 dose at 11:59, resulting in 2000 mg of APAP administered 27 minutes apart. Carvedilol doses were also given late relative to the scheduled times. Additionally, this resident had an order for fosfomycin tromethamine “every 10 days in the evening…give with breakfast,” but the MAR scheduled it at 4:00 p.m., and there was no documentation in the EMR clarifying whether it should be given in the evening or with breakfast. During interview, the DON acknowledged the order was written in a confusing manner and would need clarification, and also recognized that the MAR did not show exact administration times, which could only be determined by running a separate report. Staff interviews further demonstrated inconsistent understanding and application of flex-time and dosing intervals. LPNs and an RN stated that AM flex time allowed administration between 6:00 and 11:00 a.m. and that for twice-daily or three-times-daily medications they would “spread out” doses as best they could, but they did not reference specific intervals or manufacturer guidelines. When asked how nurses would know the exact time a flex-time dose was given before administering the next scheduled dose, the DON initially stated it was documented on the MAR, then acknowledged that the MAR did not show exact times and that a separate report was needed. The survey report states that these failures to administer drugs and biologicals per physician orders and standards of nursing practice placed residents at risk for medication errors, unmet health care needs, and decreased quality of life.
Widespread Medication Administration Errors and Omissions
Penalty
Summary
The deficiency involves the facility’s failure to maintain a functioning medication administration system that ensured medications were given according to provider orders, not omitted, and administered in accordance with the facility’s stated ten rights of medication administration. The facility’s policy on medication pass required all morning medications to be administered between 6:00 AM and 11:00 AM and referenced ten rights to medication administration, but did not define what those ten rights were. The facility’s policy on medication incidents and errors defined an omission as any dose of medication not delivered to the resident. For one resident receiving Fosfomycin Tromethamine 10 grams every 10 days for UTI prophylaxis, the MAR showed doses given on 02/10/2026 and 03/02/2026, with a code on 02/20/2026 directing staff to see the nurse’s notes. The nurse’s note documented a call to the pharmacy about the medication and that the pharmacy would send as much as insurance allowed, but there was no evidence the 02/20/2026 dose was administered, resulting in a 20‑day gap between doses. The administrator and DON were not aware of this omitted dose. During a continuous medication pass observation, an LPN prepared six morning medications for another resident, including duloxetine, Tylenol, thyroid medication, a stimulant laxative, a gout medication, and a medication for an autoimmune disease. The LPN separated the duloxetine into one cup and the remaining medications into another, did not check expiration dates, entered the resident’s room without knocking, did not verify the resident’s identity, and addressed the resident only by first name. When the resident asked what the first cup of medications contained, the LPN first stated it was duloxetine and Tylenol, then, after the resident did not understand and asked again, stated it was Tylenol; the resident then took the two pills. When handing the second cup, the LPN again told the resident it was Tylenol when asked what the medications were. In a subsequent observation with a different resident, the same LPN took an acidophilus capsule from a house‑supply bottle without checking the expiration date, admitted they did not check expiration dates because the cart was filled at the beginning of the year, and then prepared additional medications. The LPN entered the resident’s room without knocking, did not verify the resident’s name, administered medications one by one with a spoon, and each time only stated, “this is your medication,” without identifying the medication name or purpose. Interviews with multiple nursing staff showed they could not correctly state the facility’s ten rights of medication administration, each listing only five or six rights, and the DON stated they would have to follow up on what the ten rights were. Review of MARs for several residents showed no documentation that scheduled 8:00 PM or HS medications were administered on 03/15/2026. One resident had no documentation of receiving a cholesterol‑lowering medication, a pain medication, and a probiotic; another had no documentation of an anti‑anxiety medication and an overactive bladder medication; another had no documentation of a cholesterol‑lowering medication, stimulant laxative, antipsychotic, and blood pressure medication; another had no documentation of an antiviral, glaucoma eye drops, a cholesterol‑lowering medication, and a nerve pain medication; and another had no documentation of an overactive bladder medication or blood sugar monitoring. When interviewed, the administrator and DON initially stated there had been no medication errors since surveyors arrived, and the DON, who passed medications on the PM shift on 03/15/2026, believed they had administered the HS and/or 8:00 PM medications. They were informed that the sampled residents’ MARs showed omitted medications and that only a small sample of residents on that hallway had been reviewed.
Unlocked Treatment Cart and Unattended Medications on Medication Cart
Penalty
Summary
The deficiency involves failure to keep medication and treatment carts locked and medications properly stored and labeled as required by facility policy and professional standards. The facility’s policy titled “Medication and Flexible Pass Time,” dated 10/27/2023, required that medication carts be locked at all times. On the morning of 03/16/2026, surveyors observed the [NAME] Lane treatment cart unlocked on two separate occasions while the responsible nurse, an LPN identified as Staff D, was down the hallway at a different medication cart. During this time, unidentified staff were seen walking past the unlocked cart on their way to the dining room. When informed, Staff D acknowledged responsibility for the cart and confirmed it should have been locked, stating that the prior shift, which ended at 6:00 AM, must not have locked it. Upon inspection of the unlocked [NAME] Lane treatment cart with Staff D, surveyors found an open tube of Derma Fungal cream and a bottle of simple odor eliminator in the top drawer, both labeled under their warning sections to be kept out of reach of children, along with other drawers containing various treatments, ointments, and creams that could be easily removed. Additionally, on the Artist Lane medication cart, surveyors observed a small open tube of Refresh eye drops placed in a plastic medication cup on top of the cart while the assigned RN (Staff C) was approximately 10 feet away at another medication cart preparing medications. Staff B later acknowledged that the eye drops should not have been left there and that the resident had refused the drops. In separate interviews, the Administrator (Staff A) and the DON/RN (Staff B) both stated that treatment and medication carts should not be left unlocked and that medications should not be left unattended on top of the cart.
