The Oaks At Timberline
Inspection history, citations, penalties and survey trends for this long-term care facility in Vancouver, Washington.
- Location
- 400 East 33rd Street, Vancouver, Washington 98663
- CMS Provider Number
- 505206
- Inspections on file
- 22
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at The Oaks At Timberline during CMS and state inspections, most recent first.
Incomplete Care Plan for Diabetes and Insulin Use: A resident with DM was cognitively intact and receiving insulin, with an order for diabetic nail care and a later order for insulin glargine at bedtime. However, the comprehensive care plan did not include a diabetes or insulin focus/goal, and the Kardex also did not identify the resident as diabetic or note the nail care order. Staff stated they relied on the Kardex for care needs, and the DON said the Kardex was triggered from the care plan and that a diabetes care plan should have been present.
Medication administration was not done according to professional standards for one alert and oriented resident. A cup with several pills was left on the bedside table while the nurse left to get water, and the resident swallowed the medication without the nurse present. The record did not show approval for the resident to keep meds in the room or self-administer them, and the DON and an LPN stated staff were supposed to observe medication administration and not leave meds in a resident’s room.
Failure to use EBP during wound care for a resident with a Stage 3 pressure ulcer. The resident had an open wound to the mid back, but no EBP order, care plan, or sign was in place. During wound care, an LPN and the resident care manager entered the room without gowns, and the IP later stated the resident should have been on EBP. The DON said residents with open pressure wounds were expected to be on EBP.
The facility failed to label and date food items in the kitchen walk-in refrigerator, leading to the presence of expired, undated, and unlabeled opened items. The Dietary Supervisor acknowledged the oversight and discarded the items, while the Administrator confirmed the expectation for proper labeling and dating according to facility policy.
A resident with a history of depression and anxiety called for help after losing balance in bed, but an LPN did not assist, citing medication distribution duties. The resident felt unsafe and uncomfortable with the LPN's care, which exacerbated her anxiety and PTSD. The incident was reported, but the facility's investigation was unsubstantiated.
A facility failed to accurately complete the MDS assessment for a resident with diabetes mellitus. The MDS incorrectly indicated no insulin injections were given, while the EMAR showed multiple administrations of Insulin Lispro and Insulin Glargine. The Interim DON acknowledged the error and the need for modification.
The facility failed to timely implement Level II PASARR recommendations for two residents, one with serious mental health conditions and another with depression and anxiety. Recommendations for Resident 55 were delayed by 57 days, and for Resident 38 by seven months, despite receiving evaluations earlier. Staff acknowledged the delays, indicating a lapse in the process for updating care plans.
A facility failed to ensure a PASARR assessment accurately reflected a resident's mental health diagnoses, leading to an incomplete referral for a Level II PASARR. The resident, admitted with Adjustment Disorder and Bipolar Disorder, had no Level II PASARR despite a serious mental illness diagnosis. Staff acknowledged the oversight, citing an inaccurate Level I PASARR from the hospital and lack of documentation for a Level II referral.
A resident with Type 2 Diabetes Mellitus had a physician order to hold Insulin Lispro if their CBG was below 100 mg/dL. Despite this, insulin was administered on two occasions when the resident's CBG was below the threshold. A Resident Care Manager and LPN confirmed the error, acknowledging the insulin was given contrary to the physician's order.
A facility failed to provide adequate ADLs care for a resident, specifically in nail care. The resident, who required assistance with bathing and personal hygiene, was observed with long fingernails despite care plan instructions to keep them short. Staff confirmed that nail care was part of the shower routine, but it was not performed, placing the resident at risk of not receiving necessary care.
The facility failed to implement bowel management interventions for two residents, resulting in extended periods without bowel movements, contrary to the facility's protocol. Additionally, another resident did not receive scheduled dental care, with no documentation or rescheduling of missed appointments. Staff interviews confirmed these deficiencies, highlighting a lack of adherence to established care protocols.
