Three Creeks Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Pullman, Washington.
- Location
- Northwest 1310 Deane, Pullman, Washington 99163
- CMS Provider Number
- 505246
- Inspections on file
- 44
- Latest survey
- March 3, 2026
- Citations (last 12 mo.)
- 32 (1 serious)
Citation history
Health deficiencies cited at Three Creeks Post Acute during CMS and state inspections, most recent first.
The facility did not complete required PASRR Level I and Level II processes for several residents with depression, anxiety, and major depressive disorder. For some residents, Level I screens identified indicators of serious mental illness but the necessary Level II evaluations were never done, and for another resident the Level I screen was delayed until weeks after admission. A resident admitted under a 30‑day hospital exemption remained beyond that period without a new PASRR screen or Level II evaluation. The Social Services Director reported not being aware that PASRR screenings and evaluations had to be completed before admission.
The facility failed to assess and implement smoking safety measures for two residents who smoked and failed to complete required post-fall neuro checks for a resident with repeated unwitnessed falls. One resident had an incomplete smoking safety evaluation and no updated reassessment after readmission, while both residents were observed handling cigarettes in ways that were not supported by the facility’s smoking controls. The resident with falls had dementia, severe cognitive impairment, and a care plan requiring 72-hour monitoring after falls, but the record showed omitted neuro assessments and no documentation of the required monitoring after multiple unwitnessed falls.
Medication Administration Errors and Omissions: A resident with HTN received amlodipine and carvedilol even when SBP was below ordered hold parameters, and several other scheduled meds were left blank on the MAR. Another resident with psoriasis missed apremilast for an extended period when the med was unavailable, and later had severe itching and a bleeding back wound noted during wound care. A third resident with COPD and continuous O2 had missed O2 documentation, a missing Lidoderm patch entry, and unavailable gabapentin and tamsulosin on the MAR.
Failure to Perform Hand Hygiene and Maintain Ice Machine Cleanliness: During meal service, a Cook and the Dietary Manager repeatedly handled food, equipment, carts, drawers, and utensils without performing hand hygiene or changing gloves, including touching food while plating and checking temperatures. The kitchen observation also found the ice machine pushed against a dishwashing stand, with the filter slats covered in dust debris.
Staff COVID-19 vaccine status was not routinely documented, and education on risks vs benefits plus offering the seasonal vaccine was not shown for 4 sampled staff members, including RNs and NAs. The facility policy addressed resident vaccination but did not include a staff vaccination process, and leadership stated the process for tracking, educating, and offering the vaccine to staff was still being developed.
Damaged Laundry Room Environment: The laundry room had a large hole in the drywall in the soiled linen area and a cement floor with major cracks, chips, and missing sections. The Maintenance Director stated the drywall damage came from a water leak and had not been repaired, and the floor had been in disrepair for over a year. The IP and Interim Administrator both acknowledged the area was not safe or sanitary.
Failure to provide advance notice of Medicare coverage changes. Two residents remained in the facility after their Medicare Part A skilled coverage ended, but they were not given notice in advance about services that might no longer be covered. The Facility Manager confirmed the notices were not provided and stated advance notice was important so residents could understand potential costs and make informed decisions.
Uncleanable Wheelchair Equipment: A resident with heart failure, depression, hemiplegia, and moderate cognitive impairment used a wheelchair that had ace wrap-like material wrapped around the arm trough and brake extender, with a large foam piece in the center. The material was unraveled and hanging off the edges, and staff observed the wheelchair in the same condition on multiple occasions. The Therapy Director stated the equipment was not a cleanable surface and appeared to have been altered.
A resident with dementia, anxiety, stroke, and severe cognitive impairment was not provided a care planning conference opportunity, and the guardian stated they were never invited despite raising the issue multiple times. The last care conference in the record was over a year earlier, and the SSD and DON both acknowledged the guardian was not invited and that the resident had not had a care conference.
