Soundview Rehabilitation And Health Care Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Anacortes, Washington.
- Location
- 1105 27th Street, Anacortes, Washington 98221
- CMS Provider Number
- 505216
- Inspections on file
- 37
- Latest survey
- March 30, 2026
- Citations (last 12 mo.)
- 32
Citation history
Health deficiencies cited at Soundview Rehabilitation And Health Care Inc during CMS and state inspections, most recent first.
Care plans were not reviewed and revised for several residents after changes in condition and care needs. One resident’s plan was not updated after a fall, hip fracture, and surgery with a later high fall-risk assessment; another resident’s trauma-related plan lacked individualized interventions for PTSD triggers; a hospice resident’s plan omitted hospice contact/responsibility details and constipation interventions; a resident with a rapid decline after a fall was not updated to reflect dependent care needs; and a resident’s oral care plan did not reflect dental implants noted by the dental hygienist.
Insufficient staffing led to delayed call light response, missed restorative care, and inconsistent meal and medication delivery. Residents reported waiting 45 minutes to an hour for help, and one resident said call lights were not answered timely until surveyors were present. Staff described working double shifts, covering too many residents for med passes, late and cold meals, and restorative staff being pulled to the floor, while the DON acknowledged the need for more aides and possibly another nurse.
The facility failed to ensure the Dietary Manager met the required qualifications for the role. The position description required completion of a Dietary Manager course or maintenance of a Certified Dietary Manager license, but the DM had not completed the course and the Administrator was aware of this.
Failure to Follow Preplanned Menu: Staff did not follow the preplanned lunch menu, and the Dietary Manager said menu changes were not communicated to facility staff. During meal service, the scheduled dessert was found outside the safe zone and could not be served, so yogurt was substituted. A resident also asked about a baked roll listed on the menu, but the posted daily menu did not include it and no alternative was offered.
The facility failed to provide appetizing, palatable, and warm meals for multiple residents. Resident council minutes and resident interviews showed repeated complaints about cold food, inconsistent meal times, bland or overcooked items, too much chicken, and menu choices not being followed. Residents reported breakfast and lunch trays arriving cold or lukewarm, some meals being microwaved after delivery, and limited fresh fruit, vegetables, and dessert variety. One resident with pressure ulcers also reported being repeatedly served foods they disliked, despite documented preferences.
Meals were not consistently served within the posted timeframes, and breakfast trays were delayed on two hallways. Residents stated they were unaware of night snacks and staff did not offer them. Staff reported stretched-thin kitchen staffing, and observations showed breakfast carts still on the hallways well after the expected tray line time.
A nourishment refrigerator and freezer contained multiple opened, undated, expired, and moldy food items, along with dirty storage conditions and missing temperature documentation. Staff interviews showed confusion about who was responsible for storing staff food and monitoring refrigerator temperatures, with the dietary manager stating nursing handled logs and an RN stating overnight nurses completed oversight.
Staff failed to follow posted contact and transmission-based precautions for multiple residents, including entering rooms without the required gown and gloves and, in one case, without hand hygiene before removing a meal tray. Staff also did not disinfect blood glucose meters between resident uses as required by the device instructions and facility expectation, and an RN removed a soiled dressing from a resident with feces on it and then applied a clean dressing without removing gloves or performing hand hygiene.
Call Light System Not Audible in Resident Areas: The facility failed to keep the resident call light system audible in multiple areas, including Portage Hall and Ships Harbor Hall. Surveyors observed several resident call lights illuminated but not audible in the hallway, and staff confirmed the volume had been turned down, including on night shifts. The DON, Infection Preventionist, and Administrator were aware that staff had access to change the volume, and the issue was identified as a repeat deficiency.
Failure to provide privacy during resident care: A resident with cardiac disease, anxiety, depression, and cognitive impairment was exposed during wound and peri care with the privacy curtain only partly drawn and a roommate present. Another resident with pressure injury, surgical aftercare, anxiety, and depression was observed during wound dressing assessment with the blinds open and no privacy curtain, and a third resident with chronic venous insufficiency, weakness, chronic pain, and depression received incontinence care with the blinds open and privacy not protected.
Unsafe and poorly maintained resident areas were observed throughout the facility, including a shower room with stored items, missing shower equipment, loose bed rails in a resident room, a cable box hanging by cords from a wall-mounted TV, peeling floorboard molding, stained hallway carpets, and worn, torn furniture at the nurse's station. The DON, Regional Maintenance Director, NAC, and Administrator acknowledged several of these conditions, including unsecured bed rails, hanging cable boxes, and carpet replacement needs.
Failure to identify and address verbal/mental abuse occurred when a cognitively intact resident reported that a roommate was insulting them and their visitors and being mean to them. Staff knew the roommate had a history of yelling, cussing, and being verbally aggressive, but the incident record showed no interview with the resident at the time of the concern or room move, and social services only confirmed the resident still wanted to move rooms.
Unnecessary Antipsychotic Use for Resident with Dementia and Behaviors: A resident with dementia, depression, and severe cognitive impairment was given Seroquel for behaviors including yelling, screaming, hitting, grabbing, and increased confusion. The record lacked information about pre-admission behaviors and did not include personalized monitoring for psychosis, while staff noted the resident came from an ALF, believed they worked at the facility, and had also been found to have a UTI.
Failure to Report Alleged Resident-to-Resident Verbal Abuse: The facility did not report alleged verbal and mental abuse between roommates to the State Agency. Records and staff interviews showed a resident had been described as verbally aggressive, rude, belittling, and degrading toward roommates and visitors, and another resident reported being insulted by the roommate. The state reporting log showed no report of the resident-to-resident verbal altercations, and the incident report noted the room move occurred without interviews at the time of the event.
A resident with chronic venous insufficiency, weakness, chronic pain, and depression had an ADL care plan and Kardex directing 2-person assist for turning, repositioning, and personal/incontinent care to prevent rolling too close to the bed edge. During observation, an NAC provided the care alone before another NAC entered to help, and the DON stated staff were expected to follow the care plan and Kardex.
Failure to provide grooming and nail care was cited for several residents who needed staff assistance. A resident with hemiplegia reported not having toenails trimmed since admission, a resident with DM and neuropathy had repeated observations of long fingernails with debris despite weekly nail checks ordered by an LPN, and another resident with care plan instructions to keep fingernails short continued to have long nails with matter underneath. A resident with stroke-related deficits and cerebellar ataxia also had long, jagged fingernails while staff gave conflicting accounts of who was responsible for nail care.
The facility failed to coordinate ordered follow-up and wound care services for two residents. One resident with a fracture and UTI reported waiting for an ortho appt for days, while staff said the referral fax was not received and the appt was not scheduled until later, with the resident notified only shortly before the visit. Another resident with a pressure ulcer did not have the ordered alternating pressure mattress in place, and the wound vac was delayed after the wound clinic order; staff said they had trouble obtaining the device and did not document provider communications.
Failure to monitor and address significant weight loss. Two residents had documented nutritional risk and ongoing weight loss, but weights were not consistently obtained or reviewed, and the RD did not identify or add further interventions. One resident with orthopedic aftercare and UTI lost 11% in one month with low protein and albumin labs, while another resident with MI, HF, and depression lost 12.3% over 73 days despite a soft diet and supplemental shakes. Staff and the RD acknowledged the weight loss, but no additional nutritional assessments or interventions were identified.
The facility failed to provide respiratory care in accordance with physician orders for two residents. One resident with heart failure and a heart attack history had oxygen orders that were inconsistent and lacked clear titration parameters, while another resident with chronic respiratory failure, asthma, COPD, and ventilator dependence had incomplete Trilogy orders, no respiratory care plan, and observed oxygen tubing and Trilogy mask issues. Staff confirmed the missing order details and equipment care expectations.
Incomplete Dialysis Communication Documentation: The facility failed to ensure a resident with ESRD receiving hemodialysis had consistent, completed, and accurate post-dialysis communication forms. A review found multiple missing forms, and an LPN and the Resident Care Manager/LPN confirmed that the post-dialysis form should be completed when the resident returned from dialysis and documented in the EHR.
Medication administration errors exceeded the allowed rate when 3 of 26 observed doses were given late, resulting in an 11.54% error rate. An LPN administered Glargine insulin and other ordered meds after the scheduled time for two residents, and another resident received Doxazosin despite SBP being below the hold parameter. The DON stated the facility policy required meds to be given within an hour of when due, and the deficiency was identified as a repeat issue.
Medication administration errors occurred when one resident’s clonazepam dose was not documented in the MAR and another dose lacked required narcotic book documentation, including nurse signature and remaining tablet count. A second resident with dementia had conflicting Seroquel orders between a prior PRN regimen and a facility bedtime order, but the record did not show a documented order change from PRN to routine in the EHR.
Improper medication storage, labeling, and temperature monitoring were observed in the facility. An LPN left a medication cart unlocked and unattended, open Glargine insulin pens in the cart lacked open or discard dates, a pill identified as Senna was found on the floor, and a cart laptop displayed a resident's PHI while the cart was unsecured. Vaccine refrigerator temperatures were documented only once daily despite CDC guidance for more frequent monitoring.
The facility failed to obtain and honor individual bathing and showering preferences for several residents, including those with stroke-related weakness, dementia, multiple sclerosis, and other conditions. Assessments and care plans documented that residents required extensive or maximal assistance with bathing and that it was very important for them to choose the type of bath (shower, tub, bed bath, or sponge bath), yet shower records showed infrequent showers over extended periods. The DON reported that residents were bathed according to a fixed twice-weekly schedule based on room assignment, with missed or refused showers expected to be offered the next day, rather than based on individualized resident choices.
The facility failed to establish a bed rail policy and did not comprehensively assess, document, or monitor bed rail use for three residents. One resident with heart failure, a prior fall, and moderate cognitive impairment had conflicting documentation about the type of rail used, and was repeatedly observed with both upper rails raised despite being unable to explain or demonstrate their use, while staff reported the resident required two-person assistance in bed. Another resident with muscle weakness and post-stroke weakness had orders and a care plan for bilateral bedrails that did not specify upper or lower rails, and the resident was consistently observed with both upper rails raised. A third resident with dementia and total dependence for bed mobility had care plan and assessment discrepancies regarding quarter versus half rails, with only verbal consent and undocumented risk/benefit discussions, and was also repeatedly observed with both upper rails raised. Across all three cases, Enabler Assessments referenced explaining risks and benefits without detailing them or specifying rail configuration, and there was no evidence of ongoing reassessment or maintenance.
Surveyors found that the facility failed to complete required hospital transfer documentation and provide written bed-hold and appeal-rights notices for two residents sent to the ER. For both residents, Nursing Home Transfer or Discharge Notices were incomplete, lacking representative information, the receiving facility’s address, and a brief explanation for the transfer. In one case, progress notes and bed-hold forms reflected only verbal consent to hold the bed, with no evidence that written transfer/bed-hold notices were given at either hospitalization. In the other case, staff documented an unsuccessful attempt to reach a family member and the resident’s later readmission, but there was no bed-hold notification in the chart and no documentation that written transfer or bed-hold information was provided. Staff interviews indicated that both floor nurses and social services were responsible for ensuring these notices were completed and given to residents or their representatives as soon as possible.
The facility did not have a qualified dietary manager in place, and the individual temporarily filling the role lacked the necessary credentials. This left the food and nutrition services without proper oversight by a staff member with the required competencies.
Surveyors found that perishable foods, including dressings and cheese, were not properly refrigerated, and multiple food items such as bread and cookies were kept past their expiration dates in storage and pantry areas. Staff confirmed these items were expired or improperly stored and needed to be discarded.