Failure to Follow Hand Hygiene, PPE, and Glucometer/Vital Sign Equipment Cleaning Protocols
Penalty
Summary
The deficiency involves the facility’s failure to follow standard infection prevention and control practices, including hand hygiene, PPE use, and cleaning of resident care equipment such as vital sign (VS) equipment and a glucometer. Facility handouts from the Infection Prevention Manual for Long Term Care, revised 02/2018, directed staff to perform hand hygiene as part of donning PPE and to remove PPE at the doorway before leaving a resident’s room, followed immediately by hand hygiene. Despite these written procedures, staff actions during medication administration and resident care did not align with these guidelines. During continuous observation, one LPN prepared medications for a resident without performing hand hygiene, placing multiple pills into small plastic medication cups and handling the cups in the palm of unclean hands before entering the resident’s room. After the resident ingested the medications, the LPN discarded the cups, exited the room, returned to the medication cart, documented medication administration, and proceeded to another resident’s room without performing hand hygiene. Later, the same LPN was observed to perform hand hygiene before entering another resident’s room, but then inconsistently applied hand hygiene practices before and after subsequent resident care tasks. For a resident on precautions requiring gown and gloves for high-contact care, the LPN performed a blood glucose check, exited the room wearing PPE, walked down the hall, discarded an item in the sharps container, placed the glucometer on top of the medication cart, removed gown and gloves in the hallway, and returned to the cart without performing hand hygiene. The LPN then re-gowned and re-gloved without hand hygiene, entered the resident’s room with the VS cart, and later exited with PPE still on, parked the VS cart by the medication cart, removed PPE at a hallway trash can, and began preparing the resident’s medications without hand hygiene or sanitizing the VS cart or its components. The glucometer, which manufacturer guidelines required to be cleaned with soap and water or 70–80% isopropyl alcohol after use, was placed on the medication cart, then returned to its storage bag and cart drawer without being cleaned. The LPN acknowledged they were supposed to clean the glucometer with an alcohol pad after use but did not do so. Additionally, the administrator noted the lack of trash cans inside rooms of residents on precautions and stated this was unusual.
Failure to Conduct Thorough Abuse and Neglect Investigations
Penalty
Summary
The facility failed to conduct thorough investigations into allegations of abuse and neglect for two residents. For one resident with multiple sclerosis and anxiety, who was cognitively intact and experienced constant pain, the facility did not fully investigate an allegation that a nurse withheld pain medication and made derogatory comments. The investigation did not include a review of the resident's medical record to confirm medication administration times, nor did it include an interview with the nurse involved or with other residents regarding their experiences with medication administration or verbal abuse. The investigation summary instead focused on the resident's history of making allegations and ruled out abuse and neglect without substantiating the facts. For another resident with demyelination of the central nervous system, anxiety, and depression, who was dependent on staff for toileting and preferred female caregivers, the facility did not thoroughly investigate an allegation of neglect after the resident waited over an hour and a half for incontinence care. The investigation acknowledged the delay but did not identify it as potential neglect, nor did it assess whether other residents with similar care preferences were at risk. The investigation also failed to interview another resident who preferred female caregivers to determine if their needs were unmet. Interviews with facility leadership revealed a lack of awareness regarding key documentation and investigative steps, such as not reviewing relevant progress notes or interviewing involved staff. The Director of Nursing confirmed that essential investigative actions were omitted, including not checking medication administration times and not interviewing other potentially affected residents. The facility's investigations did not meet the minimum requirements outlined in their own abuse prevention policy, which mandates interviews with alleged perpetrators and thorough record reviews.
Failure to Accurately Report Staffing Hours in PBJ Submission
Penalty
Summary
The facility failed to ensure accurate submission of Payroll Based Journal (PBJ) data to CMS for Fiscal Year Quarter 4, 2024. The PBJ report submitted included only hours worked by facility-employed staff and omitted hours worked by agency or contracted staff, resulting in 28,907.80 hours unaccounted for in the report. This omission led to the facility not meeting the minimum required 3.4 Hours Per Resident Day (HPRD) and being short by 920 hours. The process for PBJ reporting involved the corporate office preparing the report, sending it to the administrator for review and approval, and then submitting it, but the failure to include agency staff hours was confirmed by the Chief Operating Officer. The inaccurate data submitted to CMS affected the reported staffing levels for the entire facility.
Failure to Maintain Financial Obligations Resulting in Disruption of Essential Resident Services
Penalty
Summary
Facility administration failed to maintain effective financial management, resulting in overdue payments to multiple vendors, including laboratory services, utilities, staffing agencies, and medical supply companies. The administration was aware of the outstanding balances and received multiple demand notices and service discontinuation warnings from vendors. Despite this awareness, the facility did not ensure timely payment, leading to a disruption in essential services. On a specific date, the laboratory services provider placed the facility on a non-payment hold, which resulted in the discontinuation of laboratory services. As a direct consequence, four residents did not receive critical laboratory tests as ordered. These included Depakote levels for two residents, which are necessary to monitor therapeutic drug levels and prevent toxicity, a Comprehensive Metabolic Panel and Complete Blood Count for another resident, and a Hemoglobin A1C test for a fourth resident. Staff interviews confirmed that the missed laboratory services were due to the vendor not coming to the facility because of unpaid bills, and there was no alternative laboratory available for these tests. Additionally, staff reported that the facility had experienced a delayed payroll, resulting in a temporary loss of staff benefits and out-of-pocket expenses for medical needs. The business office manager and administrator both indicated that invoices were forwarded to the corporate office for payment, but payments were not made in a timely manner. The failure to pay vendors on time directly impacted the facility's ability to provide necessary care and services to all residents, as evidenced by the missed laboratory tests and the risk of further service interruptions.