Failure to Provide Ordered Skin Care and Podiatry Follow-Up: A resident with cellulitis, diabetes, open leg wounds, and dry, irritated lower extremity skin did not receive ordered A&D ointment, and podiatry follow-up for thickened, discolored toenails was not arranged as expected. Records showed the ointment order was missing from the MAR/TAR, staff reported it had not been applied, and the resident’s feet remained edematous, cracked, calloused, and discolored on observation. The resident also reported not receiving special treatments or the expected podiatry visit.
Failure to prevent a heel PI: A resident with diabetes, mild cognitive impairment, and multiple skin wounds was identified as being at risk for PU/PI, but the care plan did not include heel offloading interventions while in bed. Weekly skin checks documented no concerns, yet the resident was repeatedly observed with both heels resting on the mattress and with swollen, discolored, cracked feet and legs. When the feet were finally lifted, the left heel had a non-blanching purple area about the size of a quarter that staff determined was a DTPI.
A resident with PTSD, depression, and insomnia reported severe trauma-related triggers, including fast speech, loud noises, unexpected room entry, and people approaching from behind, but the care plan did not include PTSD, triggers, or interventions to prevent re-traumatization. The social service trauma evaluation documented extensive abuse and other traumatic experiences, yet key care plan sections were blank and staff confirmed the resident’s PTSD-specific needs were not incorporated into the plan.
Expired lansoprazole was found in a medication room refrigerator for a resident who was still receiving it, and staff acknowledged it should have been discarded because its effectiveness may be affected. In addition, controlled medications for two discharged residents were destroyed in the narcotic books on the North and South carts by an RN without documentation of a second staff member present, despite staff stating that two nurses were required to verify destruction and help prevent diversion.
Delayed RD nutritional assessments and incomplete nutrition documentation for two residents. One resident with obesity, diabetes, heart failure, and foot ulcers had a late dietary profile and no RD assessment until well after admission, despite weight gain, poor blood sugar control, and reported dissatisfaction with meals. Another resident with paraplegia, obesity, diabetes, and wounds did not receive the RD admission assessment until weeks after admission; the assessment noted 60% meal intake and led to a protein supplement order, but the RD was unaware the resident was refusing it.
A resident with schizophrenia, a history of suicide attempts, and moderate depression was admitted with a care plan identifying paranoid schizophrenia and an intervention for psych consult as needed. Nursing notes repeatedly documented the resident as anxious and restless over time, and the resident reported longstanding mental illness, traumatic experiences, and a belief they would benefit from mental health services, which they had received in other settings. Despite this, the EMR showed no mental health provider involvement during the stay, and the Social Services Director acknowledged the resident’s expressed interest in such services while stating the facility had no contracted mental health provider or available mental health services.
During an extended power outage, staff failed to monitor and discard potentially hazardous foods (PHFs) such as milk that were stored above safe temperatures. Despite knowing the refrigerator temperature had reached 50°F, the affected milk was served to all residents during subsequent meals, and no food was discarded. The incident was identified as immediate jeopardy due to the risk of foodborne illness.
A resident with major depressive disorder and vascular dementia was admitted without completion of a required PASRR Level II evaluation, as indicated by their Level I screening. Facility staff did not review the necessary documentation or make the required referral prior to admission, and the resident's record lacked behavioral health provider notes and the Level II evaluation summary.
During a power outage caused by a winter storm, the facility's outdated backup generator failed to provide heat, resulting in indoor temperatures dropping to between 62 and 65°F. Staff monitored the situation and provided extra blankets, but all residents were affected by the cold conditions throughout the building.
A resident with multiple health conditions, including diabetes and recurrent C. difficile infection, was verbally abused by the DON during a care conference, where the DON made humiliating remarks about the resident's incontinence and stated the resident did not belong at the facility. Multiple witnesses confirmed the incident, and the resident expressed distress and a desire to avoid further contact with the DON. The administrator and other staff were informed but did not immediately address or report the incident.
Two residents did not receive their prescribed antibiotics as ordered due to errors in medication stop dates and missed doses. One resident's Vancomycin was discontinued earlier than intended because of a miscommunication and typographical error, while another resident missed a scheduled dose of Doxycycline, as confirmed by MAR review and staff interviews.