Surveyors observed that garbage was not properly disposed of, with both dumpsters repeatedly left open and surrounded by bags of trash, debris, and various discarded items such as mattresses and mini refrigerators. Staff were seen placing garbage in the dumpsters without closing the lids, and the area was noted to attract pests, including flies and seagulls. The administrator confirmed ongoing issues with rodents and acknowledged the need for improved cleanliness.
Surveyors identified failures in professional standards, including improper IV site and tubing management for a resident receiving IV antibiotics, administration of insulin and pain medication outside of physician-ordered parameters for multiple residents, and lack of adherence to orders for pressure-relieving devices and blood pressure medication parameters. Staff interviews and record reviews confirmed these deficiencies, with documentation and practice not aligning with physician orders or facility policy.
Surveyors observed multiple failures in infection prevention, including staff not removing contaminated gloves or performing hand hygiene during perineal care, improper use of PPE such as N95 respirators and gowns when caring for residents on transmission-based and enhanced barrier precautions, and uncovered transport of clean linens. Staff interviews revealed gaps in understanding and adherence to infection control protocols.
Two residents were allowed to self-administer respiratory inhalers without documented assessments of their cognitive and physical ability, as required by facility policy. Both residents kept inhalers at their bedside or on their person and self-administered them, but there was no evidence of completed assessments or care plan updates. Staff confirmed that assessments and secure storage were expected but not performed in these cases.
Two severely cognitively impaired residents were repeatedly observed in bed without call lights within reach, with one resident's call light found hanging on a curtain and another resident yelling during observations. Staff confirmed that call lights should always be accessible, but admitted to forgetting to provide them.
Annual performance evaluations were not completed for three staff members, and two staff members did not fulfill the required 12 hours of annual education. These deficiencies were confirmed through record reviews and administrator interviews.
Surveyors observed two instances where medications were administered late by an LPN, including an IV antibiotic and Levothyroxine, resulting in a medication error rate of 8 percent. The DON confirmed facility policy requires medications to be given within one hour of the scheduled time, but was unaware of the late administration events.
Surveyors observed that opened vials of aplisol used for TB testing were not dated or discarded as required, and temperature logs for the medication refrigerator were incomplete. An LPN confirmed the vials were not dated, and the interim DON stated that daily temperature checks were facility practice, but logs showed missed entries.
The facility failed to maintain complete and accurate medical records for two residents. One resident did not have required documentation of monitoring for medication side effects and targeted behaviors on multiple occasions, while another resident received a dose of pain medication that was not supported by an active physician order or documented in the MAR, with the only record being in the narcotic book. Staff interviews confirmed lapses in expected documentation practices.
The facility did not designate a qualified Infection Preventionist (IP) to oversee the infection prevention and control program, as required by their policy. For over two months, no individual was assigned as the on-site IP, even during a recent Influenza outbreak. Interviews revealed confusion among staff about who the IP was, and the Director of Nursing, despite having an IP certificate, confirmed that they had not assumed the role, nor had any other staff member.
The facility failed to obtain and document weights for two residents as per physician orders, leading to missed notifications of significant weight changes. One resident had missing weight records and care plans initiated posthumously, while another had undocumented weekly weights. Staff interviews revealed inconsistencies in weight documentation practices, and the facility lacked a weight policy.
The facility failed to conduct thorough investigations into abuse allegations involving three residents. A resident with a femur fracture reported rough handling and non-compliance with hip precautions by a nursing assistant. Another resident alleged abuse and neglect, but the investigation lacked comprehensive staff interviews. A third resident reported rough care and privacy violations, but the investigation was incomplete, and the wrong staff member may have been identified.
A resident reported abuse and neglect by a NAR, but the facility delayed in suspending the accused staff and initiating an investigation. The resident, who was cognitively intact, reported the incident to a NAC, who informed an LPN and the previous DNS. The accused staff continued to work the following night, and the facility administration was not notified until the next day, leading to the termination of the previous DNS for policy violations.
A resident reported an incident of alleged abuse and neglect involving a staff member, which was not reported to the state hotline within the required 24-hour period. The resident, who was cognitively intact, experienced rudeness and startling behavior from a staff member. Despite being informed, the facility staff delayed reporting the incident, violating the facility's policy and state guidelines.
A facility failed to ensure a NAR completed the required NAC certification within four months of hire. The staff member continued to work beyond the eligibility period without certification. The administrator was unaware of the completion status, leading to the staff's removal from the schedule.
The facility failed to ensure that the Director of Food and Nutrition Services had the proper qualifications. The designated staff member was not a certified Dietary Manager and was not enrolled in a certification program, placing all residents at risk of receiving dietary services from unqualified staff.
The facility failed to ensure staff compliance with Infection Prevention and Control Guidelines, affecting 14 residents requiring Enhanced Barrier Precautions (EBP). Staff lacked training and awareness of EBP, and no residents were observed on EBP. The facility also failed to establish an infection surveillance plan during a COVID-19 outbreak affecting 29 residents and did not implement a respiratory protection plan for 28 staff members. Additionally, the facility lacked a water management plan for Legionella and other pathogens.
The facility failed to ensure that the designated Infection Preventionist (IP) met the necessary qualifications for experience, education, and training or certification. The IP role was managed by multiple staff members without proper credentials, leading to incomplete data analysis and management of infections.
The facility failed to treat residents with dignity and respect, as evidenced by multiple incidents where residents' requests and needs were ignored or delayed, leading to feelings of humiliation and neglect. These incidents were not documented in the facility's logs.
The facility failed to report a COVID-19 outbreak affecting 29 residents and an unexpected death of a resident with acute pulmonary edema, COPD, and CHF. Staff were unaware of the reporting requirements, and the incidents were not logged in the state reporting log. This is a repeat citation from a previous survey.
The facility failed to meet professional standards for bowel management, PEG tube care, and resident positioning. Two residents did not receive necessary bowel medications as per physician orders, PEG tube supplies were not properly labeled or stored, and a hospice resident was not repositioned as required. Staff interviews revealed a lack of adherence to care plans and protocols.
A resident with severe cognitive impairment and a history of falls experienced nine unwitnessed falls over 90 days due to inadequate supervision and failure to update the care plan. Despite being on an anti-psychotic medication that increased fall risk, the facility did not effectively implement or update fall prevention interventions, leading to multiple injuries.
Care plans not updated for changed resident conditions and needs
Penalty
Summary
The facility failed to complete, review, and revise care plans for multiple residents after changes in condition and care needs were identified. Resident 4 was admitted with lumbar fracture healing, hypertension, and osteoporosis, had a low fall risk on admission, then fell in the bathroom, was sent to the hospital with left hip pain, and returned after a left hip fracture requiring surgery. Although a later Morse fall assessment showed the resident was at high risk for falls, the care plan did not include the fall, the surgical aftercare, or the updated high fall risk. The DON/RN confirmed the care plan had not been updated with the resident’s high fall risk or surgical aftercare. Resident 7 was admitted with major depressive disorder, generalized anxiety disorder, bipolar disorder, and PTSD. Trauma screening showed the resident experienced an extraordinarily stressful event, and the care plan identified risk for trauma or re-traumatization due to past trauma and PTSD, but it did not include individualized interventions to mitigate triggers. A psychiatric consult documented a history of hospitalization for a mental breakdown secondary to spousal abuse, and the resident stated that confrontations or loud voices trigger PTSD symptoms. Resident 8 was on hospice with a life expectancy of less than six months and had constipation, but the revised care plan did not include the hospice provider, contact information, or the division of responsibilities between the facility and hospice provider. The care plan also did not include constipation goals and interventions, and only addressed monitoring constipation within the pain care plan problem. Resident 33’s condition declined after a bathroom fall and subsequent hallucinations, with staff describing the resident as requiring dependent care, but the care plan was not updated to reflect the change in care needs. Resident 35’s records showed dentures on the care plan, but a dental hygienist note documented implants with reddened tissue and edema, and recommended reminders to brush the implants; staff stated they were unaware the resident had dental implants.
Insufficient Nursing Staff and Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient qualified staff to meet resident needs on two halls, Portage and Ship Harbor, for 7 of 12 sampled residents. The facility assessment showed an average daily census of 35.53 residents, with staffing planned at 2 nurses on days, 2 nurses on evenings, and 1 nurse on nights. The staffing pattern for the prior 31 days showed 4 days without the required 16 hours of RN coverage and 12 days without 24-hour RN coverage in the facility. Residents described long waits for assistance and inconsistent care. One resident reported waiting 45 minutes to get help to use the bathroom and said there were other times they waited almost 45 minutes. Another resident said call light wait times were grim and that staff were exhausted. A third resident said they had waited up to an hour for staff to answer the call light. During a resident council meeting, a resident stated call lights had been answered more timely since state surveyors arrived, but before that they had waited hours and hours for help and staff let the call light go off. The staffing concerns also affected care delivery. Resident 8 had an order for restorative walking 6 days a week, but documentation showed the program was completed only 5 of 31 days in January and 5 of 17 days in February. Staff reported that nursing assistants often worked double shifts, that the facility needed additional aides and another nurse, and that nurses were responsible for medication passes for about 20 residents, sometimes 23. Staff also reported late meal delivery, cold meals, inconsistent meal times, and difficulty giving medications around meals. The DON stated the facility needed more aides and possibly another nurse, that restorative staff were often pulled to the floor, and that the facility was aware of complaints about late meal trays, missed nail care, late medications, and two-person transfers being done with only one staff member present.
Dietary Manager Lacked Required Qualifications
Penalty
Summary
The facility failed to ensure the Dietary Manager had the required qualifications and competencies to carry out food and nutrition services. The facility’s position description for the Dietary Manager required successful completion of a Dietary Manager’s course from a vocational or community college or maintenance of a Certified Dietary Manager’s license with continuing education. Staff P stated they had served as Dietary Manager since December 2025 and were enrolled in the Dietary Manager course in February 2026, but had not completed it. The Administrator confirmed awareness that Staff P had not completed the Dietary Manager course.
Failure to Follow Preplanned Menu
Penalty
Summary
The facility failed to ensure preplanned menus were followed. On 03/23/2026, the Dietary Manager provided two weeks of menus, and the weekly menu for 03/26/2026 showed lunch would include cream of tomato soup, pepper steak, delicious rice, steamed vegetables, baked roll, and peach marshmallow jello salad. During an interview on 03/26/2026 at 11:46 AM, the Dietary Manager stated the facility had been pretty good about sticking to the menu and said that if there was a change, staff were not informed and the menu would be updated outside the dining room. During lunch service on 03/26/2026, the prepared peach marshmallow jello salad was observed outside the safe zone, and it was placed in an ice bath to adjust the temperature. When rechecked, it was still not in the safe zone, and the Cook stated it could not be served to residents. Yogurt was then served in place of the scheduled dessert. Later, a resident asked about the roll listed on the menu, but the Cook did not know if there had been a menu change. The daily menu posted outside the dining room did not include a baked roll, and no alternative for the baked roll was offered to residents.