Removal Plan
- Ensured resident lab testing had been completed.
- Ensured an active laboratory services vendor was in place.
- Provided evidence of vendor contract payments to ensure continuity of essential services.
- Audited resident laboratory orders.
- Obtained ordered laboratory testing for affected residents.
Failure to Provide Timely Laboratory Services Due to Vendor Non-Payment
Penalty
Summary
The facility failed to provide timely laboratory services for five residents, resulting in missed or delayed lab tests as ordered by physicians. For one resident, a urinalysis was ordered to rule out a urinary tract infection due to new delusions and hallucinations, but the sample was not collected, and there was no documentation of follow-up or physician notification regarding the missed test. Another resident did not have a Hemoglobin A1C test completed as ordered, with no documentation in the medical record or treatment administration record indicating the lab was drawn or any result received. Two residents receiving Depakote for mood and behavioral management did not have their Depakote levels drawn as ordered. The orders specified that the Depakote level should be drawn on the night shift, but the tests were not completed on the specified dates. In one case, the Depakote level was eventually obtained two days after the order, and the result was reported as low. Additionally, a complete metabolic panel (CMP) was ordered for one of these residents but was not documented as completed. Another resident with a history of diabetes had an order for a Hemoglobin A1C, but there was no evidence the test was performed or results obtained. A further resident with a recent toe amputation and gangrenous tissue was to have a CBC and CMP drawn for ongoing monitoring, but these labs were not collected as ordered. Instead, a basic metabolic panel (BMP) was drawn several days after the order, and there was no documentation that the correct labs were obtained. Staff interviews confirmed that the facility experienced issues with laboratory services due to vendor non-payment, resulting in missed lab draws and lack of follow-up or documentation regarding the missed tests.
Failure to Timely Provide Pressure Offloading Mattress Resulting in Stage 3 Pressure Ulcer
Penalty
Summary
A facility failed to ensure timely ordering and implementation of a pressure offloading mattress for a resident who was at moderate risk for pressure ulcer (PU) development and admitted with existing wounds. Upon admission, the resident had stage 2 PUs on the right and left buttocks and an unstageable PU on the left foot, but no skin breakdown on the coccyx. The initial care plan did not address existing pressure ulcers or include prevention interventions, and there was no documentation of a higher-level mattress being provided at admission. Despite the resident's risk factors and care needs, the care plan was not updated to include pressure ulcer prevention interventions until a week after admission, when a slit was first noted on the coccyx. The resident developed a stage 3 PU on the coccyx, which progressed to require wound vacuum treatment. Documentation showed inconsistent wound assessments and delayed implementation of a low air loss (LAL) mattress, which was not provided until approximately 30 days after the need was identified and the RCM was notified. Interviews with staff confirmed that there was no standard protocol for pressure ulcer prevention interventions upon admission, and staff were unclear about the process for ordering specialty mattresses. The delay in providing appropriate pressure relief measures contributed to the development and worsening of the resident's coccyx wound, which impacted the resident's rehabilitation and discharge potential.
Governing Body Failed to Maintain Financial Oversight, Resulting in Discontinued Lab Services and Missed Resident Care
Penalty
Summary
The facility's Governing Body failed to maintain oversight of the facility's finances, resulting in significant unpaid balances to multiple vendors, including laboratory services, utilities, staffing agencies, and medical supply companies. The Governing Body was aware of overdue payments and notices for discontinuation of services but did not ensure that these financial obligations were met. As a result, the laboratory services provider discontinued services due to non-payment, and other vendors issued urgent notices threatening to cease services or disconnect utilities. Due to the discontinuation of laboratory services, necessary lab tests for several residents were not obtained as ordered. Specifically, residents who required Depakote levels, comprehensive metabolic panels, complete blood counts, and hemoglobin A1C tests did not receive these services. Staff confirmed that the laboratory did not come to the facility as scheduled, and there was no documentation explaining the missed lab draws. Additionally, staff were not aware if providers had been notified about the missed labs, and alternative laboratory options were limited. Interviews with facility staff and administration revealed that invoices were processed and sent to the corporate office for payment, but payments were delayed or not made, leading to daily calls from vendors regarding overdue balances. Payroll was also delayed on one occasion, resulting in staff temporarily losing benefits and having to pay out of pocket for medical expenses. The facility was also behind on required Safety Net Assessment payments, which had been referred for collection, further impacting cash flow and the ability to pay vendors.
Failure to Conduct Thorough Investigations of Incidents and Medication Errors
Penalty
Summary
The facility failed to conduct thorough investigations into incidents involving accidents, potential abuse, neglect, and medication errors for several residents. In multiple cases, investigations lacked comprehensive documentation, including missing or incomplete witness statements, insufficient details about the circumstances of the incidents, and failure to determine the root cause or contributing factors. For example, after a resident with Alzheimer's dementia was found on the floor with a head injury, the investigation did not include statements from the assigned nursing assistant, lacked information on the resident's care prior to the fall, and omitted a summary of the incident's cause or necessary corrective actions. Additionally, post-fall monitoring was incomplete, and the incident was reported late to the state. Another resident with multiple sclerosis and severe cognitive impairment experienced multiple falls, yet investigations did not include statements from all relevant staff, failed to assess environmental or equipment factors, and did not address whether care plan interventions were implemented. In one case, a resident was found on the floor after their wheelchair rolled back during a haircut, but the investigation did not review the wheelchair's condition or the environment. In another, a resident with significant cognitive impairment was found on the floor in the dining room, but the investigation did not address positioning or follow-up care. The facility also failed to thoroughly investigate a medication error involving duplicate orders for Alendronate, resulting in the resident potentially receiving double doses. The investigation did not verify the number of tablets dispensed by the pharmacy, nor did it determine how the duplicate order was entered without system or pharmacy alerts. Across all incidents, there was a consistent lack of comprehensive review, failure to identify involved staff, and absence of summaries detailing the who, what, where, when, and how of each event, as well as missing documentation of whether care plans were followed.