During a COVID-19 outbreak, the facility failed to complete required testing for 8 staff members and did not implement its respiratory protection program timely for 4 staff members. The outbreak involved 10 residents and 5 staff testing positive. Additionally, there was no documentation of COVID-19 testing for 29 residents, despite claims of twice-weekly testing. Inconsistent leadership during the outbreak may have contributed to these deficiencies.
The facility failed to store, label, and discard food according to professional standards, as observed in the kitchen. Expired and unlabeled food items, including wilted lettuce, undated crispy fried onions, and moldy milk, were found in various storage areas. The Dietary Manager acknowledged the oversight, which posed a risk for foodborne illness.
A facility failed to ensure a completed POLST was present for a resident who was cognitively intact and capable of making healthcare decisions. The resident was documented as a full code, but no POLST form was found in their medical record or the facility's binder. The resident confirmed no discussion about their CPR preferences had occurred. The Administrator and DON acknowledged the oversight and confirmed it was being addressed.
A facility failed to provide a Notification of Medicare Non-Coverage (NOMNC) to a resident two days before a planned discharge, preventing the resident from appealing the termination of Medicare services. The resident, who had a history of Myocardial Infarction and recent Coronary Artery Bypass, was alert and oriented. The DON confirmed the omission of the required notice.
A facility failed to document a resident's hospital transfer adequately, leaving the transfer form incomplete and lacking critical information about the resident's care needs and status. Interviews with staff confirmed that the expected documentation and notification procedures were not followed, as no progress note was made in the resident's record.
A facility failed to provide a bed-hold notice to a resident with cognitive impairment and other diagnoses when they were transferred to the hospital for unresponsiveness. The required notice was not documented in the resident's record, and staff interviews confirmed the oversight.
A resident with COPD and heart failure did not have current and complete oxygen orders, despite requiring supplemental oxygen for about a month. Observations showed varying oxygen flow rates and improper use of the nasal cannula. The care plan lacked respiratory interventions, and there was no physician order for oxygen until mid-November, placing the resident at risk for respiratory complications.
The facility did not employ sufficient staff with the necessary certifications for nutritional services, affecting 30 residents. The Dietary Manager lacked the required certification, as confirmed by both the manager and the facility's Administrator. Additionally, the facility did not have a full-time Registered Dietician.
A resident with a history of hip fracture and dementia fell and sustained a lower leg injury, which was not documented or assessed until five days later. The delay in treatment led to a necrotic, contagious wound infection, extending the resident's stay in the facility. The infection was resistant to many antibiotics, requiring a change in discharge plans to prevent spreading the bacteria.
A resident with a history of hip fracture and dementia fell and sustained a skin tear after standing from a wheelchair. The facility failed to notify the resident's representative of the incident until five days later, as confirmed by staff interviews. This delay in communication raised concerns about the severity of the injury and the involvement of the representative in healthcare decisions.
A resident with dementia and a history of hip fracture experienced a worsening wound on their leg after a fall, which was not documented or assessed for several days. The wound increased in size and severity due to delayed medical treatment. Despite staff awareness, the incident was not reported as required, indicating a failure to comply with reporting policies.
A resident with dementia and a history of hip fracture fell after getting out of their wheelchair unassisted, resulting in a skin tear. The facility delayed initiating an investigation and implementing preventative measures for five days, despite the incident being witnessed by the administrator. This delay was a repeat deficiency from a previous report.
The facility failed to provide sufficient nursing staff, resulting in delayed responses to call lights and unmet care needs for residents. Residents experienced long wait times for assistance, leading to incontinence episodes and missed showers. Staff interviews revealed chronic understaffing, with administrative staff aware but not addressing the issue. The Resident Council also documented complaints about long wait times and insufficient nursing assistants.
Two residents received meals at unsafe temperatures, with one resident's meal served cold and not reheated by staff. The facility's food temperature monitoring was incomplete, and the Food Service Manager admitted to not using the correct form since a kitchen transition.