Cold, Unappetizing Meals and Unmet Food Preferences
Penalty
Summary
The facility failed to provide appetizing, palatable, and warm food for 7 of 7 residents reviewed for dining, including residents 2, 7, 9, 18, 24, 26, and 27. Resident council minutes from multiple meetings showed repeated complaints that sauces lacked flavor, mac and cheese sauce was no longer good, residents wanted more fresh fruit and vegetables, menu selections were not being followed, and residents wanted hot food, more green salads, diabetic-friendly desserts, and more dessert variety. The minutes also reflected repeated concerns that too much chicken was being served. During a resident council group interview, residents stated that food was arriving cold by the time it reached them, that they were often the last residents to receive meals, and that staff sometimes had to microwave trays. One resident stated breakfast trays were delivered while staff were still providing care, another said trays sometimes arrived as late as 9:00 AM, and lunch could arrive anytime between 12:00 PM and 1:00 PM. A registered dietician stated cold food had been the biggest complaint from residents and that residents also reported food quality concerns, including cold temperature and overcooked items. Staff interviews confirmed ongoing complaints about cold meals and inconsistent meal times. Resident interviews and observations showed repeated examples of cold or unappetizing meals. One resident stated hot food was served cold and described cold scrambled eggs and waffles that were not good. Another resident reported cold cereal, cold eggs, and toast cut into small pieces that they did not like. A resident stated meals were always cold and that they felt like the last resident to receive food. Another resident, who had diagnoses including pressure ulcers, stated the food was poor, wrote down what had been served since admission, and reported being repeatedly served rice and green beans despite preferences for something different; the resident’s food preference record documented dislike of green beans and apples. Other residents reported cold eggs, lukewarm meals, dry or spicy food, lack of butter, and meals that were not warm when served.
Delayed Meals and Unavailable Night Snacks
Penalty
Summary
Meals and snacks were not consistently served within the posted timeframes for residents on two hallways. Staff stated breakfast was scheduled for 7:30 AM to 8:00 AM, while the dietary manager stated breakfast was expected from 7:15 AM to 8:15 AM, lunch from 12:00 PM to 1:00 PM, and dinner from 5:00 PM to 6:00 PM. During observations, breakfast trays for room service remained on the Portage hallway at 8:44 AM, and staff confirmed the breakfast cart had not yet reached the Ships Harbor hallway. On another observation, the breakfast cart was still on the Portage hallway at 8:20 AM while trays were being served, and staff later observed the cart on the Ships Harbor hallway at 8:45 AM with trays being delivered to resident rooms. In resident council, residents stated they were not aware of possible night snacks and staff did not offer them. The dietary manager stated they were unaware that breakfast trays were not being delivered to some residents until 8:45 AM or later and said kitchen staffing was stretched thin. Staff also reported that the breakfast cart could take until 9:00 AM to reach the Ships Harbor hallway. The report identified that 5 of 7 residents were not receiving nourishing snacks at night and that there was longer than a 14-hour wait between dinner and breakfast for residents on two hallways.
Nourishment Refrigerator Food Safety and Temperature Monitoring Failure
Penalty
Summary
The facility failed to ensure resident meals were prepared and stored in accordance with professional standards of food safety in the nourishment refrigerator and freezer. During observation, the refrigerator contained multiple opened, undated, and expired food items, including sandwiches, cobbler, hardboiled eggs, peanut butter and jelly, fried chicken, noodle soup, cheeseburger sliders, half-eaten salad, eggs, milk, half and half, moldy cheese, fast food, a half-eaten burrito, opened soda, grapes, an opened melon and pineapple tray, carrots and rice/chicken, a food item in a plastic cup, pickled herring, Asian spice sauce, and wild sockeye salmon. The refrigerator bottom drawer was empty, dirty, and had debris and yellow spill marks. The freezer also contained undated and unlabeled items, including a grocery store plastic bag frozen to the door storage, a banana in a bag, and chimichangas. The temperature log for the nourishment refrigerator was found in a drawer next to the refrigerator and was dated July 2025 with multiple missing entries; no other temperature logs were located or provided. In interviews, Staff L, NAC, stated they were leaving with their paper bag and burrito from the nourishment refrigerator and said they did not know where their lunch should be kept. The Dietary Manager stated dietary staff were not responsible for checking the nourishment refrigerator temperature and that nursing staff were responsible for maintenance and logging temperatures. An Infection Control/RN stated the nourishment refrigerator temperatures and oversight were completed by nurses on the overnight shift.
Failure to Follow Precautions, Glucometer Disinfection, and Hand Hygiene
Penalty
Summary
Staff failed to follow Contact Precautions and transmission-based precaution signage for multiple residents. Resident 20 had an indwelling catheter and a UTI with MRSA, and Resident 33 had an indwelling catheter and a UTI with ESBL. Both residents had Contact Precautions signs posted outside their rooms directing staff to wear gown and gloves when entering. Observations showed CNA staff entering Resident 20’s room without gown or gloves on multiple occasions, and a CNA entered Resident 33’s room without gown or gloves despite the posted precautions. The Infection Preventionist stated that residents on Contact Precautions should be isolated to their rooms as much as possible, and the DON stated the team decides which precautions residents should be, but no documentation was provided to justify Contact Precautions versus Enhanced Barrier Precautions for Resident 33. Staff also did not follow the transmission-based precautions posted for Resident 49. During one observation, an LPN was in the resident’s room with no PPE and stated they did not require PPE because they did not provide care to the resident. During another observation, a NAC entered the room without PPE or hand hygiene, removed the resident’s breakfast tray, and stated they were unsure whether PPE was required if they were not providing care. The Infection Preventionist stated staff were expected to follow the TBP signage and should have worn gloves and a gown to enter Resident 49’s room. The facility also failed to ensure proper disinfection of blood glucose meters and hand hygiene during wound care. Blood glucose monitors on Portage Hall were kept in individual pouches, and staff stated they were cleaned after each use with alcohol prep pads, while the meter user manual required cleaning and disinfection after use on each patient with approved disinfecting wipes. The IP and DON stated the expectation was to disinfect the glucometers between each use with Super Sani-Cloth wipes. In a separate observation, an RN removed a dressing with feces on it from Resident 28, then applied cream and placed a clean foam dressing without removing gloves or performing hand hygiene. The DON stated the RN should have completed hand hygiene and put on new gloves between removing the soiled dressing and applying the clean dressing.
Call Light System Not Audible in Resident Areas
Penalty
Summary
The facility failed to maintain a resident call light system that was functionable and audible in both Portage Hall and Ships Harbor Hall. During multiple observations, call lights were seen illuminated in resident rooms and above room doors, but they were not audible in the hallway or throughout the halls. In Ships Harbor Hall, call lights in several rooms were observed on but not audible, including instances where the sound was only faintly audible at the nurses’ station computer and not in the halls. Maintenance staff were observed moving wires by the call light monitor computer screen, and the sound was audible only when at the monitor. Staff interviews confirmed that the call light volume had been turned down, including on night shifts. A NAC stated the volume must have been turned down, and a Staffing Coordinator said the call light sound had been very light but could still be heard if staff listened closely. An Infection Preventionist stated the call light volume was supposed to be up and audible, but staff had access to change it. The Administrator stated they were aware the call light volume was being turned down and that the expectation was for call lights to be audible at all times. The deficiency was identified as a repeat deficiency from 05/14/2025.
Failure to Provide Privacy During Resident Care
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity and failed to protect resident rights by not providing privacy during care for three residents reviewed for dignity. The report states that the facility policy on Resident Rights requires employees to treat residents with kindness, respect, and dignity, and that residents have the right to a dignified existence and to be supported in exercising their rights. Resident 28, who was admitted with cardiac disease and anxiety and whose MDS showed depression, anxiety, and cognitive impairment, was observed during wound care and peri care with the privacy curtain only halfway pulled and the resident exposed from the waist down while the roommate was present. Resident 27, admitted with pressure-induced deep tissue injury, surgical aftercare, anxiety, and depression, was observed during wound dressing assessment with the door closed but without the privacy curtain drawn and with the window blinds open to the parking lot. Resident 31, admitted with chronic venous insufficiency, weakness, chronic pain, and depression, was observed receiving incontinence care with the window blinds open and without privacy protection.
Unsafe and Poorly Maintained Resident Areas
Penalty
Summary
The facility failed to ensure a clean, safe, comfortable, and homelike environment in multiple areas, including Portage Hall, Ship Harbor Hall, a shower room, and resident rooms reviewed for bed rail securement, cable box securement, and floorboard condition. In the shower room, surveyors observed a bathroom area with a sign for staff use, a tiled room with a missing shower head and handle and various items stored there, and another room used as a shower room that contained assorted items piled in the corner, a hair-washing blow-up sink, bagged items, and shoes. Staff B, the DON, stated the items in the shower room storage area were stored by social services and needed to be removed. In resident room [ROOM NUMBER], surveyors observed bilateral half bed rails, with the left rail wobbly and not securely attached on two separate observations. Staff M, the Regional Maintenance Director, later confirmed the left side bed rail was not securely attached and Staff K stated it needed to be tightened. In another resident room, a television-mounted cable box was observed hanging from the TV by cords on multiple occasions, and Staff O stated there were several rooms with cable boxes hanging by cords and that they had not fallen yet. Surveyors also observed peeling floorboard molding behind a bed in room [ROOM NUMBER], and in Ship Harbor Hall and Portage Hall they observed stained carpets and worn, torn furniture at the nurse's station. The Administrator and DON stated they were in the process of replacing the carpet, and the Administrator stated they were unaware of the peeling floorboard molding.
Failure to Protect Resident from Verbal Abuse by Roommate
Penalty
Summary
The facility failed to ensure the identification of verbal and mental abuse and failed to protect a resident from an alleged perpetrator after abuse concerns were reported. A cognitively intact resident admitted with diagnoses including fracture and UTI reported that their roommate was insulting them and their visitors, calling them stupid, and the resident later stated the roommate had been mean to their visitors. The resident’s progress notes documented concerns about the roommate being verbally abusive to visitors, and the resident was moved to another room two days after the concern was first reported to nursing. Record review and staff interviews showed the roommate had a history of yelling, cussing, and being verbally aggressive toward others, and staff described the behavior as verbal or mental abuse. Staff stated they were aware of prior concerns involving the roommate and other roommates, but the incident report documented that there were no noted interviews with the resident at the time of the incident or at the time of the room move. The social services manager stated they met with the resident only to confirm the room move and did not speak with them about the interactions that led to the request.
Unnecessary Antipsychotic Use for Resident with Dementia and Behaviors
Penalty
Summary
The facility failed to ensure that a resident was not administered an antipsychotic medication unless it was necessary to treat a specific condition documented in the clinical record for one of five sampled residents, Resident 35. Resident 35 was admitted with diagnoses including dementia with behaviors and major depressive disorder, and the admission MDS showed severe cognitive impairment with a BIMS score of 4 out of 15. The CAA documented Seroquel was prescribed to treat dementia with behaviors, and the care plan identified target behaviors such as yelling/screaming at staff, hitting/grabbing staff, and increased confusion, but there were no monitors personalized to capture psychosis. The record also showed a pharmacy review recommending the provider review Seroquel use because the resident had been taking an as-needed dose prior to admission. Behavior monitors for December documented multiple instances of yelling/screaming at staff across shifts, and a behavioral progress note later described the resident as pleasantly confused with a bright affect and fully engaged in conversation. The electronic health record contained no information regarding the resident’s behaviors prior to admission, while staff interviews stated the resident came from an assisted living facility, often believed they worked at the facility, and yelled out; another staff member stated antipsychotics were used for hallucinations and dementia with behaviors, and the DON stated the resident had been sent to the ER and found to have a UTI.