Failure to Complete and Update PASRR Assessments as Required
Penalty
Summary
The facility failed to ensure that Pre-Admission Screening and Resident Review (PASRR) assessments were accurately completed prior to or upon admission, or updated when residents' conditions changed, for four out of five residents reviewed. Specifically, two residents were admitted without a Level I PASRR completed preadmission, with the assessments being performed only after admission. Another resident's PASRR did not accurately reflect all relevant diagnoses, such as psychotic or delusional disorders, and was not revised upon admission. Additionally, a resident who began experiencing hallucinations and delusions did not have their PASRR updated to reflect these significant changes in condition. Record reviews and staff interviews revealed that the social worker responsible for PASRR completion and accuracy was uncertain about the process and acknowledged errors in the documentation. One resident's PASRR indicated depression but did not trigger a required Level II evaluation, contrary to PASRR instructions. The administrator confirmed awareness of the requirement for preadmission Level I PASRRs but was unsure why they were not completed as required. These deficiencies were identified through observation, interview, and record review, and were in violation of the facility's own policy and state regulations.
Failure to Verify Active OBRA Status for CNAs
Penalty
Summary
The facility failed to ensure that nine Certified Nursing Assistants (CNAs) had active Omnibus Budget Reconciliation Act (OBRA) verifications at the time of their employment and while working in the facility. Employment records showed that one CNA was hired and worked with an expired OBRA verification, and a review of all facility staff revealed a total of nine staff members with expired OBRA verifications. The Business Office Manager acknowledged awareness of the expired OBRA status for at least one CNA and provided documentation showing the expiration. The manager also stated that OBRA verifications were only being updated as they expired and that there was no plan in place to update expired verifications prior to employment. Additionally, the facility did not have OBRA documentation for any agency staff. Interviews with facility staff confirmed that the identified CNAs with expired OBRA verifications had been scheduled and working in the facility. The Business Office Manager expressed uncertainty about how to address the expired verifications and indicated that staff would need to be removed from the schedule until their OBRA status could be verified as active. The Administrator confirmed that there had been a period when OBRA verifications were not processed in a timely manner, resulting in staff being taken off the schedule. The Administrator also stated that agency staff should have OBRA verifications and that CNAs without current OBRA documentation should not work until the issue is resolved.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete, accurate, and systematically organized medical records for several residents, as required by policy and regulatory standards. For three residents reviewed, there were multiple omissions in Medication Administration Records (MAR) and Treatment Administration Records (TAR), including missing documentation of medication administration, behavior and side effect monitoring, anti-coagulant bleeding monitoring, hours of sleep, weekly skin checks, and pain assessments. These omissions were noted across several months and shifts, making it unclear whether prescribed care and monitoring were provided as ordered by physicians. Additionally, for one resident, the facility did not follow up on a PASRR evaluator's identification of an erroneous diagnosis of bipolar disorder, which originated from a hospital record. The incorrect diagnosis remained in the resident's medical record, MAR, and care plan, despite the evaluator's findings. Interviews with staff revealed a lack of awareness regarding the documentation errors and the absence of ongoing documentation audits at the time of the survey.
Failure to Immediately Report Potential Neglect and Substantial Injury
Penalty
Summary
The facility failed to immediately report a potential case of neglect involving a resident with significant cognitive impairment who required supervision for toileting. The resident was found on the floor with a 2-inch laceration on the forehead, labored breathing, and signs of distress after being left unsupervised on the toilet, contrary to their care plan. The incident was unwitnessed, and the assigned nursing assistant did not provide the required supervision. The facility's investigation identified contributing factors such as poor lighting, confusion, drowsiness, impaired memory, and gait imbalance. The injury was substantial, occurring in an area not generally vulnerable to trauma. Despite facility policy and state guidelines requiring immediate reporting of suspected abuse, neglect, or substantial injuries to the state hotline, the incident was not documented as reported. Staff interviews confirmed the expectation to report such injuries, but the state reporting log did not reflect that the incident was reported as required. The failure to report the potential neglect and injury was identified during the survey and cited as a deficiency.
Failure to Revise Care Plans for Residents on Psychotropic Medications
Penalty
Summary
The facility failed to ensure that care plans were revised as required for two residents who were receiving psychotropic medications. For one resident with moderate dementia, depression, and anxiety, the care plan did not include the symptoms the resident was experiencing, resident goals, or non-pharmacological interventions, despite the use of anti-anxiety and antidepressant medications. The care plan only listed administering medication as ordered and monitoring for adverse effects. Similarly, another resident with major depressive disorder, who was experiencing hallucinations and delusions and was being treated with multiple antidepressants and an antipsychotic, had care plans that also lacked documentation of symptoms, resident goals, and non-pharmacological interventions. The deficiency was identified through interviews and record reviews, which showed that the care plans for both residents were not updated to reflect their current symptoms or needs, as required by the Resident Assessment Instrument (RAI) manual. The administrator acknowledged awareness of care planning issues and stated that work had begun to address them. The lack of comprehensive and updated care plans was found to have the potential to impact staff knowledge of resident needs.