Failure to Complete Required PASRR Screenings and Evaluations for Residents With Mental Illness
Penalty
Summary
The facility failed to ensure required Preadmission Screening and Resident Review (PASRR) processes were completed prior to or in conjunction with admission for multiple residents with mental health diagnoses. One resident with depression and anxiety was admitted with a Level I PASRR screen indicating serious mental illness, but the required Level II evaluation was never completed. Another resident with major depressive disorder also had a Level I screen showing indicators of serious mental illness, yet no Level II evaluation was performed. A third resident with depression and anxiety did not have a Level I PASRR screening completed until several weeks after admission, rather than prior to admission as required. In addition, a resident with depression was admitted under a 30‑day hospital exemption and had a Level I PASRR screen that did not indicate the need for a Level II evaluation. This resident remained in the facility beyond the 30‑day exemption period, but a new PASRR screening and Level II evaluation were not completed after the exemption expired. During an interview, the Social Services Director, who began employment in July 2025, stated they were not aware that PASRR screens and Level II evaluations were required to be completed before residents were admitted, and acknowledged the importance of incorporating evaluator recommendations into the care plan and providing behavioral health services.
Failure to assess smoking safety and monitor after unwitnessed falls
Penalty
Summary
The facility failed to ensure safety risk preventative measures were assessed and implemented for two residents who smoked. Resident 19 had a smoking safety evaluation that documented tobacco use, but the form did not indicate inability to light, hold, or extinguish tobacco safely, and no updated smoking safety evaluation was completed after readmission. The comprehensive care plan did not address smoking. Resident 19 had diagnoses including substance abuse disorder and diabetes, was cognitively intact, and was observed with cigarettes on the nightstand, smoking outside, and placing a cigarette on the wheel of the wheelchair or in a pocket before returning to the room and discarding it in the garbage can. Resident 18 had a smoking safety evaluation stating the resident used tobacco and was safe to do so when wearing glasses, and the resident had diagnoses including emphysema, anxiety, and chronic pain. Observations and interviews showed both residents smoked in a manner that was not supported by facility smoking controls. Resident 19 stated they smoked off the premises and put the cigarette out before returning, but was observed smoking and handling the cigarette by placing it on the wheelchair wheel and then in a pocket before discarding it in the room trash. Resident 18 stated they went off the property to smoke and disposed of cigarette butts in a bottle, trash can, or personal trashcan, and during observation the resident hid the cigarette between their legs and quickly put it out when approached by staff. Staff stated residents who smoked were supposed to go off the property and that it was not appropriate to bring cigarettes back into the facility to throw them away. Staff also acknowledged there was no receptacle for cigarette disposal and no smoking blanket to put out a fire. The facility also failed to monitor Resident 4 after multiple unwitnessed falls. Resident 4 had diagnoses including dementia, anxiety, and stroke, severe cognitive impairment, required moderate to substantial assistance with activities of daily living, and had two or more falls. The fall care plan directed nursing staff to monitor the resident for 72 hours after falls for pain, bruises, and changes in mental status. Although the facility incident log showed multiple unwitnessed falls and initial neurological assessments were completed, the neurological assessment sheets contained omissions and the record showed no documentation that neurological monitoring was completed after the unwitnessed falls. Staff stated neurological assessments should be completed for 72 hours after an unwitnessed fall and acknowledged that Resident 4 did not have the required neurological assessments completed.