Failure to Report Alleged Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to ensure that alleged verbal and mental abuse and resident-to-resident altercations were reported to the State Agency for 2 of 2 residents reviewed for abuse and neglect reporting. The facility policy stated staff were mandated reporters and were to report suspected abuse to the state agency, and the Purple Book required reporting through the state reporting log within 5 days of discovery. Review of the state reporting log from December 2025 through March 23, 2026 showed no reports of resident-to-resident verbal altercations. Resident 14’s progress note documented a concern that their roommate, Resident 35, was verbally abusive to their friends during a visit, and Resident 14 later stated the roommate had been insulting them and their visitors by calling them stupid. Resident 35’s record also documented that a roommate had described them as verbally aggressive and rude, and staff interviews confirmed they had been informed Resident 35 had been rude, belittling, and degrading toward roommates and families. The incident report documented Resident 35 had a history of verbal aggression toward a roommate, had an interaction with Resident 14 and their visitors, and the room move was completed afterward; however, there were no interviews with Resident 14 at the time of the incident or room move, and no state report was noted.
Failure to Follow 2-Person Assist Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident 31. Resident 31 was admitted with diagnoses including chronic venous insufficiency, weakness, chronic pain, and depression. Their ADL care plan documented the need for extensive assistance of 2 staff to turn and reposition in bed and for personal care to help prevent them from rolling too close to the edge of the bed. Their Kardex, dated 03/23/2026, also directed that they required extensive assist of 2 staff for turning, repositioning, and personal care to prevent rolling to the edge of the bed with potential to fall. During continuous observation on 03/23/2026 from 10:32 AM to 11:13 AM, Staff L, NAC, was observed providing personal care and incontinent care that required extensive bed mobility to Resident 31 without another staff member present. At 10:47 AM, Staff L stated they had asked another NAC for assistance before starting the care, and Resident 31 encouraged Staff L to get someone to help because Staff L did not feel comfortable leaving them alone. At 10:51 AM, Staff S, NAC, entered and asked if assistance was needed. In interview, Staff L stated they needed another staff member to complete care for Resident 31. The DNS stated the expectation was that staff review the care plan and Kardex and that Resident 31 required 2-person assist for incontinent care and bed mobility.
Failure to Provide Grooming and Nail Care
Penalty
Summary
The facility failed to provide assistance with grooming, including nail care, for residents who were unable to complete these activities independently. The facility policy stated nursing assistants were to provide ADL assistance based on the resident’s individualized plan of care and report changes in performance or abilities to the licensed nurse. Review of the cited residents’ records and observations showed that staff did not consistently provide or coordinate nail care as required by the residents’ care plans, Kardexes, or provider orders. Resident 7, admitted with diagnoses including hemiplegia, left hip fracture, and osteoarthritis, was assessed as needing one-person assistance for grooming. During interview and observation, the resident stated they had not had toenails trimmed since admission and that the toenails were long and extending over the toe. The resident later reported that Staff H, a shower aide, trimmed the toenails after the resident asked for help. Resident 9, admitted with diabetes mellitus with neuropathy, heart failure, and muscle weakness, had provider orders for weekly nail checks by an LPN, but observations on multiple dates showed long fingernails with yellow, brown, or discolored matter underneath. Staff gave conflicting statements about who was responsible for diabetic nail care, with one LPN stating diabetic residents’ fingernails were not supposed to be cut by staff and the DON stating licensed nurses were responsible for Resident 9’s fingernail care. Resident 31, admitted with chronic venous insufficiency, weakness, chronic pain, and depression, had a care plan intervention to keep fingernails short and a Kardex directing the same, yet repeated observations showed long fingernails with matter underneath. Staff F stated nail care could be done by NACs unless the resident was diabetic, while Staff I stated they had not looked at the resident’s nails. Resident 37, admitted with stroke-related deficits and cerebellar ataxia, required extensive assistance for all grooming, but observations showed long, jagged fingernails over several days. The resident had prior documentation of self-inflicted facial scratches and bloody or sharp fingernails, and subsequent notes documented additional scratches to the face while the nails remained untrimmed. Staff statements showed inconsistent understanding of who was responsible for nail care, with some staff stating NACs should clip nails for non-diabetic residents and others stating nurses or podiatry handled certain nail care tasks.
Failure to Coordinate Ordered Follow-Up and Wound Care Services
Penalty
Summary
The facility failed to ensure that two residents received care and services in accordance with professional standards of practice, the comprehensive person-centered care plan, and resident choices. For Resident 14, who was admitted with diagnoses including fracture and urinary tract infection, the record showed discharge instructions and a provider note directing follow-up with an orthopedic physician. The care plan also documented the need for orthopedic follow-up. However, the resident stated they had been asking for an orthopedic appointment for 11 days and had not received information from nursing staff or nursing assistants. Staff later stated that referrals and appointments were handled by HIM and that a fax was sent to the orthopedic clinic, but the clinic did not receive it and the appointment was not scheduled until contact was made later. Progress notes did not document any information about scheduling the orthopedic appointment, and the resident stated they were only told about the appointment about 30 minutes before it occurred. For Resident 27, who was admitted with a pressure ulcer of the left buttock, the MDS and CAA documented skin care needs and wound clinic involvement. The care plan included wound care per wound clinic orders, continued wound clinic appointments, and supplements including Vitamin C and Zinc. Wound clinic orders also included a specialty bed or mattress for pressure reduction, Vitamin C 1000 mg daily, Zinc 25 mg daily, and initiation of a wound vac. The order summary reflected orders for an alternating pressure mattress, Vitamin C, Zinc, and wound care with wound vac use. Survey observations showed Resident 27’s bed did not have an alternating pressure mattress on multiple dates. The wound vac was not placed until 8 days after the wound clinic order was received. Staff stated they attempted to obtain the wound vac through a medical supply company but the facility did not have a contract and had to find another company. Staff also stated the alternating pressure mattress was not indicated because the resident was independently ambulatory, and acknowledged that the mattress was not on the bed. Staff further stated they had not documented their conversations with providers regarding the wound vac in the resident’s medical record.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to comprehensively assess and revise nutritional interventions for two residents with significant weight loss. One resident was admitted with orthopedic aftercare following left femur surgery and a urinary tract infection, and the admission MDS identified a potential nutritional risk related to the fracture and infection. The resident’s care plan called for weekly weights, RD review, and lab monitoring, but weights were not obtained consistently with the order. The resident weighed 187.6 lbs on 02/21/2026 and 166.2 lbs on 03/21/2026, an 11% loss in one month. The admission nutritional assessment documented a goal to maintain current weight and monitor intake, weights, and labs, but no additional nutritional assessments were documented. Labs from 02/23/2026 showed low protein and albumin levels. During interview, the RD stated they had not evaluated the resident and could only find the initial nutritional assessment. The RD acknowledged the resident had a significant weight loss and that there had been more than two weeks without a documented weight, but no additional interventions had been added because the weight loss had not been identified. Nursing staff stated weights were obtained by NACs and documented by nurses, and the DON stated residents were expected to be weighed the first three days and then weekly. The DON also stated they would expect daily weights for at least three days if weight loss was documented, but staff were unaware of this resident’s weight loss and weekly weights had not been documented. A second resident admitted with diagnoses including heart attack, heart failure, and depression had documented nutritional risk related to variable meal intake and minimal appetite. The resident’s care area assessment identified interventions including a soft and bite-sized diet, supplemental shakes, and RD review, with a goal to minimize risk and improve appetite. The RD admission review set a goal of no significant weight changes and recommended supplemental shakes twice daily. Despite this, the resident lost weight from 105.8 lbs to 94.2 lbs, a 12.3% loss in 73 days. Provider notes documented adult failure to thrive, persistent weight loss, and decreased oral intake, but no additional recommendations or interventions were identified. The RD stated the resident had significant weight loss, was refusing snacks and shakes, and had been discussed without additional recommendations.
Incomplete respiratory orders and equipment care
Penalty
Summary
The facility failed to ensure respiratory care and services were provided in accordance with physician orders and accepted professional standards of practice for 2 residents. For Resident 11, who was admitted with diagnoses including heart failure and heart attack, observations showed the resident in bed with oxygen via nasal cannula attached to an O2 concentrator set at 1.5 lpm, and later with the nasal cannula not inserted in the nose. The record showed orders for oxygen to keep saturation above 90 percent, an order to titrate off oxygen, and an order to change O2 tubing and water weekly, but the documentation also showed the oxygen orders were discontinued on different dates and Staff I stated the resident should have had a specific titration order and parameters. Progress notes documented the resident was dependent on oxygen. For Resident 44, who was admitted with chronic respiratory failure, severe persistent asthma, COPD, and dependence on a respiratory ventilator, physician orders documented oxygen at 2 lpm by nasal cannula and Trilogy use at bedtime or during sleep as needed, but the settings section was left blank. Observations showed the resident with oxygen in place, the Trilogy machine on the nightstand, and the Trilogy mask with white debris on it; the oxygen tubing was also observed without a label or date and later on the floor. The care plan had no documentation related to respiratory needs, including the Trilogy machine and oxygen. Staff D and Staff B stated that expected orders should include oxygen flow rate, tubing changes, Trilogy settings, and cleaning, and confirmed the resident did not have a respiratory care plan or complete orders for the oxygen or Trilogy equipment.
Incomplete Dialysis Communication Documentation
Penalty
Summary
Provide safe, appropriate dialysis care/services for a resident who requires such services. The facility failed to ensure that Resident 6, who was admitted with end stage renal disease and received hemodialysis every Tuesday, Thursday, and Saturday, had consistent, completed, and accurate assessments on the facility's dialysis communication form sent to the dialysis center for coordination of care and services. In a review of post-dialysis communication forms for the period from 01/28/2026 through 03/26/2026, 12 forms were missing out of 25 opportunities. Staff Q, LPN, stated that after Resident 6 returned from dialysis, staff were to complete the post-dialysis communication form and document it in the EHR. Staff D, Resident Care Manager/LPN, confirmed the missing dates and stated that the evening shift nurse should complete the post-dialysis form when Resident 6 returned from dialysis and document it in the EHR.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure medication administration error rates remained below 5 percent. During observation of 26 medication administration opportunities, 3 medications were given late, resulting in an 11.54% error rate. The facility policy required medications to be administered safely and according to the PCP order, including checking the ordered frequency and confirming when the last dose was given. Staff I, an LPN, stated that Resident 5 preferred insulin after eating and was unsure whether that preference was reflected in the order or care plan, while the resident’s Glargine insulin was ordered for 8:00 AM and was administered about 1.75 hours late. Resident 9, who was cognitively intact, also had Aspirin 81 and Losartan Potassium ordered for 8:00 AM and received them about one and a half hours late during observation. Resident 2, who had hypertensive heart disease with heart failure, had an order to hold Doxazosin Mesylate if systolic blood pressure was less than 100. Review of the MAR showed Doxazosin Mesylate 6 mg was administered when blood pressures were 99/58 and 96/57. Staff E stated medications were to be passed one hour before or after the scheduled time, and the DON stated the facility policy was that medications should be given within an hour of when due. The DON was unaware that Resident 5 and Resident 9’s medications were given late and that Resident 2 received Doxazosin outside the ordered parameters. This was identified as a repeat deficiency.
Medication Administration and Order Documentation Errors
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors when medications were not administered according to physician orders for one resident and when administered medication was not documented for another resident. The facility’s medication administration policy stated that medications are to be documented after being given, including the time, route, and other required information. One resident with bipolar disorder, major depressive disorder, anxiety disorder, and PTSD had an order for clonazepam 1 mg by mouth every 12 hours as needed for anxiety. The narcotic book documented one dose administered at 3:31 PM with 39 tablets remaining, and another tablet documented at 8:16 PM without a dose signed out, nurse signature, or tablet count; a sticky note asked a RN to sign. The resident’s MAR did not document the clonazepam dose given at 3:31 PM. Another resident with dementia with behaviors had admission orders showing Seroquel 25 mg as needed for agitation from a prior placement and a separate facility admission order for Seroquel 25 mg at bedtime for dementia with behavioral disturbances. The pharmacy review later noted the medication had been used as needed at the prior placement and requested clarification, but the electronic record did not show an order at admission or at the time of the pharmacy review changing Seroquel from as needed to routine.