Failure to Hold Cardiac Medications per Physician Orders
Penalty
Summary
The facility failed to follow physician orders and professional standards of care for medication management in three out of five residents reviewed. Specifically, nursing staff administered cardiac medications, including Amlodipine and Metoprolol, to residents despite physician orders to hold these medications if certain blood pressure (BP) or heart rate (HR) parameters were not met. For example, one resident with a history of atherosclerosis, prosthetic heart valve, hypertension, and hyperlipidemia received these medications on multiple occasions when their HR or diastolic BP was below the ordered threshold. Another resident with congestive heart failure, atherosclerotic heart disease, and a cardiac pacemaker was given Amlodipine when their systolic BP was below the ordered limit. A third resident with hypertension also received Amlodipine when their BP or HR was below the specified parameters. Interviews with nursing staff confirmed that they were aware of the need to check vital signs and hold medications per parameters, yet the medication administration records (MARs) showed repeated instances where medications were given despite abnormal vital signs. The administrator also confirmed the expectation that medications should be held according to the parameters set by the physician orders. These findings were based on record reviews and staff interviews, and reference was made to WAC: 388-97-1060 (1).
Failure to Ensure Adequate Hydration for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that a resident with severe vascular dementia and a history of UTIs consistently received adequate fluids to meet their daily estimated needs of 1900 cc. Despite the resident's significant cognitive impairment and need for extensive assistance with eating, multiple observations over several days revealed that fluids were not consistently available at the bedside, and when present, were often out of reach. Documentation showed that the resident's daily fluid intake ranged from 336 cc to 1056 cc, never meeting the required amount. Family members expressed concern about the lack of fluids at the bedside during visits, and staff interviews confirmed that the resident rarely initiated drinking independently and required cues and hand-held assistance. Clinical records and care plans lacked specific documentation or interventions regarding hydration, aside from general encouragement for good nutrition and hydration. There were no recent laboratory assessments to monitor hydration status, and staff were not aware of any hydration concerns. Observations also noted physical signs of dehydration, such as a dry tongue. The administrator stated that the expectation was for nursing to provide water regularly and for dietary to supplement fluids as needed, but these practices were not consistently implemented or documented for this resident.
Failure to Provide Effective Pain Management and Timely Assessment
Penalty
Summary
A deficiency occurred when staff failed to adequately reassess, report, or provide effective pain management for a long-term resident who was mildly cognitively impaired. The facility's policy required staff to identify situations that increase pain, understand the rationale for pain medication, and document pain levels when pain increases. Despite this, the resident repeatedly expressed significant pain, particularly in the gluteal region, during routine activities such as repositioning and peri-care. Observations showed the resident attempting to reposition themselves, vocalizing pain, and reporting high pain scores, yet staff did not consistently assess or respond to these complaints as required. Interviews with staff revealed that pain assessments were only being conducted weekly rather than before and after medication administration, contrary to facility policy. The medical provider was not informed of the resident's increased pain, and pain assessments were not documented following administration of scheduled pain medication. Physical observations later revealed red areas and an open wound on the resident's buttocks, indicating ongoing discomfort and lack of effective pain management. Staff acknowledged that complaints of pain were not always followed by appropriate assessment or notification to the provider.
Failure to Complete and Document Annual Staff Performance Reviews
Penalty
Summary
The facility failed to complete annual staff performance reviews as required and did not provide education based on the outcomes of these reviews for one of five sampled staff members. Specifically, a nursing assistant certified (NAC) hired in December 2022 had an annual performance evaluation that was not dated or signed by either the evaluator or the staff member, and only one page of a two-page evaluation was available. No additional documentation was provided for this staff member's performance evaluation. During an interview, the administrator confirmed that evaluations had only recently been updated and were now being conducted on staff anniversary dates, but no further information was provided.
Duplicate Medication Orders and Administration Error
Penalty
Summary
The facility failed to ensure accurate pharmaceutical services for a resident with osteoporosis by allowing duplicate orders for Alendronate 70mg to be entered and administered. The resident had an original physician's order for Alendronate 70mg once weekly on Mondays at 5:00 AM, but a second, duplicate order was later entered for the same medication and dose to be given on Sundays at 7:00 AM. Medication Administration Records showed that both doses were signed as given on multiple consecutive weeks. Staff responsible for resident care were unaware of the duplicate order until it was brought to their attention, and there was an expectation that the system or pharmacy would catch such duplications. Additionally, the facility's medication error report did not thoroughly investigate whether the pharmacy supplied extra tablets or reconcile discrepancies in staff statements regarding the administration of the duplicate medication.
Failure to Prevent Duplicate Medication Orders and Ensure Accurate Pharmaceutical Review
Penalty
Summary
The facility failed to ensure that pharmaceutical services were provided in accordance with established procedures to guarantee accurate order entry, dispensing, and administration of medications for a resident with osteoporosis. Specifically, a duplicate order for Alendronate 70mg was entered, resulting in the resident receiving the medication twice weekly instead of once, as intended. Medication Administration Records confirmed that both doses were administered on consecutive Sundays and Mondays. This duplication error was not identified or addressed by the facility's medication management system or during the monthly consultant pharmacist review. Additionally, the resident had an active order for Enoxaparin, an injectable blood thinner, with no documented stop date or clarification of the treatment course. The consultant pharmacist's review did not address the duplicate Alendronate order or clarify the ongoing use of Enoxaparin, despite reviewing the resident's regimen monthly. Interviews with facility staff and the consultant pharmacist revealed an overreliance on the system to flag duplications and a lack of proactive review to identify and resolve medication order issues.