Medication Administration Errors and Omissions
Penalty
Summary
The facility failed to ensure medications were administered as ordered for 3 of 11 sampled residents. Resident 4 had orders for amlodipine and carvedilol with parameters to hold the medications when systolic blood pressure was less than 120, but the January and February 2026 MAR showed doses were given on multiple occasions when the blood pressure was below the ordered hold parameters. The MAR also showed blank entries for Risperdal and sucralfate on 01/25/2026 and 02/06/2026, cetirizine on 02/06/2026, and buspirone and lactobacillus on the evening of 02/13/2026. Resident 30 had an order for apremilast twice daily for psoriasis. The January 2026 MAR showed the medication was not administered from 01/07/2026 through 01/27/2026, with code 6 entered to indicate the medication was unavailable. During a wound care observation on 03/02/2026, Resident 30 was noted to have severe itching, a red back with flaky dried skin, and an irregular wound on the upper mid-back that was bleeding and required treatment. Staff D stated the resident had been unable to get apremilast for a period of time and that it was important for the resident to receive it because it helped treat the psoriasis. Resident 48 was admitted with pain, BPH, and COPD and required continuous oxygen. The February 2026 MAR showed blanks for oxygen administration on the evening shift of 02/17/2026 and 02/18/2026 and on the day shift of 02/22/2026. The MAR also showed a code 9 for the Lidoderm patch on 02/18/2026 with a progress note stating there was no patch to remove, and a code 9 on 02/22/2026 without a progress note. In addition, gabapentin and tamsulosin were coded as unavailable on 02/22/2026. Staff interviews confirmed that medications were expected to be administered as ordered and that unavailable medications should be ordered timely.
Failure to Perform Hand Hygiene and Maintain Ice Machine Cleanliness
Penalty
Summary
Food was not handled in accordance with professional standards during meal service when two dietary staff members failed to perform hand hygiene and repeatedly contaminated their gloved hands while plating and preparing food. Staff S, a Cook, was observed wearing the same gloves while plating food, touching biscuits, moving carts that other staff had touched, opening drawers, handling the microwave, cutting chicken strips, touching the blender, placing a plate in the dirty dish area, adding gravy to the blender, picking up a meal card, and continuing to plate food without changing gloves or performing hand hygiene. Staff T, the Dietary Manager, was observed removing gloves and placing chicken in the microwave without hand hygiene, handling chicken from the oven, checking temperatures, putting on gloves without hand hygiene, touching the microwave, cleaning the thermometer, touching the counter, giving a plate to Staff S, using tongs to flip pork, opening the microwave again, touching pork while checking temperature, and later removing gloves without hand hygiene before using tongs again. The kitchen sanitary environment was also deficient because the ice machine was not maintained cleanly. During observation, the right side of the ice machine was pushed against a metal stand used for dishwashing, preventing the filter from being observed. The Maintenance Director stated the ice machine was cleaned monthly and filters were changed every six months. When the top of the ice machine was lifted, the filter slats on the right side were covered in dust debris, and the Maintenance Director stated that dust debris may enter the ice machine and that keeping the filter clean was important for sanitation and to keep the machine cool.
Staff COVID-19 Vaccine Documentation and Education Not Maintained
Penalty
Summary
The facility failed to routinely maintain documentation of staff COVID-19 vaccination status, provide education on the risks versus benefits, and offer the COVID-19 vaccine to 4 of 6 sampled staff members reviewed for immunizations. The facility policy titled COVID-19 Immunization, revised January 2026, addressed offering the vaccine to residents unless medically contraindicated, providing and documenting education in the resident medical record, and obtaining consent if desired, but it contained no documentation related to the staff COVID-19 vaccination process. During record review and interviews, Staff I, a RN, could not recall whether the facility offered the seasonal COVID-19 vaccine; the only documentation found was a mobile phone screenshot showing a prior COVID-19 vaccination from 01/06/2021 and a declination dated 03/03/2026 with no documentation that education on risks versus benefits was provided. Staff J, a NA, Staff K, a RN, and Staff L, a NA, had no documentation of COVID-19 vaccination status, education on risks versus benefits, or that the seasonal vaccine was offered. Staff A, Interim Administrator, stated they were unsure of the facility process for tracking staff vaccination status or how education was provided, and Staff D, Infection Preventionist, stated they were still developing a process to track, educate, and offer the vaccine to staff. The facility was able to obtain the COVID-19 vaccine, and Staff D stated Staff I was offered the vaccine during the survey and declined.