Improper Medication Storage, Labeling, and Temperature Monitoring
Penalty
Summary
The facility failed to ensure proper labeling of insulin in the Portage Hall medication cart, failed to correctly monitor temperatures of vaccines in the medication fridge, and failed to secure medication carts in the Portage Hall and Ship Harbor Hall medication carts and one medication room. In the Portage Hall medication cart, three open Glargine insulin pens were observed without an open or discard date. Staff confirmed the dates were missing and stated that an open insulin pen without an open or discard date should have been discarded and replaced with a new dated pen from the fridge. The Portage Hall medication cart was also observed unlocked and unattended on two occasions, including one instance when a laptop with a resident's protected health information was open on the cart. In another observation, a brown round pill was found on the floor between resident rooms, and Staff identified it as Senna that had been spit out. In the medication room, the fridge contained Spikevax COVID vaccine, pneumonia vaccine, and influenza vaccine, but temperature checks were documented only once daily on night shift, and staff stated that was the routine practice. The facility policy and CDC guidance reviewed with the report addressed locking medication carts and checking and recording vaccine refrigerator temperatures.
Failure to Obtain and Honor Resident Bathing Preferences
Penalty
Summary
The deficiency involves the facility’s failure to obtain and honor residents’ bathing and showering preferences, including type, frequency, and time of day, for multiple residents. For one resident with a stroke and right-sided weakness, the admission MDS showed no cognitive impairment and no showers received during the assessment period, and the baseline care plan lacked documentation of daily bathing/showering preferences. The resident’s care plan indicated extensive assistance was needed, yet documentation showed only four showers provided over 26 days. Another resident with dementia and moderately impaired cognition had an MDS indicating it was very important to choose between a shower, tub bath, or bed bath, and the care plan documented a need for maximal assistance. Documentation showed this resident received three showers over 32 days, with one documented refusal. A third resident with multiple sclerosis had a care plan stating they were to be showered twice weekly and as necessary, but documentation over two separate date ranges showed only one shower in 14 days and no showers during an earlier period. A fourth resident with weakness and high blood pressure was dependent for bathing per the admission MDS and required extensive assistance per the Kardex, yet documentation showed only four showers over 22 days. A fifth resident with a stroke and right-sided residual paralysis had an admission MDS indicating it was very important to choose among tub bath, shower, bed bath, or sponge bath, and a care plan documenting extensive assistance with bathing needs, but documentation showed only four showers over 39 days. In an interview, the RN/DON stated residents were showered twice weekly according to a fixed room-based schedule, and that if a shower was refused or not offered, the expectation was that it would be offered the following day, indicating reliance on a set schedule rather than individualized resident bathing preferences.
Failure to Assess, Document, and Monitor Bed Rail Use for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to have a bed rail/side rail policy and to comprehensively assess, document, and monitor the use of bed rails for three residents. The facility did not develop a side rail/bed rail policy, and the DON was unable to state where risks and benefits were documented or how often side rails were reassessed. Enabler Device Assessments for the residents noted that risks and benefits of side rail use were explained, but the medical records lacked documentation of what specific risks and benefits were discussed, and there was no evidence of ongoing monitoring or maintenance of the bed rails. For one resident with heart failure, a fall with weakness, and moderate cognitive impairment, the Enabler Device Assessment indicated use of a half side rail to maximize independence and stated that risks and benefits were explained, but did not specify the number or location of rails or detail the risks and benefits. The ADL care plan documented use of a quarter side rail to assist with bed mobility. Multiple observations showed this resident in bed with both upper side rails raised while eating meals and resting. During interviews, the resident was unable to state whether they could use the side rails for turning or even place their hand on the rail, while an agency NAC reported that the resident required two-person assistance for bed mobility and stated the resident was able to use the side rails. Another resident with muscle weakness and a stroke with left-sided weakness, and no cognitive impairment, had a physician order and care plan indicating use of bilateral bedrails to maximize independence with turning and repositioning, but the order did not specify whether upper or lower rails were used. The Enabler Device Assessment again stated that risks and benefits were explained without documenting what they were or specifying the rail configuration. Observations repeatedly showed this resident in bed with both upper side rails raised while eating meals. A third resident with high blood pressure and dementia, dependent on staff for bed mobility and transfers, had a care plan allowing bilateral quarter side rails to assist with bed mobility, and an Enabler Assessment documenting use of a half rail, ability to remove it independently, and that risks and benefits were discussed with a family member who gave verbal consent. However, the record did not specify the number or location of rails or the content of the risk/benefit discussion, and observations showed both upper side rails raised when the resident was in bed or when the bed was unoccupied.
Incomplete Hospital Transfer Documentation and Missing Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to complete required hospital transfer documentation and provide proper written notices regarding transfer, appeal rights, and bed-hold policies for residents sent to the hospital. Facility policy on Admission, Transfer & Discharge – Bed Hold Policy required written information to residents or representatives specifying the duration of the state bed-hold policy, with two notices: one in advance of transfer and a second at the time of transfer or within 24 hours for emergencies, and documentation of attempts to reach the representative if contact was not made. A separate Bed Hold Policy Notification required the resident or representative to return a signed notification to the business office within 24 hours of transfer or discharge if they chose to retain the bed, and specified the amount to be charged for retaining the bed. For one resident, the Nursing Home Transfer or Discharge Notices for two separate hospitalizations were incomplete. The notices, dated for each transfer, stated that the transfer was necessary for the resident’s welfare and that their needs could not be met at the facility, but did not include the resident representative’s information, the address of the receiving facility, or a brief explanation of why the resident was sent to the ER. Progress notes showed that social services staff left a voicemail regarding bed hold and later documented that a family member verbally consented to hold the bed, and Bed Hold Policy Notification forms reflected verbal consent to hold the bed for each hospitalization. However, there was no documentation in the medical record that a written discharge/transfer notice and bed-hold information were actually provided to the resident or representative at the time of either hospital transfer. For another resident, a progress note documented that the resident was sent to the hospital via stretcher, and a later Nursing Home Transfer or Discharge Notice again stated that the transfer was necessary for the resident’s welfare and that their needs could not be met at the facility. This notice was also incomplete, lacking the resident representative’s information, the address of the receiving facility, and a brief explanation of the reason for ER transfer. Progress notes showed that social services attempted to contact the resident’s family member but were unable to leave a voicemail, and later documented the resident’s readmission. There was no documentation that a written discharge/transfer notice or bed-hold information was provided to the resident or representative at the time of transfer, and no Bed Hold Policy Notification was found in the chart for this hospitalization. Staff interviews confirmed that both floor nurses and social services were responsible for completing and providing transfer/discharge and bed-hold notices, and that these were expected to be given to residents and/or representatives as soon as possible, including after weekend transfers.
Lack of Qualified Dietary Manager
Penalty
Summary
The facility failed to designate a qualified individual to serve as the director of food and nutrition services. Review of the key personnel list during the entrance conference revealed that no staff member was listed as the dietary manager. Interviews with dietary staff and the administrator confirmed that the facility did not currently have a dietary manager, and the person temporarily filling the role lacked the necessary dietary credentials. This resulted in the absence of a staff member with the required competencies and skills to oversee food and nutrition services, as required by regulation.
Improper Food Storage and Expired Items in Food Service Areas
Penalty
Summary
Surveyors observed that the facility failed to properly store, distribute, and serve food in accordance with professional standards for food service safety. In the dry food storage room, individual containers of honey mustard dressing labeled 'keep refrigerated' were found stored in a cardboard box on a shelf at room temperature. Staff from dietary services confirmed that these dressings should have been refrigerated and would need to be disposed of due to improper storage. Further inspection of the pantry area in the resident dining room revealed additional issues. A plastic container of shredded cheese with an expiration date that had already passed was found in the refrigerator. On the counter, a bin of individual honey mustard dressings, also labeled 'keep refrigerated,' was left unrefrigerated. A half loaf of bread and individual packages of chocolate chip cookies were also found with expiration dates that had already passed. Staff members acknowledged that these items were expired or improperly stored and needed to be discarded.
Improper Garbage Disposal and Unsanitary Dumpster Area
Penalty
Summary
The facility failed to properly dispose of garbage and maintain cleanliness in the dumpster area, as observed on multiple occasions. Both dumpsters outside the facility were repeatedly found with their lids open, and staff were seen placing garbage inside without closing the lids. The area surrounding the dumpsters contained plastic bags of garbage, a protein drink carton with a straw, scattered debris, and two 5-gallon buckets filled with a thick sludge material topped with water. Additionally, there was a knee-high pile of yard waste, three mattresses, a cloth recliner chair, and four mini refrigerators next to the dumpsters. Flies were observed in the area, and a seagull was seen inside one of the dumpsters, removing garbage. During an interview and observation with the facility administrator, the same unsanitary conditions were noted, including the presence of used gloves and random papers behind the dumpsters. The administrator acknowledged ongoing issues with squirrels and mice around the dumpsters and was unaware of the contents of the sludge-filled buckets. The administrator confirmed that the dumpster lids should be kept closed and that the area required cleaning. These findings were cited as a failure to comply with proper garbage disposal and environmental cleanliness requirements.
Failure to Meet Professional Standards in IV Care, Medication Administration, and Pressure Ulcer Prevention
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality in several areas, as evidenced by direct observations, interviews, and record reviews. For one resident receiving intravenous (IV) medication, the facility did not follow its own policies regarding IV site and tubing management. The resident had a peripheral IV device with undated and frayed dressings, and the IV tubing was not labeled with the date, time, or nurse initials. The IV site dressing was discolored, peeling, and not changed as required, and the resident reported having to hold the IV in place due to leakage. Additionally, there was confusion among staff regarding the type of IV device in place, with physician orders incorrectly indicating a PICC line when only a peripheral IV was present. Infection control practices were not followed, as the IV tubing end was not capped when not in use. The facility also failed to ensure medications were administered according to physician orders and established parameters for multiple residents. One resident received insulin injections outside of the specified blood sugar parameters on numerous occasions, and staff did not notify the provider when medication was held or administered outside of these parameters. Another resident was given oxycodone for pain ratings below the ordered threshold, with multiple documented instances of administration for pain scores less than 7, contrary to the physician's order. Staff interviews confirmed a lack of awareness and adherence to these medication administration parameters. In addition, the facility did not ensure the use of pressure-relieving devices as ordered. One resident with an order for an alternating pressure mattress (APM) was observed to have a standard mattress in place during multiple observations, despite staff documentation indicating the APM was checked and functioning. Staff confirmed the APM had been removed, but documentation continued to reflect its presence and use. Another resident received blood pressure medication outside of the ordered parameters for pulse and systolic blood pressure, with several doses administered when vital signs were below the specified thresholds.