The facility did not ensure that nursing assistants were screened through the nurse aide registry before providing care. Staff C, hired as a nursing assistant, lacked documentation from the registry. Staff B, responsible for human resources, misunderstood the registry requirements, thinking they applied only to NARs and not NACs. This oversight was being addressed at the time of the interview.
Incomplete Care Plan for Diabetes and Insulin Use
Penalty
Summary
The facility failed to develop a comprehensive care plan for Resident 34, who was admitted with multiple diagnoses including Diabetes Mellitus. The Medicare 5-Day MDS dated 12/28/2025 showed the resident was cognitively intact, had Diabetes Mellitus, and was receiving insulin injections. Physician orders dated 11/20/2025 documented that an LN was to perform diabetic nail care, and a later order dated 12/30/2025 showed Insulin Glargine daily at bedtime. The resident’s comprehensive care plan, initiated 11/20/2025, did not include a focus area or goal for diabetes and/or insulin use. The resident’s Kardex dated 03/03/2026 also did not identify the resident as diabetic or indicate that LNs were to perform diabetic nail care. During interview, the resident stated he had diabetes and was on insulin. Staff reported that care needs such as nail care or diabetes information were obtained from the Kardex, and the DON stated the Kardex information was triggered from the care plan and that a diabetes care plan should have been present.
Medication Left Unsupervised in Resident Room
Penalty
Summary
Medication administration was not performed according to professional standards of practice for one sampled resident. During an observation and interview, a small clear cup containing several pills was seen sitting on the resident’s bedside table while the nurse had left the room to get water. The resident stated that the nurse had left the medications there and then swallowed them without the nurse present. The resident’s quarterly MDS dated 02/07/2026 indicated the resident was alert and oriented. Record review did not show that the resident was approved to keep medications in the room or to take medications without nursing supervision. The facility’s policy on self-administration of medications required that the ability of an alert resident to self-administer be determined and that appropriate notation be placed in the care plan. During interviews, an LPN stated nursing was supposed to stay and observe a resident taking medication, and the DON stated staff were not to leave medication in a resident’s room and were supposed to monitor the resident taking the medication; the DON also stated a resident needed to be assessed, have an order, and be care planned before self-administering medications.
Failure to Use Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Provide and implement an infection prevention and control program was not maintained when the facility failed to implement Enhanced Barrier Precautions during wound care for a resident with a Stage 3 pressure ulcer to the mid back over a bony prominence. The resident was moderately cognitively impaired and at risk for pressure ulcers. Physician orders directed daily wound cleansing and dressing changes with collagen powder or sheet, calcium alginate, and bordered foam, and the skin care plan documented impaired skin integrity related to the Stage 3 pressure ulcer. Record review showed no physician order or care plan for Enhanced Barrier Precautions. During observation, the wound nurse/LPN and the resident care manager/LPN entered the resident’s room and performed wound care without donning a gown, and no EBP sign was posted outside the room. In interview, the wound nurse stated the resident did not have an EBP sign and that signs were posted when a gown was needed for wound care. The infection preventionist stated residents with excessive wound care or saturated dressings were placed on EBP and said she thought contained wounds did not need EBP, then acknowledged that pressure-related wounds needed to be on EBP and that this resident should have been on EBP. The DON stated it was her expectation that residents with open pressure wounds were on EBP.
Improper Food Labeling and Dating in Kitchen Refrigerator
Penalty
Summary
The facility failed to ensure proper labeling and dating of food items in the kitchen walk-in refrigerator, which was observed to contain expired, undated, and unlabeled opened items. Specifically, a jar of Maraschino cherries, a jar of peeled garlic, and a jar of Worcestershire sauce were labeled with use-by dates, while a jar of raspberry vinaigrette dressing and a bag of shredded cheddar cheese were not labeled or dated. Staff F, the Dietary Supervisor, acknowledged the oversight and discarded the items, stating that they should not have been there. The facility's policy requires opened items to be used within three days and unopened items to adhere to use-by dates. Staff A, the Administrator, confirmed the expectation for food items to be dated and labeled according to facility practice.
