Spokane Valley Health And Rehabilitation Of Cascad
Inspection history, citations, penalties and survey trends for this long-term care facility in Spokane Valley, Washington.
- Location
- East 17121 Eighth Avenue, Spokane Valley, Washington 99016
- CMS Provider Number
- 505099
- Inspections on file
- 39
- Latest survey
- November 24, 2025
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Spokane Valley Health And Rehabilitation Of Cascad during CMS and state inspections, most recent first.
Multiple residents reported frequent delays in receiving assistance with ADLs and restorative care due to inadequate staffing. Residents described waiting extended periods for help with toileting and bathing, with some missing showers for days or weeks. Staff interviews confirmed that there were not enough nursing assistants to consistently provide care, and restorative aides were sometimes reassigned to cover floor duties, resulting in missed restorative services.
Three cognitively intact residents requiring ADL assistance did not consistently receive scheduled bathing as outlined in their care plans, with significant gaps between documented baths and no records of refusals or alternative care. Resident and staff interviews confirmed inconsistent bathing, and documentation was maintained only electronically.
Multiple residents experienced lapses in care due to staff not fully assessing, implementing, or documenting physician orders and interventions. This included unaddressed constipation, lack of timely blood sugar monitoring, improper insulin injection site rotation, delayed response to changes in condition, and incomplete documentation and follow-through on IV therapy orders.
A resident with complex medical needs experienced pain and distress during a transfer when only one staff member assisted, despite a care plan requiring two-person assistance with a mechanical lift. The incident, witnessed by a family member, was not thoroughly investigated by the facility, as key witnesses were not interviewed, staff statements were incomplete, and the reasons for not following the care plan were not explored.
Three residents with cognitive and physical impairments experienced repeated falls and injuries due to the facility's failure to develop and implement effective interventions for fall prevention and safe transfers. Care plans were not updated to address cognitive decline, impulsivity, or unsafe footwear, and staff frequently did not follow care plan instructions for supervision and assistance, resulting in unsupervised ambulation, inappropriate footwear use, and single-person transfers when two-person assistance was required.
A resident dependent on staff for bed mobility and transfers did not consistently receive the required two-person assistance with a mechanical lift, as staff frequently performed these tasks alone due to inadequate staffing levels. Staff reported high resident assignments and difficulty obtaining help, while ancillary staff with expired credentials were sometimes used for assistance. Additionally, the DON did not maintain a valid RN license for the state, resulting in a lapse in authorized nursing leadership.
A resident with advanced kidney disease was administered fluconazole at double the prescribed dose for several days due to a failure in the facility's medication administration process. The error was not documented in progress notes, and staff were unable to provide information on the discrepancy. The DON confirmed the error after reviewing the resident's records.
A resident with cognitive impairments experienced a fall during an external appointment, resulting in a hospital transfer. The facility failed to notify the resident's representative, who was responsible for medical decisions. The DON confirmed the incident should have been reported, but it was not communicated, and an investigation was still ongoing.
A resident with cognitive impairments and high fall risk was sent unaccompanied to an external appointment, despite needing staff assistance for daily activities. The care plan required close monitoring, but there was no assessment for safety during the appointment. Staff interviews revealed a lack of communication and coordination regarding the need for accompaniment.
A resident with severe cognitive impairment and a history of wandering and poor boundaries was found in another resident's room, engaging in inappropriate behavior. Despite a care plan requiring monitoring, the resident was able to enter the room and act without immediate intervention, leading to a deficiency in protecting residents from abuse.
The facility inaccurately submitted staffing data to CMS for Q1 2024, reporting levels below mandated requirements. The DON noted changes during this period might have led to incorrect reporting, and the Operations Director found unreported data from external staffing agencies.
The facility failed to provide appetizing and palatable food, affecting six residents who reported the food as horrible, tasteless, and sometimes unidentifiable. Observations confirmed meals were unappetizing and not at safe temperatures. The Dietary Manager was unaware of complaints and suggested a new cook might be hesitant to use spices.
The facility failed to implement enhanced barrier precautions for residents at risk of transmitting MDROs, with staff not using appropriate PPE during care. Infection prevention policies were outdated, and the water management plan was not specific to the facility. Hand hygiene practices were inadequate, and a resident with a positive TB skin test did not receive follow-up testing.
The facility failed to provide education and documentation for influenza and pneumococcal vaccines for four residents, despite policies requiring such actions. Residents with conditions like COPD, diabetes, and malnutrition were not documented as having received or been offered the vaccines, and staff were unable to locate necessary records.
The facility failed to document COVID-19 vaccination status and provide education on the vaccine for several residents with conditions like COPD and diabetes. Staff interviews revealed a lack of record audits and challenges in managing immunization processes.
The facility failed to maintain resident dignity for three individuals. A resident with a brain injury was undignifiedly referred to as a 'feeder' by staff. Two residents with urinary catheters had their collection bags uncovered, compromising their privacy. Staff interviews confirmed these actions were not in line with maintaining resident dignity.
A resident who required assistance with daily activities fell while being helped to the toilet, but the incident was not investigated or reported according to facility policy. Staff failed to document the fall, and the physician's assistant was notified five days later. The DON confirmed the incident should have been reported as a fall.
A facility failed to complete an accurate and timely PASARR for a resident with a mental health diagnosis. The resident was admitted with paranoid personality disorder, but the PASARR was completed four days late and did not reflect this diagnosis. Additionally, when the resident's diagnoses changed to include anxiety and depression, the PASARR was not updated to assess the need for specialized mental health services.
The facility failed to implement care plan interventions for three residents, leading to deficiencies in their care. A resident at risk for choking was observed eating without supervision, another with hemiplegia was not assisted out of bed for meals, and a third with ulcers did not receive required offloading of pressure. Staff were unaware or did not adhere to care plan instructions.
A facility failed to provide a complete discharge summary for a resident, omitting the recapitulation of care and services received. The resident, who was cognitively intact and required assistance with daily activities, was discharged after receiving therapy for a urinary tract infection and sepsis. The discharge summary lacked details on the destination and care provided, as confirmed by the DON.