Failure to Ensure Required Training for Nursing Assistant Certified Staff
Penalty
Summary
The facility failed to ensure that one of five nursing assistant certified (NAC) staff received the required training in dementia care, abuse and neglect, communication, quality assurance performance improvement (QAPI), and the mandated 12-hour annual training. Review of the staff member's training record showed only a few completed documents related to abuse/neglect and care of the cognitively impaired, with no evidence of other required trainings. Interviews with facility staff revealed that there was no system in place to track the 12-hour education requirement for agency NACs, and responsibilities for tracking and providing training were unclear among staff. This deficiency was previously cited in a prior statement of deficiencies.
Failure to Ensure Nursing Assistant Maintained Active Certification
Penalty
Summary
The facility failed to ensure that a staff member working as a Nursing Assistant Certified (NAC) maintained an active professional certification. Review of the staff member's employment and certification records showed that their NAC certification had expired, yet they continued to work on multiple dates without a valid certification. The staff roster and timecard confirmed the staff member was scheduled and worked as an NAC during the period their certification was expired. The Business Office Manager acknowledged that although the staff member was hired with an active certification, there was a failure to follow up and verify the renewal of the certification, and the monthly license audit process had not been completed prior to discovering the lapse. The Interim Director of Nursing Services stated that all NACs are expected to have current certification.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide necessary supervision and services for a resident, resulting in an elopement incident. The resident, who had diagnoses including peripheral vascular disease, heart disease, and Alzheimer's disease, was found outside the facility by a neighbor. The facility's policy required residents to be assessed for wandering risk at admission, with specific interventions for those at increased risk. However, the resident's assessments initially determined they were not at risk for elopement, and their care plan for elopement risk was resolved without proper documentation or follow-up. Interviews with staff revealed a lack of awareness and communication regarding the resident's elopement risk and the facility's procedures. Staff members were unaware of the wander risk book and the resident's care plan updates. The Director of Nursing Services and the Clinical Regional Nurse did not ensure the resident had a wander guard, and there was confusion about the resident's risk status. This deficiency was a repeat issue from a previous survey, indicating ongoing problems with the facility's supervision and risk management processes.
Failure to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, sanitary, and homelike environment in both resident units and the outdoor space. Observations revealed multiple issues including loose wallboard, broken ceiling tiles, mismatched paint, large dark stains on floors, and gouges in the drywall in various rooms. Additionally, the courtyard was overgrown with grass and weeds, and cluttered with gardening supplies, which was visible from resident rooms. Interviews with residents confirmed their dissatisfaction with the state of the courtyard, and the administrator acknowledged the absence of a maintenance person and a gardener, indicating ongoing issues with facility upkeep. Furthermore, the facility experienced problems with hot water availability, impacting residents' ability to receive showers. One resident reported not receiving a shower due to the lack of hot water, and a nursing assistant confirmed that showers were not being provided at the time. Water temperature measurements in the facility kitchen showed significantly low temperatures, ranging from 61.9 to 97 degrees Fahrenheit. The administrator admitted that the hot water issue was still being addressed. This deficiency was noted as a repeat citation from a previous survey.
Failure to Prevent Recurrent Falls and Injuries
Penalty
Summary
The facility failed to provide adequate supervision, implement interventions, and update the care plan to prevent accidents and falls for Resident 31. Despite being identified as a high fall risk due to multiple medical conditions including chronic respiratory failure, severe protein calorie malnutrition, muscle wasting, metabolic encephalopathy, cognitive communication deficit, and dementia, the resident experienced 11 falls between December 2023 and April 2024. The facility's fall care plan, initiated on 09/13/2023, included interventions such as ensuring the call light was within reach, offering toileting after G-tube feedings, and placing a sign in the room to remind the resident to use the call light. However, these interventions were not consistently updated or effectively implemented following each fall incident, leading to recurrent falls and injuries for the resident. The facility's investigations into each fall incident revealed that no new interventions were implemented after the falls on 01/04/2024, 01/07/2024, 01/09/2024, 01/16/2024, 02/14/2024, 02/18/2024, 03/06/2024, 04/04/2024, 04/22/2024, and 04/24/2024. The resident continued to self-transfer and not use the call light, which were identified as contributing factors to the falls. Despite the resident sustaining injuries such as skin tears, bruising, and bumps to the head, the facility did not implement additional or alternative interventions to prevent further falls. Observations made on multiple dates in May 2024 showed that the resident's environment did not consistently include all planned interventions, such as a sign to remind the resident to use the call light. Interviews with facility staff, including the Licensed Practical Nurse/Resident Care Manager, the Director of Nursing Services, and the Corporate Nurse, confirmed that fall interventions were supposed to be added to the care plan and communicated during shift changes. However, the Director of Nursing Services admitted that no new interventions were initiated for any of the 11 falls because the resident chose to self-transfer. The Administrator also stated that the resident's multiple falls had not been reviewed during the facility's Quality Assurance and Performance Improvement (QAPI) meetings. This lack of consistent and effective intervention and care plan updates contributed to the resident's recurrent falls and injuries.
Failure to Complete Annual Performance Evaluations for CNAs
Penalty
Summary
The facility failed to complete required annual performance evaluations for three Certified Nursing Assistants (CNAs) who had been employed at the facility for more than one year. Specifically, Staff E, hired on 01/04/2013, Staff F, hired on 06/09/2020, and Staff G, hired on 12/06/2021, did not have annual performance reviews for the prior year in their employee files. This deficiency was confirmed during an interview with the Administrator on 05/14/2024, who acknowledged that the annual performance evaluations were not conducted. This failure to ensure staff members met yearly performance and competency requirements placed residents at risk for diminished quality of care.