Resident's Call for Help Unanswered by LPN
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by an incident involving a resident who called out for help and was not immediately assisted by a licensed nurse. The resident, who was moderately cognitively impaired and had a history of depression and anxiety, experienced increased anxiety when others were angry or aggressive. On the day of the incident, the resident lost balance while trying to sit up on the side of the bed and called out for help, fearing a fall. A licensed nurse, identified as Staff G, was distributing medication and did not assist the resident, instead telling the resident that she could not help at that moment. The resident expressed feeling unsafe and uncomfortable with Staff G's care, stating that the incident made her feel like it was acceptable to stop dialysis and die. The resident's care plan indicated that staff should speak calmly to her, especially given her increased anxiety around anger or aggression. Despite the resident's distress, Staff G did not immediately respond to the call for help, and it was a Certified Nursing Assistant (CNA) who eventually assisted the resident. The resident's recount of the incident, as well as statements from other staff members, indicated that Staff G had yelled that she was busy and could not help, which was perceived as neglectful and disrespectful by the resident. The incident was reported to the facility's administration, and an investigation was conducted. However, the investigation was deemed unsubstantiated by the administrator. The resident's past medical and psychosocial history, including a history of abuse and panic attacks, was noted to have been triggered by the event. The facility's Social Services Director documented that the resident's PTSD and anxiety were exacerbated by seeing Staff G after the incident, further impacting the resident's trust and sense of safety within the facility.
Inaccurate MDS Assessment for Insulin Administration
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected a resident's health status and care needs. Specifically, for one resident with a diagnosis of diabetes mellitus, the Admission MDS inaccurately indicated that the resident did not receive insulin injections in the last seven days. However, a review of the resident's November 2024 Electronic Medication Administration Record (EMAR) showed that the resident received Insulin Lispro and Insulin Glargine on multiple occasions during that period. This discrepancy was acknowledged by the Interim Director of Nursing Services, who confirmed that the MDS was not coded correctly and needed modification.
Delayed Implementation of PASARR Recommendations for Two Residents
Penalty
Summary
The facility failed to implement the recommendations from the Level II Preadmission Screen and Resident Review (PASARR) for two residents, which placed them at risk of not receiving necessary mental health services. Resident 55, who was admitted with serious mental health conditions including Major Depressive Disorder and PTSD, had a Level II PASARR evaluation that recommended specific interventions for his care plan. However, these recommendations were not incorporated into his care plan until 57 days after admission, despite the facility receiving the PASARR evaluation 31 days after his admission. Similarly, Resident 38, who was admitted with Depression and Anxiety Disorder, had a Level II PASARR evaluation that included recommendations for her care plan. These recommendations were not added to her care plan until seven months after the evaluation was completed. The delay in incorporating these recommendations into the care plans of both residents indicates a failure in the facility's process for timely updating care plans based on PASARR evaluations. Interviews with facility staff revealed that there was an acknowledgment of the delay in implementing the PASARR recommendations. Staff C, a Regional Patient Advocacy Resource, confirmed that the recommendations for Resident 55 should have been incorporated sooner, and Staff A, the Administrator, agreed that the recommendations should have been implemented before the actual date. For Resident 38, Staff C indicated that the facility's process involved monthly follow-ups, but the responsibility for updating the care plan with PASARR recommendations lay with Social Services, which was not done in a timely manner.