Infection Control Deficiencies: Hand Hygiene, PPE, and Linen Management
Penalty
Summary
Multiple deficiencies in infection prevention and control were observed throughout the facility, including failures in hand hygiene, use of personal protective equipment (PPE), and linen management. During incontinent care for a resident, staff members failed to remove contaminated gloves and perform hand hygiene between tasks, instead touching clean briefs, drawers, and applying skin barrier with soiled gloves. Staff interviews confirmed a lack of adherence to proper glove removal and hand hygiene protocols during perineal care. Staff did not consistently follow transmission-based precautions for residents who tested positive for COVID-19. Several staff members entered rooms of COVID-19 positive residents without the required N95 respirators, gowns, gloves, or eye protection, despite clear signage indicating these requirements. In some cases, staff wore only surgical masks or failed to change PPE between resident rooms, and one staff member entered a room without any N95 masks available. Staff interviews revealed gaps in understanding and compliance with PPE protocols, including the need for N95 respirators and eye protection. Enhanced Barrier Precautions (EBP) were not properly implemented for residents with wounds or indwelling devices. Staff provided direct care, such as wound care and IV antibiotic administration, without donning gowns as required by EBP protocols. Additionally, clean linens were transported into the facility uncovered and handled with bare hands, contrary to facility policy. Interviews with staff and leadership indicated incomplete education on EBP and infection control procedures, contributing to the observed non-compliance.
Failure to Assess Residents for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents were properly evaluated and assessed for the safe self-administration of medications, as required by facility policy. Specifically, two residents were observed to have respiratory inhalers at their bedside or on their person, and both reported self-administering these medications. Review of the medical records and staff interviews confirmed that neither resident had undergone a documented assessment for their cognitive and physical ability to safely self-administer medications, nor was there documentation in the medical record or care plan updates reflecting such an assessment. Facility policy requires that residents be assessed for cognition and physical ability before being permitted to self-administer medications, with documentation and care plan updates to follow if deemed appropriate. Observations showed that one resident, with a history of depression, muscle weakness, and cognitive communication deficit but assessed as cognitively intact, kept an inhaler at the bedside and self-administered it. Another resident, alert and oriented, kept an inhaler in their shirt pocket and also self-administered it. Staff interviews confirmed that the expectation was for assessments and secure storage, but these steps were not completed for the residents involved.
Failure to Ensure Call Lights Within Reach for Cognitively Impaired Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents who were both severely cognitively impaired, as documented in their quarterly MDS assessments. Multiple observations over several days showed that one resident was repeatedly found in bed without a call light within reach, with the device noted to be hanging on a curtain instead. Staff interviews confirmed that the expectation was for all residents to have call lights within reach, but staff admitted to forgetting to provide this for the resident. Another resident, also severely cognitively impaired, was observed in bed with the call light out of reach on multiple occasions. During these times, the resident was noted to be yelling. Staff, including the Interim Director of Nursing Services, acknowledged that all residents should have access to a call light, regardless of their ability to use it. These observations and staff statements demonstrate a failure to reasonably accommodate the needs and preferences of these residents.
Failure to Complete Annual Staff Evaluations and Required Education
Penalty
Summary
The facility failed to complete annual performance evaluations for three out of five sampled staff members, as required. Additionally, two staff members did not complete the mandated 12 hours of annual education, with one missing 2 hours and another missing 5 hours. These deficiencies were identified through document reviews and interviews, which confirmed the absence of annual evaluations in employee files and incomplete education hours for the affected staff. The findings were based on a review of facility records and direct statements from the facility administrator.
Medication Error Rate Exceeds Regulatory Threshold Due to Late Administration
Penalty
Summary
The facility failed to ensure that medication error rates remained below 5 percent, as required. During observation of 25 medication administration opportunities, 2 errors were identified, resulting in an 8 percent error rate. One resident, admitted with pneumonia and digestive system disease, had a physician order for Zosyn IV antibiotic to be administered every eight hours at specific times. Staff G was observed administering this IV antibiotic one and a half hours late, explaining that medications were given in the order of residents down the hallway rather than by scheduled time. The Director of Nursing Services stated that facility policy required medications to be given within one hour of the scheduled time and was unaware of the late administration. Another resident, who was not cognitively impaired, was prescribed Levothyroxine for thyroid issues, which should be administered on an empty stomach 30 to 60 minutes before breakfast for optimal absorption. Staff G, an agency LPN, administered the resident's 7:00 AM dose of Levothyroxine one and a half hours late. These late administrations were directly observed and documented by surveyors, contributing to the facility's medication error rate exceeding the regulatory threshold.
Failure to Label and Discard Opened Medications and Maintain Refrigerator Temperature Logs
Penalty
Summary
Surveyors found that the facility failed to properly label and discard opened vials of aplisol, a solution used for tuberculosis testing, in the medication room refrigerator. During observation, two open vials of aplisol were found without any date indicating when they had been opened, despite the product label stating it expired 30 days after opening. A Licensed Practical Nurse confirmed that the vials were not dated upon opening and acknowledged that they should have been discarded. Additionally, the facility did not consistently record the temperature of the medication refrigerator as required by facility policy. Review of the temperature logs revealed multiple dates where no temperature was recorded. The interim Director of Nursing stated that the practice was to check the refrigerator temperature daily, with the night shift staff responsible for this task, but the logs showed this was not consistently done.
Incomplete Medical Records and Medication Documentation
Penalty
Summary
The facility failed to ensure complete, accurate, and accessible medical records for two residents. For one resident with bipolar disorder, depression, and anxiety, there were multiple instances where required documentation was missing. Physician orders required monitoring and documentation of adverse side effects related to antipsychotic and antidepressant medications, as well as targeted behaviors associated with the resident's mental health conditions, to be completed three times daily. However, documentation was missing on several specific dates across three consecutive months. Interviews with staff revealed that the expectation was for licensed staff to complete documentation by the end of each shift, but the Director of Nursing Services was unaware that this was not being consistently done. For another resident reviewed for pain management, a dose of Hydromorphone was signed out in the narcotic book, but there was no active physician order for the medication at the time, nor was there documentation of administration in the Medication Administration Record (MAR) or progress notes. The order for the pain medication was not confirmed until later that day, after the medication had already been signed out. Staff confirmed that the only documentation of the dose was in the narcotic book, with no corresponding entry in the resident's clinical record.
Failure to Designate an On-Site Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified individual as the Infection Preventionist (IP) responsible for the infection prevention and control program. This deficiency was identified through interviews and record reviews, revealing that the facility had not had an IP on-site for over two months. The facility's policy required the IP to be employed on-site at least part-time. During an interview, the Administrator admitted that no individual had been designated as the on-site IP during a recent Influenza outbreak. Additionally, a Registered Nurse was unsure about who the IP was, and the Director of Nursing, who held an IP certificate, confirmed that they had not worked as the IP in the facility, nor had any other staff member for months.
Failure to Obtain and Document Resident Weights
Penalty
Summary
The facility failed to ensure that two residents with physician orders for daily and weekly weights had their weights obtained as required. Resident 1, who had diagnoses including heart failure and hypertension, had a physician order for daily weights with instructions to notify the provider if there was a significant weight change. However, there were missing weight records for several days, and no documentation indicated that the provider was notified of the resident's weight fluctuations. Additionally, care plans for hypertension and respiratory issues were initiated after the resident had passed away, indicating a lapse in timely care planning. Resident 2, admitted with conditions such as chronic heart failure and post-surgery recovery, was supposed to have weekly weights recorded. However, there were multiple instances where the required weekly weights were not documented in the treatment administration record or the electronic medical record. Interviews with staff revealed inconsistencies in the process of obtaining and documenting weights, with some staff not providing the necessary lists or failing to document weights accurately. The facility was unable to provide a weight policy and procedure when requested, highlighting a lack of structured guidance for staff. Interviews with various staff members, including nursing assistants and registered nurses, revealed a lack of consistent communication and documentation practices regarding residents' weights. This deficiency in obtaining and documenting weights placed residents at risk of poor health outcomes, as significant weight changes were not communicated to healthcare providers as required.
Inadequate Investigation of Abuse Allegations
Penalty
Summary
The facility failed to conduct thorough investigations for allegations of abuse and neglect involving three residents. Resident 3, who was admitted with a right femur fracture and required specific hip precautions, alleged that a nursing assistant was rough during care and did not follow the necessary precautions. Despite the grievance being filed, the facility did not investigate the allegation of the staff failing to adhere to the hip precautions, and key staff members were unaware of the specific allegations. Resident 1, who was cognitively intact and had a history of major depressive disorder and muscle weakness, reported an incident of abuse and neglect by a nursing assistant. The facility's incident report lacked comprehensive interviews with other staff members to rule out further instances of abuse, and the investigation did not thoroughly address the allegations of rough handling during care. Resident 2, diagnosed with bipolar disorder and diabetes, reported that a nursing assistant was rough during care and did not respect their privacy. The investigation was incomplete, as it did not include follow-up interviews with staff from other shifts. Despite the suspension of the identified staff member, the resident reported that the same nursing assistant continued to provide care, indicating a possible misidentification of the staff involved.
Failure to Protect Resident from Abuse and Neglect
Penalty
Summary
The facility failed to protect a resident from abuse and neglect by staff, as evidenced by an incident involving a Nursing Assistant Registered (NAR) who was reported to have been rude and rough with a resident. The resident, who was cognitively intact and had diagnoses including major depressive disorder and muscle weakness, reported the incident to a Nursing Assistant Certified (NAC) on the morning following the alleged abuse. The NAC informed a Licensed Practical Nurse (LPN) and the previous Director of Nursing Services (DNS) about the allegation. However, the accused staff member was not suspended until the following day, and the resident was not interviewed until two days after the incident was reported. The facility's policy required immediate suspension of staff accused of abuse and prompt reporting to the Administrator or Director of Nursing Services. Despite this, the accused staff member continued to work the night following the report, and the facility administration was not informed until the day after the incident was reported. The previous DNS was terminated for failing to follow the facility's abuse and neglect policy, and there was no documentation of their termination in their employee file. The facility also failed to report the incident to the Department of Health as required.
Failure to Timely Report Alleged Abuse and Neglect
Penalty
Summary
The facility failed to immediately report an allegation of abuse and neglect involving a resident, which was brought to the attention of a staff member. The incident involved a resident who was cognitively intact and had diagnoses including major depressive disorder and muscle weakness. The resident reported to a Nursing Assistant Certified (NAC) that another staff member had been rude, initially refused to assist with removing a blanket, and threw a package of wipes near the resident's head, startling them. This incident occurred on July 14, 2024, but was not reported to the state hotline until July 16, 2024, exceeding the 24-hour reporting requirement. Interviews with staff revealed that the NAC informed the nurse on duty and the prior Director of Nursing Services (DNS) about the incident, and a note was placed in the social services office. However, the mandated reporting to the state hotline was not done immediately as required by the facility's policy and state guidelines. The administrator acknowledged the delay in reporting, and the current DNS confirmed that such allegations should be reported to the state hotline promptly. This delay in reporting placed residents at risk for potential unidentified mistreatment.
Failure to Ensure Timely Certification of Nursing Assistant
Penalty
Summary
The facility failed to ensure that a staff member with a Nursing Assistant Registered (NAR) license completed the necessary training and certification to become a Nursing Assistant Certified (NAC) within four months of hire. Staff E was hired on April 24, 2024, as a NAR and was required to complete the NAC class and pass the state license exam by August 24, 2024. However, Staff E continued to work as a NAR beyond this date, specifically on the night shifts of August 27 and August 28, 2024, without having completed the required certification. During an interview, the facility's administrator, Staff A, acknowledged that Staff E was involved in a program to become an NAC but was unaware of their completion status. It was later confirmed via email that Staff E was no longer eligible to work as a NAR after August 24, 2024, and had been removed from the schedule.