The facility failed to provide consistent bathing and grooming for three residents, leading to poor personal hygiene. A resident with paraplegia was observed with greasy hair and facial stubble, despite a care plan for regular bathing. Another resident reported infrequent baths, and documentation confirmed irregular bathing schedules. A third resident, with obesity and candidiasis, kept a personal record showing significant gaps between showers. Staff interviews revealed challenges in completing bathing tasks due to time constraints and the absence of a dedicated bath team.
A resident with cognitive impairment and depression did not receive an adequate program of activities that matched their interests, leading to boredom and diminished quality of life. The facility's activity program was limited due to staffing issues, and staff acknowledged the need for more engaging activities.
A resident with a history of pressure ulcers did not consistently receive pressure-relieving interventions, leading to the reopening of a wound on their left heel. Despite a care plan that included repositioning and the use of a foam boot, staff often failed to apply these measures when the resident was in bed, contributing to the deterioration of the heel condition.
A facility failed to maintain consistent communication with a dialysis clinic for a resident with kidney disease and diabetes, as required by an agreement. The absence of dialysis communication forms on multiple occasions in July 2024 led to a lack of coordination in the resident's care. Staff interviews confirmed the importance of these forms for collaboration, highlighting a significant deficiency in the facility's processes.
The facility failed to ensure timely physician visits for two residents, leading to potential unmet medical needs. One resident with kidney disease and chronic UTIs had not seen a physician within the required timeframe, while another resident with anxiety and insomnia experienced issues with medication changes. Staff interviews revealed confusion about the required frequency of physician visits.
The facility did not complete annual performance reviews for three nursing assistants, AA, BB, and CC, as required. Staff AA, hired in May 2022, and staff BB and CC, hired in July 2023, lacked documentation of their evaluations. The Director of Nursing confirmed the absence of these reviews, placing residents at risk of receiving care from inadequately trained staff.
Two residents with severe mental health conditions did not receive necessary behavioral health services. One resident, with psychosis and schizoaffective disorder, lacked specific care plan interventions and had minimal psychiatric visits. Another resident, with major depressive disorder, had an incomplete care plan and unaddressed requests for increased medication and counseling. Staff were unaware of these needs, and the facility lacked a dedicated behavioral health provider.
An LPN administered incorrect doses of Azelastine and Mesalamine to a resident and omitted Acetylcysteine, Spiriva Respimat, and Ipratropium-Albuterol, resulting in a medication error rate of 12.5%. The LPN acknowledged the errors, citing the resident's preference and unawareness of the correct dose, as well as a delay in medication delivery.
During a survey, a facility was found to have expired medications and undated multi-dose vials in a medication room, along with missing refrigerator temperature logs. Unsecured insulin needles were also discovered in a closed unit, posing a risk of needlestick injuries. Staff were unsure of responsibilities for medication management and temperature logging.
A dietary staff member at the facility did not have the required Washington State Food Worker Card, instead possessing a non-approved certificate from Food Handler Solutions. The staff member worked several shifts in the kitchen without the appropriate credentials. The HR Manager was unaware of the certificate's invalidity in Washington State, leading to the staff member being barred from work until obtaining the correct credential.
A nursing assistant failed to perform hand hygiene during meal service, as observed in one of four meals. The staff member, identified as Staff JJ, was seen delivering meal trays and assisting residents with eating without washing hands between tasks. This included handling food items and utensils for multiple residents without proper hand hygiene. Staff JJ admitted to forgetting the procedure due to being busy, and the infection preventionist confirmed the requirement for hand hygiene between tasks.
The facility failed to provide necessary pharmacy services for three residents, leading to deficiencies in medication management. A resident with anemia did not receive Procrit injections due to incomplete pharmacy forms. Another resident with diabetes did not receive long-acting insulin, glargine, due to unavailability and lack of follow-up. A third resident with Multiple Sclerosis did not receive tizanidine and L-Lysine due to communication failures and unrequested pharmacy orders.
A resident did not receive prescribed medications, tizanidine and L-Lysine, due to improper discontinuation by nursing staff without proper authorization. The facility's Director of Nursing was unaware of the discontinuation, and Medical Records staff confirmed no unscanned orders existed. A signed provider order did not include these medications, highlighting a lapse in medication management procedures.
A facility failed to maintain complete and accurate medical records for a resident receiving Procrit for anemia treatment. The resident's MAR indicated an order for Procrit, but it was not documented as administered. Interviews revealed the resident received the medication at a nephrologist's office, but there was no documentation of this in the electronic medical record. Staff confirmed the lack of records and stated that information would need to be manually entered.
A resident with a history of dementia and aspiration was served an inappropriate meal texture, leading to a choking incident. Despite being on an L3 diet, which excludes certain textures, the resident was given tater tots, resulting in coughing and gagging. The dietary staff failed to follow the diet spread sheet, leading to the incident.
The facility failed to provide CPR in accordance with national standards to a resident with a Full Code status, moving the resident to a bed instead of performing CPR on a firm surface. Additionally, two staff members lacked current CPR certification credentials.
Insufficient Staffing Leads to Delays in ADL and Restorative Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the care needs of residents, specifically in the areas of activities of daily living (ADLs) and restorative nursing services. Multiple residents reported frequent delays in receiving assistance, including waiting extended periods for help with toileting and bathing. During a Resident Council meeting, all attendees stated they often had to wait a long time for care due to inadequate staffing, with some residents reporting missed showers for days or even weeks. One resident described using their cell phone to call the facility for help when their call light was not answered, and still experienced significant delays. Observations and interviews confirmed that residents were left waiting for basic care, such as being assisted off a bedpan or to the bathroom, and some residents were not receiving restorative programs for conditions like hand contractures. Staff interviews revealed that the facility had attempted to reassign duties among nursing assistants to address bathing needs, but this approach was ineffective and led to further staffing challenges. Staff members, including the Human Resource Director and LPNs, acknowledged that there were not enough nursing assistants to consistently complete showers and restorative services. The staffing coordinator confirmed that restorative aides were sometimes pulled to work the floor, resulting in restorative services not being provided. Facility leadership stated that staffing was based on resident census and state minimum requirements, but acknowledged issues with residents not being bathed. The deficiency was attributed to insufficient staffing rather than staff unwillingness to perform care.