Deficiencies in Food Storage, Preparation, and Hand Hygiene
Penalty
Summary
The facility failed to ensure food was stored, prepared, and served under sanitary conditions in the kitchen. The kitchen handwashing sink did not have hot water, with temperatures recorded as low as 60.1°F and fluctuating up to 97.4°F over several days. Staff Q, the Dietary Manager, acknowledged the issue and stated that repairmen were working on it. Additionally, there was no established process for cooling foods to be reused at a later meal, and foods were cooled at room temperature before being placed in the refrigerator without temperature checks to ensure safe cooling times. This lack of procedure was confirmed by Staff Q during an interview. Furthermore, Staff R, a Dietary Aide, was observed not performing hand hygiene when transitioning between the dirty and clean sides of the dishwashing process, and Staff S, another Dietary Aide, did not wash their hands after cleaning counters before plating food. Staff Q had to remind Staff S to wash their hands, highlighting a lapse in hand hygiene practices. These deficiencies in food storage, preparation, and hand hygiene practices placed residents at risk for foodborne illnesses. The observations and interviews revealed that the facility did not adhere to professional standards for food safety, as evidenced by the improper cooling of foods, inadequate handwashing facilities, and failure to perform hand hygiene during critical points in food handling. The ongoing issue with the hot water supply in the kitchen further exacerbated the risk, as it hindered proper sanitation practices. Staff interviews confirmed the lack of proper procedures and awareness regarding food safety protocols, contributing to the overall deficiency in maintaining sanitary conditions in the kitchen.
Deficiency in CNA Training and Education
Penalty
Summary
The facility failed to ensure that three of five Certified Nursing Assistants (CNAs) reviewed for training had the required 12 hours per year of in-service education and the required annual dementia training. Staff E, hired on 01/04/2013, did not have the required 12 hours of in-service education for the prior year. Staff F, hired on 06/09/2020, did not have the required 12 hours of in-service education or the required dementia training for the prior year. Staff G, hired on 12/06/2021, also did not have the required 12 hours of in-service education or the required dementia training for the prior year. The facility's administrator acknowledged challenges in retrieving older training records and admitted that dementia training had not been conducted for a while, and there was no tracking of the 12 hours of in-service education for all requested staff.
Failure to Honor Resident's Bathing Preferences
Penalty
Summary
The facility failed to honor a resident's choice regarding bathing frequency, specifically for Resident 21. Despite the resident's preference to bathe twice a week, documentation showed that the resident had only bathed three times in the last 30 days and had refused once. There was no documentation explaining the refusal or indicating that staff had re-approached the resident about the refusal, as required by the facility's policy. Interviews with the resident and staff confirmed that the resident was not being bathed as often as desired and that there was a lack of follow-up when the resident refused a bath. Additionally, the resident reported not receiving a shower on a specific day due to the unavailability of hot water. Staff interviews corroborated that the protocol for re-approaching residents who refuse a bath was not consistently followed. This failure to accommodate the resident's bathing preferences and to document and address refusals as per policy placed the resident at risk for unmet bathing needs and diminished quality of life.
Failure to Follow PASRR Process for Two Residents
Penalty
Summary
The facility failed to ensure the Preadmission Screening and Resident Review (PASRR) process was followed for two residents, leading to deficiencies in their care. Resident 37, who was admitted with bipolar disorder and schizoaffective disorder, had a Level II PASRR evaluation completed, but the full report was not incorporated into the resident's medical record or plan of care. This oversight was confirmed by the Social Services Director, who acknowledged that the PASRR Level II report had not been scanned into the record or its recommendations implemented. Similarly, Resident 8, admitted with major depressive disorder, anxiety disorder, and hypertension, was identified with Serious Mental Illness (SMI) indicators on admission. Although the Level I PASRR was forwarded for a Level II evaluation, there was no documentation in the resident's Electronic Medical Record (EMR) to show that the Level II PASRR had been completed. Staff members indicated that turnover in the social services department led to the completed Level II PASRR being sent to an invalid email, and an audit was being conducted to identify other residents with similar documentation issues.
Incomplete Baseline Care Plans for Three Residents
Penalty
Summary
The facility failed to fully develop a baseline care plan and provide a written summary of the baseline care plan information for three residents. Resident 15, who was admitted with diagnoses including a left femur fracture, Alzheimer's, diabetes, and hypertension, had an incomplete baseline care plan lacking information on pain, skin conditions, fall risk, bladder incontinence, nutrition, Alzheimer's/cognition, diabetes, and hypertension. Additionally, there was no documentation that a written summary of the baseline care plan was given to Resident 15 or their representative. Similarly, Resident 191, admitted with multiple fractures, Alzheimer's, dementia with agitation, aphasia, hypertension, and constipation, also had an incomplete baseline care plan missing details on pain, fall risk, skin conditions, nutrition, incontinence, constipation, Alzheimer's, communication, care refusals, behaviors, hypertension, and anti-depressant use. There was no documentation that a written summary of the baseline care plan was provided to Resident 191 or their representative. Resident 37, admitted with bipolar disorder and schizoaffective disorder, had a Level II PASRR evaluation pending, but the baseline care plan did not address this pending evaluation. The facility was using a checklist for baseline care plans, which included a social services section and PASRR information, but this had not been completed for Resident 37. Staff K, a Registered Nurse/Corporate Nurse, confirmed the use of the checklist but did not provide additional information for the residents in question. This failure placed the residents at risk of not being informed of their medications, dietary instructions, services, and treatments to be administered, or goals of care, potentially leading to unmet care needs.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for Resident 18, who was reviewed for nutrition. Resident 18 was admitted to the facility with an order for daily weights as per the hospital discharge summary dated 04/03/2024. However, from the date of admission to 05/15/2024, staff documented only one weight on the day of admission. Staff C, an LPN/Resident Care Manager, admitted in an interview that they do not always receive or review discharge summaries and assumed another nurse would handle it. Additionally, Staff C mentioned that Resident 18 had been refusing to be weighed but failed to notify the resident's physician of these refusals. This issue was a repeat citation from previous surveys dated 02/17/2023 and 06/21/2023, indicating a persistent problem in the facility's care planning process.