Damaged Laundry Room Environment
Penalty
Summary
The laundry room was observed with a large hole in the drywall at knee level in the area where soiled linens and clothing were placed before washing, and Staff E, the Maintenance Director, stated the damage was caused by a water leak at the beginning of winter and had not yet been repaired. The laundry room cement floor was also observed to be significantly damaged, with large cracks, chips, and missing sections, creating an uneven walking surface and making it difficult to thoroughly sanitize. Staff E stated the cement floor had been in disrepair for over a year. Staff D, the Infection Preventionist, acknowledged the damaged floor was not the best cleanable surface and should be repaired timely, and Staff A, the Interim Administrator, acknowledged the area was not safe or sanitary.
Failure to Provide Advance Notice of Medicare Coverage Changes
Penalty
Summary
The facility failed to issue advance notices of potential Medicare/Medicaid non-coverage for 2 of 3 sampled residents reviewed for beneficiary notices. Resident 30’s record showed Medicare Part A skilled services began on 11/26/2025 and the last covered day was 01/14/2026, but the resident remained at the facility and was not issued a notice in advance informing them of services that may no longer be covered once insurance coverage ended. Resident 31’s record showed Medicare Part A skilled services began on 01/02/2026 and the last covered day was 02/28/2026, but the resident also remained at the facility and was not issued advance notice of services that may no longer be covered after insurance ended. During interview on 02/28/2026 at 3:00 PM, Staff C, Facility Manager, confirmed both residents were not provided notice of their benefits when their insurance coverage changed and stated that advance notice was important so residents could be informed of potential costs and make decisions based on that information.
Uncleanable Wheelchair Equipment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for Resident 41, who had diagnoses including heart failure, depression, and hemiplegia, with moderate cognitive impairments and a need for partial to substantial assistance with activities of daily living. Resident 41 used a wheelchair for mobility. During observation, the resident was lying in bed while the wheelchair had a right arm trough on it with ace wrap-like material wrapped around the outer edges and brake extender, along with a large piece of foam in the center. The ace wrap material was hanging off the edges, unraveled, and not maintained in a manner that allowed it to be cleaned. Similar observations of the wheelchair were made on multiple later dates, showing the same condition of the equipment. Staff interviews indicated that equipment issues were expected to be reported to maintenance and that resident equipment needed to be kept clean and in good repair for sanitary reasons and infection control. The Therapy Director observed the wheelchair and stated a reassessment was needed because it was not a cleanable surface, and noted the ace wrap-like material appeared to have been added to the wheelchair.
Failure to Invite Guardian to Care Planning Conference
Penalty
Summary
The facility failed to ensure that the resident or the resident’s representative was given the opportunity to participate in care planning conferences for one sampled resident with dementia, anxiety, and a stroke. The resident’s 01/26/2026 annual assessment documented severe cognitive impairment. The facility policy titled Resident Participation - Assessment/Care Plans stated residents and representatives were to be invited to participate in the development of the resident assessment and care planning conference, and that the Social Services Director or designee was to maintain records of efforts to invite them, including refusals. The resident’s guardian stated in an interview on 02/26/2026 that they had never been invited to a care planning conference and had raised the issue with the facility numerous times. Review of the medical record showed the last care conference was held on 01/23/2025, over a year earlier. The Social Services Director stated the resident did not have a care conference because cognition was impaired and there was no family involved, but also acknowledged the guardian was not invited and that the resident should have had a care conference. The DON stated care conferences were important to assess and monitor changes, discuss resident needs and discharge plans, and that family and guardians needed to be invited; the DON acknowledged the resident had not had a care conference.