Failure to Consistently Provide Scheduled Bathing for Residents Requiring ADL Assistance
Penalty
Summary
The facility failed to consistently provide bathing or showers for three of six sampled residents who required assistance with activities of daily living (ADLs), specifically bathing. Each of these residents was cognitively intact and able to make decisions regarding their care, and their care plans specified that they were to receive assistance with bathing at least twice a week, with bed baths to be provided if they refused or could not tolerate a shower. Documentation reviews revealed significant gaps between baths, with some residents going up to 28 or 34 days without a documented bath. There was no documentation indicating that the residents had refused baths or that alternative care, such as bed baths, was offered as per their care plans. Interviews with residents confirmed that they were not being bathed as scheduled, and one resident attributed the lack of bathing to insufficient staffing. Staff interviews corroborated that bathing was not being provided consistently, and all documentation was maintained electronically with no paper logs. The lack of consistent bathing and incomplete documentation of refusals or alternative care directly contradicted the interventions outlined in the residents' care plans.
Failure to Implement and Document Physician Orders and Interventions
Penalty
Summary
The facility failed to fully assess, implement, and document physician orders and interventions for multiple residents, resulting in unaddressed changes in condition and lack of appropriate care. For one resident with a history of constipation, there were repeated prolonged periods without bowel movements, with medical records showing gaps of up to 12 days. Despite standing and as-needed orders for various laxatives and enemas, documentation showed these interventions were not consistently administered or followed up on, and staff did not document the administration or effectiveness of these treatments. Additionally, after a dangerously low oxygen saturation was recorded, there was no documentation of frequent monitoring or administration of oxygen as ordered by the provider. Another resident with complex medical needs, including diabetes, did not have blood sugar checks performed as ordered, with staff only obtaining readings at bedtime instead of before meals and at bedtime. When blood pressure readings were out of range, the nurse withheld medication without a provider order or documented notification to the provider. For a resident receiving insulin, nurses continued to use the same injection site despite provider instructions to rotate sites due to bruising and tissue trauma, and there was no documentation of refusal to use alternative sites. Additionally, persistent complaints about a toenail were not escalated or monitored until the condition worsened and required medical intervention. The facility also failed to clarify and document orders related to intravenous therapy. One resident had an IV saline lock in place for a week after a one-time fluid administration, but there was no order or documentation for routine flushing and site maintenance as required by facility policy. Staff interviews confirmed that documentation and order transcription for IV care were incomplete, and the facility did not follow its own policy or provider orders for IV maintenance.
Failure to Conduct Thorough Abuse Investigation and Adhere to Care Plan
Penalty
Summary
The facility failed to conduct a complete and thorough investigation of an allegation of abuse involving a resident with complex medical conditions, including muscle weakness, difficulty walking, and right foot drop. The resident, who was dependent on staff for bed mobility and transfers, reported experiencing pain during a transfer when only one staff member assisted, contrary to the care plan requiring two-person assistance with a mechanical lift. The resident described being handled roughly and yelled at by the staff member during the incident, which was witnessed by a family member present in the room. A collateral contact also reported hearing the resident scream and noted that they had never observed two staff assisting the resident, despite frequent visits. The facility's investigation into the incident was incomplete. Although the investigation included interviews with the resident, a collateral contact, the staff member involved, other residents, and staff, there was no documentation of an interview with the family member who witnessed the event. Additionally, the investigation did not include a statement from the LPN assigned to the unit at the time of the incident. The staff interviews that were conducted were unsigned, undated, and mostly lacked staff titles, and the questions asked did not address the specifics of the incident or the staff member's conduct during the event. Furthermore, the investigation did not address why the staff member failed to follow the resident's care plan requiring two-person assistance, nor did it explore whether this practice was common among other staff or shifts. There was also no documentation that the facility inquired about the staff member's treatment of other residents or any observations of yelling. These omissions resulted in a lack of evidence demonstrating a thorough investigation as required by facility guidelines.
Failure to Develop and Implement Effective Fall Prevention and Transfer Interventions
Penalty
Summary
The facility failed to develop and implement adequate interventions to prevent falls and injuries for three residents with significant cognitive and physical impairments. For one resident with dementia, stroke, and right knee pain, the care plan did not address the resident's cognitive decline, impulsivity, or changes in bed mobility and transfer needs, despite multiple falls and documented confusion. Staff interviews revealed inconsistent awareness of care plan changes, and the care plan lacked specific interventions to address the resident's increasing tendency to self-transfer and not use the call light. Observations showed the resident wearing ill-fitting slippers and experiencing falls in various settings, including the dining room and their own room, with injuries such as head bumps and lacerations. The care plan was not revised to address the resident's mental decline, interrupted sleep, or the need for increased supervision during high-risk times. Another resident with severe cognitive impairment, a history of falls, and muscle weakness experienced multiple falls while ambulating unsupervised and wearing inappropriate footwear, such as open-toed sandals. The care plan instructed staff to provide direct supervision and use a walker for transfers, but the resident was observed walking independently and propelling themselves in a wheelchair without staff assistance. After falls, the only new intervention was to ask if the resident wanted to eat in a less stimulating environment, and there was no documentation of collaboration with the resident's representative to address unsafe footwear. Staff acknowledged that sandals were not appropriate but did not document efforts to replace them, and therapy notes regarding footwear assessment were unavailable. A third resident with muscle weakness and right foot drop required substantial assistance and the use of a sit-to-stand lift for transfers and bed mobility. However, staff interviews and observations revealed that transfers and bed mobility were frequently performed by a single staff member, contrary to the care plan's requirement for two-person assistance. Staff admitted to transferring the resident alone, sometimes physically lifting them without mechanical assistance, and not always following the care plan. The resident and a collateral contact confirmed that two-person assistance was rarely provided, and staff rationalized single-person transfers based on their own physical strength or convenience.