Failure to Maintain Clean Respiratory Equipment
Penalty
Summary
The facility failed to ensure the cleanliness of respiratory care tubing equipment for three residents, leading to the use of potentially soiled equipment. Resident 31, who had chronic respiratory failure and COPD, was observed multiple times using oxygen and nebulizer equipment that lacked documentation of regular cleaning or replacement. Staff interviews confirmed that there were no specific orders for changing or cleaning the equipment, and the tubing was not dated to indicate when it was last replaced. Similarly, Resident 33, with diagnoses including hypertensive heart disease and congestive heart failure, and Resident 141, with CHF, COPD, and respiratory failure, were also found to be using undated and potentially unclean respiratory equipment. Staff acknowledged the lack of orders and documentation for the maintenance of this equipment. The Director of Nursing admitted that the facility did not have a policy for the maintenance of oxygen and nebulizer equipment, further contributing to the deficiency.
Failure to Ensure Proper Consents and Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that Resident 8 was free from unnecessary psychotropic medications. Resident 8, who was readmitted with diagnoses including major depressive disorder, unspecified dementia with psychotic disturbance, anxiety disorder, and hypertension, was prescribed bupropion, quetiapine, and diazepam. However, the facility did not obtain consent for the use of the antianxiety medication and did not conduct gradual dose reductions (GDR) for the antipsychotic and antidepressant medications as required. The care plan indicated that a GDR was declined by the provider, but there was no documented history of GDR attempts or evidence of hallucinations in the resident's progress notes, despite the increase in quetiapine dosage at the request of the resident's representative to treat hallucinations. Interviews with staff revealed that there had been turnover in the social services department, leading to audits being initiated to review residents on psychotropic medications. The audit was reviewed in an interdisciplinary meeting to discuss potential GDRs, and monthly IDT meetings were planned to continue these reviews. Staff also indicated that the process for obtaining consents involved providing a consent form with medication risks to the resident or their representative, and the medication would not be administered until consent was obtained. Despite these processes, the facility failed to ensure proper consents and GDRs for Resident 8, resulting in a repeat citation from a previous survey.
Failure to Store Medications Safely
Penalty
Summary
The facility failed to store medications in a safe place for one resident, identified as Resident 18, who had medications stored in their room. During an observation and interview on May 9, 2024, it was noted that Lantus and Humalog insulin pens were being stored in a basin on Resident 18's windowsill. Resident 18 stated that the insulins had been there since the previous Friday. Later that day, the Director of Nursing Services was observed removing the insulins from the resident's room but was unable to provide any information on why the medications were being stored there. This failure placed residents at risk for receiving compromised or ineffective medications and for having unintended access to drugs that should have been securely stored.
Incomplete and Inaccurate Clinical Records for Resident with Skin Conditions
Penalty
Summary
The facility failed to ensure clinical records were complete and accurate for Resident 21, who was reviewed for skin conditions. Resident 21, who was cognitively intact and had a diagnosis of atrial fibrillation requiring a blood thinner medication, was observed on 05/09/2024 to have scattered bruising on their feet and lower legs in various stages of healing. However, the weekly skin assessments dated 05/04/2024 and 05/11/2024 did not document any bruising. Additionally, the Treatment Administration Record from 05/01/2024 through 05/14/2024 showed that staff were supposed to monitor for bruising three times a day and document negative (-) for no bruising and positive (+) for bruising, but the licensed staff had only documented check marks instead of the required symbols. In interviews conducted on 05/14/2024 and 05/15/2024, Resident 21 stated they did not recall how they got the bruises, and Staff C, a Licensed Practical Nurse/Resident Care Manager, acknowledged that the bruises should have been documented and monitored. Staff P, a Registered Nurse, was unable to provide further information regarding the use of check marks instead of the required symbols for monitoring adverse effects of the blood thinner medication. This failure to ensure complete and accurate clinical records placed residents at risk for unmet needs.
Inadequate Infection Control Practices During Resident Care
Penalty
Summary
The facility failed to use adequate infection control practices for Resident 18 during wound and incontinent care. Staff N, a Nursing Assistant Certified (NAC), was observed wiping the resident's groin and then, without changing gloves, wiping the resident's abdominal folds which had a rash. This action resulted in contamination of the resident's bedding, clothing, and the light pull cord. Additionally, during a wound dressing change, Staff N did not change gloves after cleaning the resident's groin and subsequently touched the resident's clean brief, gown, bedding, and call light pull cord with the same contaminated gloves. In an interview, Staff J, the RN/Infection Prevention and Control Nurse, confirmed that the staff did not follow proper procedures. Staff J mentioned that a recent inservice on pericare had been conducted, but acknowledged that more auditing, inservicing, and education were needed. This incident is a repeat citation from previous surveys conducted on 02/17/2023 and 12/13/2023.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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