Failure to Provide Ordered Skin Care and Podiatry Follow-Up
Penalty
Summary
The facility failed to seek podiatry services and failed to implement a provider order for A&D ointment for a resident with multiple skin conditions. On admission, the resident had cellulitis of both lower legs with open wounds requiring dressings and wraps, was diagnosed with diabetes, and had a care plan addressing impaired skin integrity and risk for pressure injuries. The admission assessment documented skin tears on both elbows, an open wound on the front of the left lower leg, an open venous ulcer, and cellulitis on the rear of the right lower leg. The record also showed an order for podiatry as needed for mycotic and hypertrophied toenails, but that order was discontinued shortly after admission. The physician’s history and physical documented dry and irritated skin on both lower extremities below the knees and ordered A&D ointment for dry skin on the legs. A provider order later directed staff to apply two A&D ointment packets to both legs daily for four weeks, but the February and March MAR/TAR contained no documentation of the ointment being applied. During interview, staff stated they did not remember seeing the order, confirmed it was not on the MAR/TAR, and the order was corrected at that time. A CNA skin monitor task form repeatedly noted the resident’s toenails needed clipping, but the resident’s feet were not described in the admission assessment and there were no further wound measurements or foot assessments documented in the record. On observation, the resident’s lower legs and feet remained discolored and edematous, with large scales of dry skin, scabbed areas, thick yellow calloused cracked skin on the soles and sides of the feet, and thick yellow deformed toenails. The resident stated staff were not doing any special treatments or applying lotion to the legs and feet, and later stated regular lotion had been applied only twice and not A&D ointment. Staff also stated the resident had a history of diabetes and was at risk for complications, and the social services director stated they were responsible for podiatry appointments but were not aware of the resident’s request for a podiatrist appointment. The podiatry order had been discontinued, and the resident reported the podiatrist had not visited when expected.
Failure to Prevent Heel Pressure Injury
Penalty
Summary
The facility failed to implement preventative measures to prevent avoidable pressure ulcers/pressure injuries for one resident who was reviewed for PU/PI prevention. The resident had skin tears on both elbows, an open wound on the left lower extremity, and an open venous ulcer with cellulitis on the right lower extremity at admission. The resident also had diabetes, was mildly cognitively impaired, required partial assistance with bed mobility, and was assessed as being at moderate risk for pressure ulcer development due to limited sensory perception, occasional moist skin, severely limited ability to walk and change body positions, and probable inadequate food intake. The admission care plan identified the resident as having actual skin impairments and being at risk for pressure injuries, with instructions to avoid scratching, keep skin free from excess moisture, encourage nutrition and hydration, use lotion on dry skin, check skin during cares, and report and document skin abnormalities. The resident required assistance from one staff member to turn and reposition in bed every 2 hours and as necessary. However, there were no care-planned interventions for assistive devices or positioning to offload pressure while the resident was in bed, despite the resident using a pressure relieving mattress. Weekly skin evaluations documented no skin concerns and left the sections for describing skin findings blank. During later observations, the resident was seen lying in bed with both heels resting on the mattress, and the lower legs and feet were swollen, discolored, dry, scaly, and covered with cracked calloused skin and scabbed areas. The resident stated staff were not doing any special treatments for the legs and feet and that no one had observed the feet. When the feet were lifted, the left heel had a purple, non-blanching area about the size of a quarter, which staff identified as a deep tissue pressure injury. Staff stated the interventions for the resident's heels had been missed.
Failure to Care Plan PTSD Triggers and Trauma-Informed Needs
Penalty
Summary
The facility failed to ensure trauma-informed and culturally competent care was provided for a resident with PTSD. Resident 46 was admitted with diagnoses including PTSD, depression, and insomnia, was cognitively intact, and stated they had a history of lifetime torture, guns, and sexual abuse. During observation and interview, the resident reported that fast speech, loud noises, staff entering the room without warning, and people approaching from behind triggered fear and psychologically induced seizures. The resident also stated they had told staff they needed time to respond and that their counselor had moved a year earlier, leaving them without counseling despite extreme PTSD symptoms. The resident’s baseline care plan had incomplete social service sections, with blanks for mental health needs, behavioral concerns, social service goals, and depression screening. A social service trauma evaluation documented multiple traumatic experiences, including physical and sexual assault, life-threatening injury or illness, sudden or violent death, bullying, and discrimination, along with symptoms such as intrusive thoughts, avoidance, emotional numbness, anger outbursts, difficulty concentrating, and being easily startled. However, the care plan addressed depression but did not address PTSD, triggers, or interventions to prevent re-traumatization. Staff interviews confirmed the resident’s PTSD-related needs were not yet incorporated into the care plan. A social service progress note stated the trauma assessment was not completed because the resident had a migraine and would be updated later if needed. Nursing and social service staff stated that PTSD should be included in the care plan with resident-specific triggers and interventions, but the resident’s comprehensive care plan did not contain PTSD-specific guidance. Staff also stated the resident should have had interventions placed on the care plan sooner and that the trauma evaluation should have been completed after the migraine so the plan could be updated.