Unqualified Director of Food and Nutrition Services
Penalty
Summary
The facility failed to ensure that the person designated as the Director of Food and Nutrition Services, Staff J, had the proper qualifications. Staff J, who had been employed at the facility since December 7, 2021, was not a certified Dietary Manager (DM) and was not enrolled in a program to obtain the necessary certification. This was confirmed during an interview on May 23, 2024, when Staff J stated they were not a certified DM and had been in the position for a short time. Additionally, the Chief Operating Officer, Staff A, acknowledged that Staff J was not yet enrolled in a certification program. This deficiency placed all residents at risk of receiving dietary services from staff without the required competencies and skills to carry out food and nutrition services.
Infection Control Deficiencies in Facility
Penalty
Summary
The facility failed to ensure staff compliance with Infection Prevention and Control Guidelines and national standards of practice across two hallways, affecting 14 residents who required Enhanced Barrier Precautions (EBP). Observations revealed that staff were not using appropriate personal protective equipment (PPE) such as gowns and gloves during high-contact activities for residents with wounds or indwelling medical devices. Interviews with staff indicated a lack of training and awareness regarding EBP, and no residents were observed to be on EBP during multiple walking rounds. Additionally, the facility's infection preventionist and other staff members were not clear on the implementation and requirements of EBP. The facility also failed to establish an infection surveillance plan during a COVID-19 outbreak, which affected 29 residents. The infection control log did not include an analysis, surveillance monitoring, or employee data related to the outbreak. Interviews with staff revealed that the outbreak was overwhelming, and many staff members were out sick. The Director of Nursing Services admitted that no summary or root cause analysis was completed for the outbreak, and the Chief Operating Officer was unaware of the lack of investigation and infection risk assessment. Furthermore, the facility did not implement a respiratory protection plan (RPP) for 28 of 59 employed staff, including NACs, licensed nurses, therapy staff, kitchen staff, housekeepers, and administrative staff. The facility also failed to establish a water management plan to monitor and control Legionella and other waterborne pathogens. Despite multiple requests, no water management plan was provided. Interviews with staff confirmed the absence of compliance with national infection control standards and the lack of a designated program administrator for the RPP since the previous infection preventionist left in December 2023.
Failure to Ensure Qualified Infection Preventionist
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP) met the necessary qualifications for experience, education, and training or certification to assume responsibility for the Infection Prevention Control Program (IPCP). The facility's policy required the IP to be qualified through special training certification, education, and experience, and to oversee various duties including surveillance, antibiotic stewardship, data analysis, outbreak management, and employee health and safety. However, the facility's IP, a Registered Nurse/Director of Nursing Services, only had a certificate of participation from another facility, which did not list any staff name or specific certification. Additionally, the staff roster did not reflect an IP on the facility's staff, and the facility was in a transition period for the IP role with a Licensed Practical Nurse (LPN) expected to take over the role in the future. Interviews with various staff members revealed that there had been turnover in the IP role, and there was uncertainty about the completion of infection control program tasks related to antibiotic stewardship, analysis, and assessment of infections. The facility had not had a designated IP since December 2023, and infection control practices were being managed by multiple staff members without proper qualifications. The documents provided by the facility showed incomplete data analysis and management of infections, and the staff responsible for infection control practices did not have the necessary credentials or certification. The facility's Chief Operating Officer acknowledged that the provided certification did not have a staff employee name and was unaware of any other documentation to support the qualifications of the staff in the IP role.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to ensure that each resident was treated with respect, dignity, and failed to promote and protect the rights of each resident. Resident 12, who had no cognitive impairment, reported feeling humiliated when staff refused to move a chair by the window for them to see the northern lights, citing fall risk as the reason. This incident was not logged in the facility's incident or grievance logs. Resident 19, who also had no cognitive impairment, experienced prolonged discomfort and pain due to delayed assistance after returning from dialysis. The resident felt neglected and believed they were labeled as a difficult patient, which affected the staff's attitude towards them. This issue was also not recorded in the incident or grievance logs. Resident 27, with multiple orthopedic conditions and no cognitive impairment, reported feeling humiliated due to having to wait for extended periods to be changed after a bowel movement. The resident attributed this to understaffing, and this incident was not documented in the facility's logs either. Resident 23, with multiple cardiac diagnoses and no cognitive impairment, expressed frustration at being told to go to bed by staff, which made them feel like a child. The resident preferred to stay up and walk to alleviate leg cramps. This issue was similarly not recorded in the facility's logs. The Chief Operating Officer acknowledged that residents should have a dignified existence and be treated with respect and dignity, and noted that these could be considered abuse allegations.
Failure to Report Communicable Disease Outbreak and Unexpected Death
Penalty
Summary
The facility failed to develop and implement policies and procedures for reporting a communicable disease outbreak and an unexpected death to the state reporting agency. Specifically, the facility did not report a COVID-19 outbreak that affected 29 residents between February and March 2024, nor did they log this outbreak on the state reporting log. Staff B, the Director of Nursing Services, and Staff A, the Chief Operating Officer, were unaware of the requirement to report and log communicable disease outbreaks. Additionally, the facility's infection log did not reflect staff affected by the outbreak, and there was no report filed with the Complaint Resolution Unit (CRU) for the COVID-19 outbreak during this period. The facility also failed to report and log the unexpected death of Resident 32, who had diagnoses including acute pulmonary edema, COPD, and CHF. Resident 32 was found unresponsive in their bed and passed away on May 5, 2024. There was no communication between the facility and the coroner regarding this unexpected death, and it was not logged in the state reporting log. Staff B admitted to being unaware that some unexpected deaths should be logged, reported, and investigated. Additionally, there was no Advance Directive or POLST form found in Resident 32's medical records, and Staff E stated that an unsigned POLST form would have been discarded. This is a repeat citation from a previous survey dated March 13, 2023.
Failure to Meet Professional Standards in Bowel Management, PEG Tube Care, and Resident Positioning
Penalty
Summary
The facility failed to ensure professional standards were met for several residents in various aspects of care. For two residents reviewed for bowel management, the facility did not administer necessary bowel medications as per physician orders, leading to prolonged periods without bowel movements. Resident 18 experienced significant constipation and pain due to irregular administration of Miralax and other bowel medications, while Resident 235 did not receive as-needed medications despite documented issues with bowel movements. Both residents' care plans lacked a focus on constipation, and staff interviews revealed a lack of awareness and adherence to bowel protocols. For residents with PEG tubes, the facility did not follow proper procedures for storing and labeling tube feeding supplies. Resident 30 and Resident 9 had tube feeding supplies that were not marked with dates or names, and there were no physician orders or care plan directions for the maintenance and replacement of these supplies. Observations showed that the supplies were not labeled, and unused formula was not stored according to manufacturer guidelines. Staff interviews confirmed the absence of a policy for PEG tube care and maintenance. The facility also failed to follow a toileting plan for a resident and did not ensure proper positioning and comfort for a hospice resident. Resident 8 was not offered toileting every two hours as per their care plan, leading to extended periods without being checked or toileted. Resident 6, who required repositioning every two hours and the use of heel protection boots, was observed in the same position for extended periods and without the necessary boots. Staff interviews indicated a lack of adherence to the care plan and confusion about the management of the resident's ROHO cushion for comfort and pressure relief.
Failure to Prevent Falls and Ensure Adequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision to prevent accidents for a resident with severe cognitive impairment and a history of falls. The resident, who was on an anti-psychotic medication that could cause sedation and unstable gait, experienced nine unwitnessed falls over a 90-day period. Despite being identified as a high fall risk, the resident's care plan interventions were not consistently updated or followed, and several falls resulted in injuries, including a head laceration that required hospital treatment and staples. The facility's fall assessment and management policy required a resident-centered fall prevention plan based on relevant assessment information, including medication reviews and identification of specific risks. However, the facility did not adequately review or update the resident's care plan after each fall. Interventions such as reminding the resident to use the call light and not leaving the resident unattended were either duplicated or not effectively implemented. Staff interviews revealed a lack of awareness and oversight regarding the resident's sun-downing behaviors and the potential impact of the anti-psychotic medication on fall risk. The facility's interdisciplinary team (IDT) did not conduct thorough root cause analyses or consider all contributing factors to the resident's falls. The Director of Nursing Services (DNS) and other staff members acknowledged the need for better oversight and completion of fall investigations. The Chief Operating Officer confirmed that the IDT should review the resident's health record, assessments, and conduct a root cause analysis to prevent further falls, but this process was not adequately followed for the resident in question.
Latest citations in Washington
Inaccurate PASARR screening affected two residents. One resident with vascular dementia, depression, and adjustment disorder had a PASARR level one that did not reflect mental health diagnoses, and staff stated it was inaccurate. Another resident with PTSD had a PASARR level one that did not include the PTSD diagnosis, with no additional PASARR level one or level two found in the EHR; staff stated the screening was not accurate and should have been repeated.
Undated open meds were found on 2 medication carts, including an open insulin vial and multiple open eye drop bottles with no dates. An LPN and an RN both stated the items should have been dated when opened, and the DON stated open multidose vials or bottles found without a date should be discarded immediately.
A resident with respiratory failure, HTN, and anxiety became SOB and diaphoretic, received a breathing tx, and was sent by EMS to the hospital. The facility could not locate the required SNF/NF to Hospital Transfer form or other transfer records showing what information was communicated to the receiving provider.
Care plans for two residents were not updated to match their current status and care needs. One resident had PTSD and generalized anxiety disorder and was receiving a psychotropic medication, but the care plan listed monitoring for antipsychotic and anticonvulsant meds that were not prescribed and did not include the anxiety diagnosis or related behaviors and interventions. Another resident had new upper and lower dentures, but the oral/dental care plan only noted edentulous status and difficulty chewing, with no mention of dentures or denture-related interventions.
Failure to Provide Individualized Activities: A resident with anxiety, depression, and weakness was cognitively intact but said they could not attend group activities because of leg problems and wanted more in-room activities. The resident mostly stayed in bed watching TV, and staff documentation showed only limited room visits with no consistent activity documentation despite a care plan goal for participation two to three times per week.
Failure to maintain heel offloading for a resident with a reopened DFU. A resident with dementia and dependence for mobility had a left heel wound that had healed and then reopened; the wound care provider recommended heel floating and pressure relieving boots at all times, but observations showed the resident in bed with heels on the mattress and later reclined in a wheelchair with the heel resting on the footrest strap and no boots in place. Staff stated the resident had not refused the boots or heel floating, and the care plan was not updated after the wound reopened.
Failure to Address Hearing and Vision Services for a Resident: A resident with dementia, bilateral hearing loss, and impaired vision was observed without eyeglasses or a hearing device, despite records showing admission with eyeglasses and a personal sound amplifier. The care plan addressed vision only and did not include hearing-related interventions, while staff interviews confirmed the resident’s hearing was strained and that the resident’s device use and vision needs were not fully reflected in the plan of care.
Respiratory care was not provided consistently for two residents receiving O2. One resident with COPD and chronic respiratory failure had an O2 order missing the indication for use and Sats parameters, no MAR documentation of O2 therapy, and inconsistent Sats charting. Another resident with respiratory failure was observed on continuous O2 via NC, but provider orders for O2 therapy and tubing changes were not present after readmission, despite the care plan stating the resident was dependent on O2.
A resident with dementia, hearing loss, and missing lower teeth had an MDS showing obvious or likely cavities or broken natural teeth, and the care plan identified oral/dental health problems with an intervention to coordinate dental care and transportation. Staff stated the resident’s dental needs were captured on the MDS, but no referral was made for dental services or follow-up with the dentist, and the DON said the lack of referral did not meet expectations.