Failure to Complete Accurate PASARR Assessment
Penalty
Summary
The facility failed to ensure that a Pre-Admission Screening and Resident Review (PASARR) assessment accurately reflected a resident's mental health diagnoses and that Level II PASARR evaluations were referred and completed in a timely manner. Resident 15, who was admitted with diagnoses including Adjustment Disorder and Bipolar Disorder, was found to have an incomplete PASARR process. The Admission Minimum Data Set assessment indicated moderate cognitive impairment, and the Level I PASARR did not identify the need for a Level II PASARR despite the presence of a serious mental illness diagnosis. The Electronic Health Record for Resident 15 documented a diagnosis of Bipolar Disorder and a physician's order for an antipsychotic medication, yet there was no evidence of a Level II PASARR or a referral for one. Staff C, responsible for social work and patient advocacy, acknowledged the oversight, noting that the facility received an inaccurate Level I PASARR from the hospital and failed to document a Level II referral. The facility administrator confirmed the expectation for accurate completion and referral of PASARR assessments.
Failure to Hold Insulin as Ordered for Diabetic Resident
Penalty
Summary
The facility failed to provide care and services according to professional standards of practice when insulin was not held as per physician orders for a resident reviewed for care provided meeting professional standards. The resident, who was admitted with a diagnosis of Type 2 Diabetes Mellitus, had a physician order dated 12/05/2024 for Insulin Lispro to be injected subcutaneously with meals, with instructions to hold the insulin if the Capillary Blood Glucose (CBG) level was less than 100 mg/dL. However, on 01/07/2025 and 01/14/2025, the resident's CBG levels were recorded as 91 mg/dL and 90 mg/dL, respectively, yet the insulin was administered contrary to the physician's order. Staff D, a Resident Care Manager and Licensed Practical Nurse, confirmed that the expectation was to hold the medication if the CBG was less than 100 mg/dL, acknowledging that the insulin was administered on the dates mentioned despite the CBG levels being below the threshold. This placed the resident at risk for medical complications and a diminished quality of life.
Failure to Provide Adequate Nail Care for a Resident
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADLs) care for a dependent resident, specifically in the area of nail care. Resident 25, who was alert and oriented, required substantial assistance with bathing and supervision with personal hygiene. The care plan for Resident 25 included instructions to keep fingernails short to avoid scratching and excessive moisture. Despite this, observations on two separate occasions revealed that Resident 25's fingernails were approximately 1/3 of an inch long, indicating that nail care was not performed as required. Staff members confirmed that nail care was supposed to be part of the resident's shower routine, as noted in the resident's Kardex. This oversight placed the resident at risk of not receiving necessary care and services.
Failure to Implement Bowel Management and Dental Care
Penalty
Summary
The facility failed to implement bowel management interventions for two residents, both of whom were moderately cognitively impaired. Resident 15 did not have a bowel movement for over 117 hours, and Resident 45 experienced similar delays in bowel movements, with intervals exceeding 89, 96, and 98 hours. Despite the facility's bowel protocol requiring intervention after three days without a bowel movement, the Medication Administration Records and Progress Notes for both residents did not show that the protocol was initiated. Staff interviews confirmed that the bowel management protocol should have been started but was not documented or executed as per policy. Additionally, the facility failed to ensure dental care was completed for another resident, who was also moderately cognitively impaired. This resident was referred for an emergency dental appointment for teeth extraction, with subsequent denture fitting planned. However, there was no documentation indicating that the resident attended the scheduled appointments, and staff were unable to provide reasons or documentation for the missed appointments or why they were not rescheduled. The resident expressed a desire to have the dental procedures completed, but the facility did not follow through with the necessary arrangements.
Failure to Screen Nursing Assistants Through Registry
Penalty
Summary
The facility failed to ensure that nursing assistants were properly screened through the nurse aide registry as required by OBRA before providing care to residents. This deficiency was identified for one of the two staff members reviewed for qualifications, specifically Staff C, who was hired on February 26, 2024. Upon review, it was found that Staff C's employee record lacked documentation from the nurse aide registry. During an interview on August 12, 2024, Staff B, the Human Resource and Payroll Representative, admitted to a misunderstanding regarding the registry requirements, believing it applied only to nursing assistants registered (NARs) and not to nursing assistants certified (NACs). Staff B was in the process of reviewing all NACs through the registry at the time of the interview.
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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