Failure to Provide Adequate Staffing and Maintain Valid RN Licensure
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of all residents, specifically for those requiring assistance with bed mobility and mechanical lift transfers. One resident with complex medical conditions, including muscle weakness, difficulty walking, and right foot drop, was dependent on staff for bed mobility and transfers. The resident's care plan required substantial or maximal assistance of two persons and the use of a sit-to-stand mechanical lift for transfers and repositioning. However, interviews and observations revealed that staff routinely performed these tasks alone, without the required second person, and staff reported being assigned to care for 14 to 18 residents per shift, making it difficult to comply with care plans and ensure resident safety. Multiple staff members confirmed that they often performed two-person transfers alone due to insufficient staffing, and that it was challenging to find assistance from other staff, including nurses who were occupied with other duties. Staff described situations where they had to physically move residents by themselves or seek help from ancillary staff, some of whom had expired credentials. Staff also reported that the nurse assigned to the unit was frequently unavailable to assist with transfers, and that the overall workload was too high for the number of staff present. Additionally, the facility failed to ensure that the Director of Nursing (DON) maintained a valid RN license authorizing them to work in the state. The DON's multi-state RN license had expired, and a temporary license issued in another state did not permit practice in the facility's state. This lapse in licensure was confirmed by both the state licensing board and the DON, who was unaware that the temporary license was not valid for practice in the facility's state. The administrator was informed of the invalid credentials and confirmed the need for a current state or multi-state license for the DON role.
Significant Medication Error Due to Incorrect Administration
Penalty
Summary
The facility failed to ensure that a resident received medication as ordered by the physician, resulting in significant medication errors. Resident 6, who was discharged from the hospital with orders to receive fluconazole 600mg daily until a specified date, was administered the medication twice daily for several days, effectively doubling the prescribed dose. This error occurred from 10/11/2024 to 10/15/2024, during which the resident was under the facility's care. The resident had advanced kidney disease and was to be closely monitored by nephrology, making the accurate administration of medication critical. The error was not addressed in the resident's progress notes, and the facility's staff were unable to provide information related to the discrepancy. The Director of Nursing, who began working at the facility after the incident, identified issues with the admission medication process and confirmed that the fluconazole administered did not match the hospital discharge orders. This constituted a significant medication error, as the facility did not ensure the resident's medication was administered according to the physician's orders.
Failure to Notify Resident's Representative of Fall and Hospital Transfer
Penalty
Summary
The facility failed to notify the resident's representative of an incident involving a fall and subsequent hospital transfer for a resident with significant cognitive impairments. The resident, who was dependent on staff for assistance with activities of daily living, had a surrogate decision-maker responsible for all medical and financial decisions. On a specific date, the resident experienced a fall during an external appointment, resulting in low back pain and necessitating a hospital transfer for evaluation. Despite the incident, there was no documentation indicating that the resident's representative was informed of the fall or the hospital transfer. Interviews conducted during the investigation revealed that the resident's representative was unaware of the fall and the appointment, expressing that they would not have consented to the appointment due to the resident's confusion and history of refusal with the type of provider involved. The Director of Nursing confirmed that the fall, which occurred outside the facility, should have been reported to all responsible parties. However, the incident had not been communicated to them, and an investigation was still ongoing more than a month after the event. The lack of notification to the resident's representative was a significant oversight in the facility's duty to inform responsible parties of incidents affecting the resident.
Failure to Provide Supervision for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure adequate supervision for a resident with significant cognitive impairments and a high risk of falls during an external appointment. The resident, who was dependent on staff for assistance with activities of daily living and had a history of seizures and involuntary movements, was sent to an appointment unaccompanied. The care plan required close monitoring and assistance from two staff members for transfers, yet there was no documentation of an assessment to determine the resident's safety in their wheelchair without accompaniment. Interviews revealed that the resident arrived at the appointment alone and confused, unable to provide their medical history or residence information. The resident's representative was not informed of the appointment and expressed concerns about the resident's safety. Staff interviews indicated a lack of communication and coordination regarding the need for accompaniment, with responsibilities for scheduling and assessing the need for supervision not clearly executed. The Director of Nursing and other staff members were unsure of the resident's needs for accompaniment, leading to the oversight.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse by another resident, which was identified during an investigation. Resident 2, who was severely cognitively impaired and had a history of wandering and poor physical boundaries, was found in Resident 1's room by Staff D, a Nursing Assistant. Resident 2 was observed with one hand on Resident 1's clothed breast and the other hand under the blankets. Despite being told to stop, Resident 2 responded aggressively, necessitating the assistance of two additional staff members to separate the residents. Resident 1, also severely cognitively impaired, did not recall the incident and showed no changes in behavior following the event. The investigation revealed that Resident 2 had a history of wandering into other residents' rooms and could be aggressive, as noted by Staff C, a Registered Nurse. Resident 2's care plan required staff to monitor their behavior due to poor physical boundaries. However, on the day of the incident, Resident 2 was able to enter Resident 1's room and engage in inappropriate behavior without immediate intervention. The facility's failure to adequately monitor Resident 2 and prevent the incident placed Resident 1 and potentially other residents at risk for harm.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to ensure accurate submission of direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) for Quarter 1 of 2024. This deficiency was identified through a review of the Payroll Based Journal (PBJ) submission, which is mandatory for reporting staffing information based on payroll data. The Certification and Survey Provider Enhanced Reports (CASPER) PBJ Staffing Data Report indicated that the facility reported staffing levels lower than the mandated requirements. During an interview, the Director of Nursing acknowledged that there were significant changes in the facility during this period, which may have led to incorrect reporting of hours. Additionally, the Operations Director later documented that there was unreported staffing data from external staffing agencies, supported by invoices from these agencies.
Facility Fails to Provide Palatable and Appetizing Food
Penalty
Summary
The facility failed to provide appetizing and palatable food for six out of seven sampled residents, which placed them at risk for decreased nutritional intake and a diminished quality of life. Observations and interviews revealed that residents consistently described the food as horrible, lacking taste, and sometimes unidentifiable. Specific complaints included meals that seemed incomplete, such as missing vegetables, and dishes that were unappetizing in appearance and taste, like mushy meat and lasagna without cheese or meat. Residents also reported that the food was often cold, and one resident described a meal where the meat was so fused to the bones that it was inedible. A test tray observation confirmed that the food was not colorful or appetizing, with temperatures outside acceptable parameters. The meal consisted of brown meatloaf, white mashed potatoes, white cauliflower, off-white banana cream pie, and a dark purple fruit-flavored drink, all of which were bland in taste. The Dietary Manager, when informed of the complaints, was unaware of any issues and suggested that a new cook might be hesitant to use available spices and seasonings. Despite claiming to taste the food during preparation, the manager's statements did not align with the residents' experiences.