Inaccurate Meal Intake Documentation: A resident with DM, dysphagia, and protein-calorie malnutrition was observed eating less than 25% of a meal, but the POC documented 76-100% intake. The CNA said the resident usually ate only 25-50% of meals and that intake was sometimes documented based on what a coworker reported. The LPN/RCM and DON stated meal intake should be documented accurately.
Inaccurate PASARR Screening for Two Residents
Penalty
Summary
The facility failed to ensure that two residents were screened for additional mental health supports through the PASARR process. Resident 97 was admitted with diagnoses including vascular dementia, depression, and adjustment disorder, and was able to make needs known. Review of the PASARR level one dated 04/10/2026 showed no mental health diagnoses and no need for a PASARR level two, even though the resident’s record included mental health diagnoses. During interview, the Regional Social Services staff and the Administrator stated the PASARR was inaccurate, needed modifications, and did not meet expectations. Resident 6 was admitted with diagnoses including heart failure, respiratory failure, and PTSD, and was able to make needs known. Review of the PASARR level one dated 03/30/2026 showed no serious mental illness indicators marked and no PASARR level two indicated, and the EHR contained no other documented PASARR level one or level two. The Social Services Director stated the hospital-provided PASARR was reviewed for accuracy and, if inaccurate, another level one would be completed, and stated this resident’s PASARR did not include PTSD and should have had another level one completed. The Administrator also stated the PASARR was not accurate and another level one needed to be conducted, but none could be located in the EHR.
Undated Open Medications on Medication Carts
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications for 2 of 3 sampled medication carts reviewed for medication storage and labeling, including carts on the 400 and 500 halls. On the 500 hall medication cart, an open vial of insulin and an open bottle of eye drops were observed with no dates. During interview, an LPN stated that when an insulin vial or bottle of eye drops is opened, it should be dated immediately and said both items should have been dated upon opening; the LPN stated they would dispose of the undated vial and bottle. On the 400 hall medication cart, two open bottles of eye drops were observed with no dates. During interview, an RN stated both bottles should have been dated as soon as they were opened and said they would get new eye drops and dispose of the undated bottles. The DNS/RN stated that if an eye drop was opened it should have been dated immediately and that any open multidose vial or bottle found without a date should be discarded immediately.
Missing Hospital Transfer Documentation
Penalty
Summary
The facility failed to ensure hospital transfer documentation was completed for one resident who was transferred to the hospital after complaining of not being able to breathe and appearing diaphoretic. The resident had diagnoses of respiratory failure, high blood pressure, and anxiety disorder, and was able to make needs known. A breathing treatment was provided, and the provider agreed to send the resident out for further evaluation, after which emergency transportation took the resident to the hospital. Record review found no documentation showing what information was provided or communicated to the receiving facility for the transfer. Staff stated that transfer documentation should have included a SNF/NF to Hospital Transfer form, the resident's face sheet, and the medication and treatment administration records, but they were unable to locate documentation showing these items were completed or sent for the resident's hospital transfer.
Care plans did not reflect current diagnoses, medications, or denture status
Penalty
Summary
The facility failed to ensure that care plans were revised and accurately reflected residents’ current status and care needs for 2 of 21 sampled residents. Resident 6 was admitted with diagnoses including heart failure, respiratory failure, and PTSD, and was able to make needs known. The EHR showed Resident 6 also had generalized anxiety disorder and was receiving a psychotropic medication, but the current care plan dated 05/05/2026 documented monitoring for side effects of antipsychotic and anticonvulsant medications even though Resident 6 was not prescribed those medications. The care plan also identified PTSD but did not include generalized anxiety disorder or behaviors to monitor and interventions related to PTSD or anxiety disorder. Staff F, LPN/CC, stated the care plan did not accurately reflect the resident’s current status or prescribed medications, and Staff B, DNS, stated it did not meet expectations because it did not address the anxiety disorder or target behaviors and interventions. Resident 71 was admitted with diagnoses including PTSD, high blood pressure, and depression and was able to make needs known. Observation on 05/06/2026 showed a denture cup by the sink with the resident’s name on the lid and new upper and lower dentures dated 01/12/26. The resident stated the lower dentures did not fit well and that denture adhesive had been provided, but the dentures still did not fit right and the resident had not told staff yet. The focused oral/dental care plan, initiated on 06/23/2026, identified the resident as edentulous and having difficulty chewing, but did not show that the resident had dentures or include interventions related to denture use or maintenance. Staff E, CNA, stated they had not seen the resident wear dentures and were unaware of the new dentures, Staff C, LPN/CC, stated the care plan should have been updated when the dentures were obtained, and Staff B, DNS, stated the care plan should have reflected the dentures and interventions.
Failure to Provide Individualized Activities
Penalty
Summary
The facility failed to provide individualized activities for Resident 5, who was admitted with diagnoses including anxiety disorder, depression, and weakness. The admission MDS dated 01/14/2026 showed the resident was cognitively intact. During interviews on 05/03/2026 and 05/06/2026, Resident 5 stated they could not attend in-person activities because of their legs, wanted more activities to occupy them, mostly stayed in bed watching TV, and did not remember the last time activities staff visited to offer activities. The resident also stated activities staff would need to offer something they were able to do because they had difficulty doing some activities. The activities care plan dated 12/26/2026 showed a goal for Resident 5 to participate in activities two to three times per week. Progress notes documented one visit on 12/22/2026 to provide a welcome packet and encourage participation in daily activities, but no further activity documentation was found in the progress notes. Staff H stated room visits should include puzzles, arts and crafts, visiting, and chatting, and that documentation was placed in tasks, but the task record showed no documentation of activities for the past 30 days. Staff J stated paper documentation existed for room visits and that Resident 5 was on a list for room visits every Monday and Wednesday, while the room visit documentation showed only four visits on 01/26/2026, 02/06/2026, 03/10/2026, and 04/08/2026.
Failure to Maintain Heel Offloading for Reopened DFU
Penalty
Summary
The facility failed to consistently implement pressure reducing strategies for a resident with a left heel diabetic foot ulcer that had reopened. The resident was admitted with diagnoses including left hip fracture with surgical repair, a blood clot of the left lower leg, and dementia, and was dependent on staff for mobility and unable to make needs known. The baseline care plan and care plan both included heel offloading interventions, and the wound care provider initially recommended heel floating with pillows or wedge and pressure relieving boots. The wound later resolved, but a weekly skin assessment documented that the left heel wound reopened and was very painful to touch. After the wound reopened, the contracted wound care provider documented that the DFU to the left heel had reopened and recommended the resident wear pressure relieving boots at all times. The current care plan reviewed after the wound reopened did not include new interventions related to the reopened wound. Observations showed the resident seated in a reclined wheelchair with the left foot/heel resting on the footrest strap and no pressure relieving boots in place, and later lying in bed with both heels directly on the mattress without being floated and without boots. Staff interviews indicated the resident had not refused the boots or heel floating, and the LPN/CC and DON stated the resident should have been assessed and the plan of care updated when the wound reopened.
Failure to Address Resident Hearing and Vision Needs
Penalty
Summary
The facility failed to address one resident’s hearing and vision needs. Resident 112 was admitted with diagnoses including a leg fracture, dementia, and hearing loss in both ears, and was able to make needs known. The record showed the resident lost their glasses and was given readers, but the resident did not wear them because they were concerned that wearing glasses that were not their prescription would further degrade their vision. Observation did not show glasses in the resident’s room, and the resident stated they did not use a hearing aid. The resident was observed to be hard of hearing, requiring an elevated voice and repeated questions to understand. The admission MDS dated [DATE] documented adequate hearing with hearing aid and adequate vision with corrective lenses, while the significant change MDS dated [DATE] documented moderate difficulty hearing without a hearing aid and impaired vision without corrective lenses. The care plan initiated 02/24/2026 addressed impaired vision with interventions to arrange consultation with eye care practitioners as needed and remind the resident to wear glasses, but it did not include a focus area or interventions for hearing loss or use of hearing aids. A resident clothing list showed the resident admitted with one pair of eyeglasses and one Super Ear headset personal sound amplifier, yet observation and interview showed the resident in bed without eyeglasses or a hearing device, with the amplifier stored in the bedside table drawer. Staff interviews confirmed the resident’s hearing was strained, that the hearing device and glasses were not being used, and that the resident’s hearing device use should have been included in the plan of care and the resident should have been referred for eye care assessment.
Respiratory Care Orders and Documentation Not Maintained
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for two residents receiving oxygen therapy. One resident with COPD and chronic respiratory failure with hypoxia was observed multiple times lying in bed receiving oxygen at 2 L via nasal cannula. The resident’s oxygen order, dated 02/15/2026, allowed 1 to 4 L per minute continuously via nasal cannula, but it did not include an indication for use or oxygen saturation parameters. The April and May 2026 MARs did not show documentation of oxygen therapy being provided, and the TARs showed only an order to change oxygen tubing if damaged or visibly soiled, not an order for oxygen therapy. Oxygen saturations were not documented consistently daily from 04/01/2026 through 05/04/2026. A second resident with respiratory failure, high blood pressure, and anxiety disorder was observed in the room receiving oxygen at 6 L via nasal cannula on multiple occasions. The resident stated they needed oxygen therapy to breathe, and the care plan identified the resident as dependent on oxygen and to receive oxygen per provider orders. However, provider orders reviewed on 05/04/2026 showed no orders for oxygen therapy or for changing oxygen tubing. Staff stated the oxygen and tubing-change orders had been discontinued when the resident went to the hospital and were not added back to the MAR or TAR when the resident readmitted to the facility.
Failure to Refer Resident With Identified Dental Needs
Penalty
Summary
The facility failed to ensure that Resident 112 received needed dental care. Resident 112 was admitted with diagnoses including a leg fracture, dementia, and hearing loss in both ears. Observation on 05/03/2026 showed the resident had missing lower teeth. The admission MDS, dated [DATE], documented obvious or likely cavities or broken natural teeth, and the care plan dated 02/24/2026 identified oral/dental health problems related to likely cavities or broken teeth with an intervention to coordinate dental care and provide transportation. During interviews, Staff G, Regional Social Services, stated Resident 112's dental needs were captured on the 02/24/2026 MDS and the resident was not referred for dental services. Staff M, Social Services Director, stated residents with dental needs should be referred to social services to be scheduled for assessment by a dental care practitioner, and that Resident 112 should have been referred after the MDS assessment. Staff B, DON, stated residents with identified dental needs should be referred for follow-up with a dentist and that Resident 112 should have been referred to the in-house dental provider; Staff B stated the lack of referral did not meet expectations.
Inaccurate Meal Intake Documentation
Penalty
Summary
The facility failed to accurately document the amount of food eaten for Resident 13, who was admitted with diagnoses including diabetes mellitus, dysphagia, and protein-calorie malnutrition. The quarterly MDS dated 02/12/2026 showed the resident was moderately cognitively impaired. During observation on 05/05/2026 at 12:09 PM, a meal tray was delivered to the resident’s room, set up on a bedside table, and the resident was observed eating slowly, eating less than 25% of the meal, then laying back in bed and closing their eyes while the tray remained in the room. Staff later removed the tray, but the POC documentation for lunch on 05/05/2026 recorded that Resident 13 ate 76-100% of the meal. During interview, the CNA stated the resident typically ate 25-50% of meals and never ate all of the food, and that if they did not pick up a tray they would ask a coworker what the resident ate before documenting it. The CNA stated they were told the resident ate 75-100% of lunch, so that is what was entered. The LPN/RCM stated staff should document meal intake accurately in POC, and the RN/DNS stated it was their expectation that all staff document meal intake accurately.
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