Inadequate Infection Control and Prevention Measures
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for four residents who were at risk of transmitting multi-drug resistant organisms (MDROs). Resident 69, who had a stage 4 pressure ulcer and an indwelling urinary catheter, was observed without proper signage or personal protective equipment (PPE) in place. Staff members were seen entering the room and providing care without wearing gowns, contrary to the care plan instructions. Similarly, Resident 1, who required EBP due to an indwelling catheter, was not provided with the necessary PPE during care activities, as staff only used gloves and not gowns. Resident 7, who had a feeding tube and required EBP, was also not provided with the appropriate PPE during medication administration and personal care. Staff members failed to wear gowns, and one staff member was unaware of the EBP requirements. Resident 73, who had a PICC line, was not given the necessary precautions during medication administration, as staff did not wear gowns despite the presence of EBP signage. These lapses in infection control practices placed residents at risk of cross-contamination and infection. The facility also failed to maintain its infection prevention policies and water management plan. The infection prevention policies had not been reviewed annually as required, and the water management plan was outdated and not specific to the facility. Additionally, hand hygiene practices were inadequate during wound care and medication administration, as staff did not perform hand hygiene when changing gloves. Furthermore, a resident with a positive tuberculosis skin test did not receive appropriate follow-up testing, indicating a lapse in tuberculosis surveillance.
Failure to Provide Vaccine Education and Documentation
Penalty
Summary
The facility failed to ensure that residents were provided with education regarding the risks and benefits of influenza and pneumococcal immunizations, and that they received the immunizations or did not receive them due to contraindications or refusals. This deficiency was identified for four out of five sampled residents. The facility's policies, revised in 2022 and 2023, required that residents and family members receive education about the benefits of these vaccines, and that residents be offered the vaccines unless contraindicated, already received, or refused. However, a review of resident records revealed a lack of documentation for education, consent, or refusal for the vaccines. Resident 36, with diagnoses including COPD and diabetes, had no documentation of receiving or being offered the vaccines. Resident 48, with morbid obesity and diabetes, was not documented as having received the vaccines, and there was no explanation for their ineligibility. Resident 66, with malnutrition and diabetes, and Resident 69, with diabetes and pressure ulcers, also had no documentation of receiving or being offered the vaccines. The Director of Nursing was unable to locate the necessary documentation, and the Infection Prevention staff acknowledged that the immunization process was incomplete and that no audits had been conducted to ensure compliance.
Deficiency in COVID-19 Vaccination Documentation and Education
Penalty
Summary
The facility failed to ensure that resident records included evidence of COVID-19 vaccination status, education regarding the vaccine, and documentation of vaccine offers, refusals, contraindications, or administrations for four out of five sampled residents. This deficiency was identified during a review of resident records, which showed no documentation of COVID-19 vaccination or booster doses, complete immunization history, or education on the risks and benefits of the vaccine for Residents 36, 48, 66, and 69. These residents had various diagnoses, including chronic obstructive pulmonary disease, diabetes, morbid obesity, malnutrition, and pressure ulcers. Interviews with facility staff revealed that the Director of Nursing was unable to locate the necessary documentation for the residents in question. Additionally, the Registered Nurse responsible for Infection Prevention acknowledged that the facility had been working on the immunization process but had not been conducting record audits to ensure vaccines were offered or education was provided. The nurse also mentioned that they had been handling both Infection Prevention and Resident Care Manager duties, which hindered their ability to follow up on the vaccination process.
Dignity Issues in Resident Care
Penalty
Summary
The facility failed to provide care in a dignified manner for three residents, leading to a deficiency in resident rights. Resident 4, who had a traumatic brain injury and spastic hemiplegia, was referred to as a 'feeder' by staff, which was considered undignified. During a meal observation, a staff member instructed others to serve residents needing assistance last, using the term 'feeders.' Interviews with staff revealed discomfort with this terminology, indicating a lack of awareness about appropriate language to use for residents requiring feeding assistance. Resident 58, who had an indwelling urinary catheter due to benign prostatic hyperplasia and neurogenic bladder, was observed with an uncovered urine collection bag during a meal. The resident expressed discomfort with the visibility of the urine and mentioned that the cover for the bag was sent to the laundry, leaving them without a replacement. This lack of privacy was noted as a dignity issue, as the resident felt exposed without the cover. Resident 67, diagnosed with prostate cancer and chronic urinary retention, also used a urinary catheter. Observations showed the urine collection bag was frequently left uncovered and placed on the floor. Staff interviews confirmed that the bag should have been stored in a privacy bag to maintain dignity. The Director of Nursing acknowledged this oversight, recognizing it as a dignity issue, as the resident often transferred themselves, leaving the catheter bag exposed.
Failure to Investigate Resident Fall
Penalty
Summary
The facility failed to investigate a fall involving a resident, identified as Resident 285, who required partial to moderate assistance with activities of daily living. According to the facility's policy on Fall Response and Management, nursing staff were required to complete a post-fall investigation, notify the physician, and communicate the event and any intervention changes to the staff. However, after Resident 285 fell on 08/02/2024 while being assisted to the toilet, these procedures were not followed. The fall was not documented in the accident and injury log, and the physician's assistant was not notified until five days later. Interviews with staff revealed discrepancies in the recognition and reporting of the fall. Staff D, a Nursing Assistant, witnessed the incident but did not classify it as a fall since the resident did not hit the ground. Staff E, an LPN, was unaware of any falls since the resident's admission and noted that an x-ray was conducted due to pain complaints, which showed no injury. The Director of Nursing later confirmed that the incident should have been reported and investigated as a fall, as it involved an unintentional change in position.
Failure to Complete Accurate and Timely PASARR
Penalty
Summary
The facility failed to ensure that a Pre-Admission Screening and Resident Review (PASARR) was completed accurately and prior to the admission of a resident with a mental health diagnosis. Specifically, Resident 23 was admitted with a diagnosis of paranoid personality disorder, but the PASARR completed by a social worker four days after admission did not indicate any serious mental health indicators, and the box for personality disorders was unchecked. Furthermore, when additional mental health diagnoses of anxiety and depression were added to Resident 23's record, the facility did not complete a new PASARR to assess the need for specialized mental health services. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged the requirement for PASARR completion prior to admission and updates when changes occur.
Failure to Implement Care Plan Interventions for Residents
Penalty
Summary
The facility failed to implement care plan interventions for three residents, leading to deficiencies in their care. Resident 1, who was at risk for choking, was observed eating without the required supervision and assistance, despite care plan instructions to monitor and cue the resident for safety. Staff members were unaware of the need for supervision, indicating a lack of adherence to the care plan. Resident 4, diagnosed with hemiplegia and difficulty swallowing, was supposed to be assisted out of bed for meals in the dining room or supervised in the hallway. However, the resident was repeatedly observed eating in bed without the necessary supervision, contrary to the care plan. Staff were uncertain about the reasons for the dining room requirement and did not document refusals to get out of bed, showing a gap in following care plan directives. Resident 283, who had ulcers on their lower extremity, required offloading of pressure from their heels as per the care plan. Observations showed the resident's heel resting on the mattress without offloading, and staff acknowledged the need for reminders to ensure compliance. The Director of Nursing confirmed the necessity of offloading for residents with wounds, highlighting the failure to implement this intervention.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to complete a discharge summary for a resident, which included a recapitulation of the resident's stay, as required by regulations. This deficiency was identified for a resident who was cognitively intact and required assistance with activities of daily living. The resident was admitted for physical and occupational therapy following a urinary tract infection and sepsis. Upon discharge to another facility, the discharge summary completed by a Physician Assistant did not specify the destination or provide a detailed account of the care and services received during the resident's stay. The Director of Nursing confirmed that a recapitulation of stay/discharge summary is necessary when a resident is discharged.
Inconsistent Bathing and Grooming in LTC Facility
Penalty
Summary
The facility failed to consistently provide necessary bathing and grooming assistance to three residents, leading to deficiencies in personal hygiene and care. Resident 1, diagnosed with paraplegia and dependent on staff for activities of daily living, was observed with greasy hair and facial stubble, indicating a lack of regular bathing and shaving. Despite having a care plan that required bathing up to twice a week, records showed infrequent bathing, with significant gaps between documented bathing dates. Interviews with staff revealed challenges in completing bathing tasks due to time constraints and the absence of a dedicated bath team. Resident 43, who required moderate assistance for bathing, reported dissatisfaction with the frequency of their baths, which were supposed to occur twice weekly. Documentation showed that the resident was bathed only a few times over several months, far less than the scheduled frequency. Staff interviews confirmed the difficulty in adhering to the bathing schedule due to the time required for each resident and the competing demands of other care tasks. Resident 5, with diagnoses including obesity and candidiasis, also experienced irregular bathing despite a care plan specifying showers twice a week. The resident kept a personal record of their bathing schedule, which highlighted significant lapses between showers. Staff interviews acknowledged the issue, noting that missed showers were supposed to be made up by the next shift, but this was not consistently happening. The lack of regular bathing was recognized as a concern for maintaining skin health and preventing infections.
Inadequate Activity Program for Resident
Penalty
Summary
The facility failed to provide an ongoing program of activities that met the interests of a resident with moderate cognitive impairment, dementia, and depression. The resident expressed interest in activities such as books, music, animals, religion, spending time outdoors, and group activities. However, the resident's participation in activities was limited, with records showing involvement in arts and crafts twice, music once, an outside activity, and an entertainment activity once. Observations revealed the resident was often not engaged in activities, and staff interviews confirmed a lack of sufficient activities on the unit. Staffing issues contributed to the deficiency, as the Activity Director mentioned being short-staffed and having difficulty retaining an activities assistant. Staff members, including a Nursing Assistant and a Registered Nurse, acknowledged the lack of activities and the need for more hands-on and stimulating options for residents. The Director of Nursing also recognized the need for growth in the activities program and was in the process of initiating spiritual services. Despite the resident's expressed interests, the facility did not adequately provide activities that aligned with those interests, leading to the resident experiencing boredom and a diminished quality of life.
Inconsistent Pressure Ulcer Care for Resident
Penalty
Summary
The facility failed to consistently implement pressure-relieving interventions for a resident with a history of pressure ulcers, specifically on the left heel. The resident, who had a traumatic brain injury, hemiplegia, and a Stage 3 pressure ulcer on the left heel, was observed multiple times without the necessary protective boot or pillows to elevate the heels while in bed. Despite having a care plan that included the use of an air overlay mattress, repositioning every 2-3 hours, and floating heels, these interventions were not consistently applied, leading to the reopening of a wound on the resident's left heel. Observations and interviews revealed that while the resident wore a foam boot when in a wheelchair, staff often needed reminders to elevate the resident's heels or apply the boot when the resident was in bed. Staff acknowledged the inconsistency in following the care plan, noting that the resident sometimes kicked pillows away but did not remove the foam boot. The lack of consistent application of pressure-relieving measures contributed to the deterioration of the resident's heel condition, as evidenced by the presence of a wound covered with black eschar and subsequent observations of a dark red area with drainage.
Failure in Dialysis Communication and Coordination
Penalty
Summary
The facility failed to maintain consistent and ongoing communication and collaboration with the dialysis facility for a resident who required dialysis services. Resident 65, who had kidney disease and diabetes, was admitted to the facility and required dialysis treatment. An agreement between the facility and the dialysis center stipulated that care for residents receiving dialysis should be coordinated to ensure continuity of care and the resident's well-being. However, the facility did not adhere to this agreement, as evidenced by the absence of dialysis communication forms on multiple occasions in July 2024. These forms were meant to be sent with the resident to the dialysis clinic and returned with them to ensure any necessary changes to the resident's care could be processed. Interviews with facility staff revealed that the communication forms were not consistently returned with the resident, and there was a lack of follow-up when forms were missing. Staff E, a Registered Nurse, acknowledged that the forms did not always return with the resident and emphasized the importance of contacting the clinic if the forms were not returned. Staff B, the Director of Nursing, confirmed that the facility used these forms for communication with the dialysis clinic and that they should have been sent and received consistently. The failure to maintain this communication placed the resident at risk for unmet care needs and medical complications.
Failure to Ensure Timely Physician Visits for Residents
Penalty
Summary
The facility failed to ensure that residents were seen by a physician within the required timeframes, affecting two of the eight sampled residents. Resident 59, who had kidney disease and chronic urinary tract infections, expressed concerns about not having seen a physician despite requesting to do so. The last documented physician visit for Resident 59 was on 06/12/2024, with a significant gap since the previous visit on 09/18/2023. The facility's records indicated that a physician's assistant had seen the resident multiple times, but there was no documentation of a physician visit within the required three-month interval. Resident 5, who had generalized anxiety disorder and insomnia, was also affected by the facility's failure to adhere to the required physician visit schedule. The resident preferred being seen by a physician assistant and reported issues with medication changes made by a physician. The review of records showed that Resident 5 had not been seen by a physician within the required 90-day interval between 10/18/2023 and 01/31/2024. Interviews with staff revealed confusion about the required frequency of physician visits, with discrepancies in understanding whether visits should occur every 60 or 90 days.
Failure to Conduct Annual Performance Reviews for Nursing Assistants
Penalty
Summary
The facility failed to complete a yearly performance review for three sampled nursing assistants, identified as AA, BB, and CC, as required by regulations. Staff AA was hired on May 3, 2022, and there was no documentation of an annual performance evaluation. Staff BB and CC were hired on July 1, 2023, and July 13, 2023, respectively, and similarly lacked documentation of their annual performance evaluations. This oversight was confirmed through an email correspondence with the Director of Nursing, who acknowledged that no annual performance reviews had been completed for these staff members. This failure placed residents at risk of receiving care from inadequately trained staff.
Failure to Provide Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health services for two residents, leading to a deficiency in care. Resident 7, who was admitted with severe mental health conditions including psychosis and schizoaffective bipolar disorder, was not provided with adequate behavioral health services. Despite a PASARR level II assessment indicating the need for specialized services, the resident's care plan lacked specific goals or interventions for their behavioral health needs. The resident was only seen once by a Psychiatric Nurse Practitioner, and there were no further documented behavioral health visits, leaving the resident without the necessary support for their mental health conditions. Resident 36, diagnosed with major depressive disorder and borderline personality disorder, also did not receive appropriate behavioral health services. The resident's care plan was incomplete, lacking specific interventions for their depression and anxiety. Despite a provider's order for psychiatric evaluation and treatment, there was no documentation of mental health services being provided by Social Services. The resident expressed a need for increased antidepressant dosage and counseling, but these needs were not addressed, and no appointments were made for counseling. Interviews with staff revealed a lack of awareness and follow-through regarding the residents' behavioral health needs. The Director of Nursing acknowledged that PASARR level II recommendations were not implemented due to a change in social workers and the absence of a dedicated behavioral health provider. The facility's current provider group was unable to offer comprehensive behavioral health services, resulting in unmet needs for the residents.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, as evidenced by five medication errors identified for one resident during 40 medication opportunities, resulting in an error rate of 12.5 percent. During an observation, a Licensed Practical Nurse (LPN) administered medications to a resident, including Mesalamine and Azelastine nasal spray, but failed to administer Acetylcysteine, Spiriva Respimat, and Ipratropium-Albuterol. The incorrect doses of Azelastine and Mesalamine, along with the omission of the other medications, constituted medication errors. The LPN acknowledged administering the incorrect dose of Azelastine and Mesalamine and omitting the other medications. The LPN stated that the resident preferred two sprays of Azelastine and was unaware of the incorrect Mesalamine dose at the time of administration. The LPN also mentioned that the omitted medications were out of stock and had been ordered from the pharmacy the previous week but had not yet been delivered.
Medication Management and Security Deficiencies
Penalty
Summary
The facility failed to ensure proper management of medications and medical supplies, as observed during a recertification survey. In one of the medication rooms inspected, expired medications were not disposed of, and multi-dose vials were not dated when opened. Specifically, a multi-dose vial of tuberculin serum was found without an opening date, and several expired items, including needles, Heparin flushes, sodium bicarbonate tablets, and B-complex multi-vitamins, were present. Additionally, there were no current logs for refrigerator temperatures for August 2024, and previous months' logs had multiple omissions. Staff O, an LPN, acknowledged the lack of dating on the multi-dose vials and disposed of the expired medications but was unsure about who was responsible for maintaining the medication room and logging refrigerator temperatures. Furthermore, the surveyors found unsecured insulin needles in a closed nursing station on a unit that had been shut down since May 2024. The needles were stored in unlocked cabinets, posing a risk of needlestick injuries. Although there were no residents in the vicinity at the time of the initial observation, residents from an assisted living facility were later seen walking past the unsecured area. Staff B, the Director of Nursing, was unaware of the unsecured needles and emphasized the importance of securing them to prevent resident access. The maintenance staff was notified, and the unsecured needles were subsequently removed.
Dietary Staff Lacked Valid Food Worker Card
Penalty
Summary
The facility failed to ensure that dietary staff had the required qualifications, specifically a current Washington State Food Worker Card, for one of the twelve dietary staff reviewed. Staff EE, who was hired on June 21, 2024, did not possess the necessary state-approved food worker card. Instead, Staff EE had a certificate from Food Handler Solutions, dated July 4, 2024, which was not recognized as valid in Washington State. This certificate was intended only for personal development and preparation for state-provided training. Staff EE worked in the kitchen from August 1st to 4th and August 7th to 11th, without the appropriate credentials. During an interview, the Human Resources Manager, Staff P, admitted to verifying food handler's cards by obtaining the receipt and confirmation number but was unaware that the Food Handler Solutions Certificate was not valid in Washington State. Consequently, Staff EE was not allowed to continue working until obtaining the appropriate credential through the Washington State Department of Health.
Failure to Perform Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to ensure proper hand hygiene was performed by a nursing assistant, identified as Staff JJ, during meal service, which was observed during one of four meals. On multiple occasions, Staff JJ was seen delivering meal trays to residents without performing hand hygiene between tasks. Specifically, Staff JJ was observed pushing a resident in a wheelchair into the dining room and then delivering a meal tray to another resident, cutting a sandwich, and refilling a coffee cup without washing hands. This pattern continued as Staff JJ handled meal trays for additional residents, unwrapping food items, pouring water, and placing utensils without performing hand hygiene. Further observations revealed that Staff JJ delivered a meal tray to a resident in their room, assisted the resident to sit up, and then proceeded to another room with a meal tray without washing hands. Additionally, Staff JJ was seen assisting a resident with eating by spooning food into their mouth without prior hand hygiene. In an interview, Staff JJ acknowledged the need for hand hygiene between passing meal trays but admitted to forgetting due to being busy. The infection preventionist confirmed that hand hygiene should be performed when entering or exiting a resident's room and between handling meal trays.
Deficiencies in Medication Management for Three Residents
Penalty
Summary
The facility failed to provide necessary pharmacy services to meet the needs of three residents, leading to deficiencies in medication management. Resident 1, diagnosed with anemia, was not administered Procrit injections as ordered due to the facility's failure to complete necessary pharmacy forms, resulting in the resident's family having to arrange for the medication to be administered externally. The facility's Director of Nursing (DNS) claimed that the medication was not refused due to cost, but there was no follow-up with the pharmacy once the resident's representative took over the medication administration. Resident 2, who has diabetes, did not receive their prescribed long-acting insulin, glargine, from the time of admission. The medication was not available in the facility, and there was no documentation of follow-up with the pharmacy or notification to the provider about the unavailability of the medication. The DNS was unaware of the missing medication and acknowledged that the pharmacy should have sent it with the other admission medications. Resident 3, diagnosed with Multiple Sclerosis, did not receive their prescribed tizanidine and L-Lysine due to a lack of communication and follow-up between the facility and the pharmacy. The DNS was not aware of the discontinuation of these medications and noted that the orders were discontinued by nursing staff who were not present. The facility's central supply did not stock L-Lysine, and it was not requested from the pharmacy, leading to the resident not receiving the supplement as ordered.
Failure in Medication Management for a Resident
Penalty
Summary
The facility failed to adhere to professional standards of practice in medication management for a resident, leading to the discontinuation of prescribed medications without proper authorization. Specifically, the resident was not provided with the prescribed muscle relaxant tizanidine from July 3 to July 7, and the order was discontinued on July 8. Similarly, the over-the-counter supplement L-Lysine was not administered from July 3 to July 8, with the order discontinued on July 9. There was no documentation in the resident's July 2024 Medication Administration Record (MAR) or progress notes regarding these medications, and a provider note dated July 8 did not list any medication changes. Interviews with facility staff revealed a lack of awareness and documentation regarding the discontinuation of these medications. The Director of Nursing (Staff A) was unaware of the circumstances and confirmed that the orders were discontinued by nursing staff without electronic signatures from an authorized health care practitioner. Medical Records staff (Staff E) confirmed that all current provider orders were scanned into the electronic records, and no unscanned orders existed for the resident. A signed provider order dated July 11 did not include the tizanidine and L-Lysine, indicating a lapse in following proper procedures for medication management.
Incomplete Medical Records for Resident Receiving Procrit
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, specifically regarding the administration of Procrit, an injectable medication for anemia treatment. The resident's Medication Administration Record (MAR) for July 2024 indicated an order for Procrit to be administered once daily every 14 days, starting on July 11, 2024. However, the MAR showed that the resident was not receiving the medication. A progress note from July 9, 2024, mentioned that the resident's family would provide the Procrit, but there were no subsequent notes confirming that the medication was administered, either at the facility or during external provider visits. Interviews with facility staff revealed that the resident received Procrit at their nephrologist's office, but there was no documentation in the resident's electronic medical record regarding the transport to the external provider or the treatment received. The Director of Nursing confirmed the lack of records from the nephrologist's office and stated that staff would have to manually enter such information into the resident's record. The Medical Records staff also confirmed that they had not been instructed to follow up or add any records to reflect the care and services provided during the resident's external visits.
Failure to Provide Appropriate Diet Texture
Penalty
Summary
The facility failed to provide a resident with the appropriate diet texture, leading to a choking hazard. The resident, who had a history of dementia, stroke, and aspiration, was on a mechanically altered diet as per physician orders. Despite the resident's diet being downgraded to L3: Advanced texture, which excludes hard, crunchy, and sticky foods, they were served a meal that included tater tots, a food not suitable for their dietary needs. This resulted in the resident coughing and gagging, requiring staff intervention to clear their airway. The incident occurred because the dietary staff did not adhere to the diet spread sheet, which clearly outlined the necessary substitutions for residents on an L3 diet. The cook and nursing assistant involved were not fully aware of the resident's dietary restrictions, leading to the inappropriate meal being served. The dietary manager or cook in charge was responsible for posting the diet spread sheet daily, but inconsistencies in the spreadsheet's accuracy led to staff not consistently checking it. This oversight placed the resident at risk for decreased nutritional intake and serious injury.
Failure to Provide Effective CPR and Ensure Staff Certification
Penalty
Summary
The facility failed to ensure staff provided CPR in accordance with national standards for effective CPR to a resident with a Full Code status. The resident was found on the floor by a nursing assistant and was still breathing at that time. However, the resident stopped breathing and no longer had a pulse by the time additional staff arrived. Instead of performing CPR on the firm surface of the floor, the staff moved the resident to the bed, which is a soft surface, and began CPR without a backboard. This action was against the American Heart Association (AHA) guidelines, which recommend performing CPR on a firm surface. The facility's emergency cart, which contained a backboard, was not utilized during the incident. Staff B, who was involved in the incident, did not provide a clear reason for moving the resident to the bed before starting CPR. Additionally, Staff C, who assisted, was under the impression that the resident was already deceased and was being moved for post-mortem care. The facility also failed to ensure that two staff members, Staff B and Staff D, had current CPR certification credentials. Staff B's employee file did not contain a CPR card, and although Staff B verbally reported having a current CPR card, it was not provided to the facility. Similarly, Staff D's employee file did not contain a CPR card, and there was no documentation to confirm attendance at a CPR class provided by the facility. The Director of Nursing acknowledged these deficiencies and noted that the facility had identified concerns related to the provision of effective CPR during their investigation.
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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