Expired Medication Kept and Controlled Substances Destroyed Without Required Two-Staff Verification
Penalty
Summary
The facility failed to accurately reconcile controlled medications in both the North and South medication carts. In the North Cart narcotic book, a discharged resident’s hydrocodone was destroyed by Staff I, RN, without documentation that a second staff member was present. In the South Cart narcotic book, a discharged resident’s pregabalin was also destroyed by Staff I without a second staff member present. Staff R stated that two staff members were required to destroy narcotics, and Staff I stated that two nurses had to sign the narcotic book verifying the number of narcotics destroyed and that narcotics were destroyed using Drug Buster to help prevent diversion. Staff B, the DON, acknowledged that Staff I signed the narcotic sheets by themselves and stated the expectation was to have two nurses present. The facility also failed to discard expired medication in the medication room refrigerator. During observation, a bottle of lansoprazole for Resident 49 was found in the refrigerator with an expiration date of 02/23/2026, yet the medication administration record showed the resident continued to receive it in February and March 2026. Staff R stated they administered the lansoprazole that morning and acknowledged expired medication should be discarded because its efficacy may be affected. Staff D stated the medication had been missed during a refrigerator check because it was on the side of the door, and Staff B stated expired medications may lose their effectiveness.
Delayed RD Nutritional Assessments and Incomplete Nutrition Documentation
Penalty
Summary
The facility failed to ensure timely nutritional assessments and completion of nutritional requirements by the Registered Dietician for two residents with complex medical needs. One resident was admitted with obesity, diabetes with foot ulcers, and heart failure, was cognitively intact, dependent for bed mobility and toileting, and had a care plan addressing nutritional risk related to excessive carbohydrate intake, undesirable food choices, and obesity. Although admission orders included a consistent carbohydrate diet with large protein portions and staff were directed to follow RD recommendations, the initial dietary profile was not completed until more than two months after admission, and there were no RD assessments or entries in the record before the later nutrition assessment. For that same resident, the later RD nutrition assessment was completed during a Nutrition at Risk meeting related to non-pressure wounds, but the form did not include entries for medications, pertinent lab data, estimated caloric, protein, or fluid needs, meal intake percentage, whether nutritional needs were being met, nutritional goals, interventions, or the nutritional plan. The resident’s record also documented a 25-pound weight gain since the prior month, ongoing poor blood sugar control, non-compliance with wound care and dietary measures, and the resident stated they had spent large amounts of money on food because they did not like many of the meals and had not been seen by the RD. The second resident was admitted with paraplegia, obesity, diabetes, and a history of pressure ulcers, was cognitively intact, dependent for ADLs, and had wounds on the back related to psoriasis and pressure. The care plan identified nutritional risk and risk for dehydration, and orders included a regular diet with RD recommendations for diet changes and supplements. The RD admission assessment was completed more than six weeks after admission and documented average intake of 60% for most meals and that needs were met with the current diet and intake, with Prosource added daily for wound healing. The resident later refused Prosource and received only four doses in February, and the RD stated they were not aware of the refusal and acknowledged missing the admission assessments for both residents.
Failure to Provide Mental Health Services for Resident With Schizophrenia and Depression
Penalty
Summary
The facility failed to ensure that a resident with known schizophrenia and moderate depression received necessary mental health services during their stay. The resident was admitted with diagnoses including a fractured right hip and schizophrenia, and their admission MDS documented a depression screening with a score indicating moderate depression. The resident’s care plan identified a focus on paranoid schizophrenia with delusions, hallucinations, and paranoia, and included an intervention for a psychiatric consult as needed. Progress notes documented that the resident had a history of three prior suicide attempts, the most recent in 2019 following the unexpected death of their mother, and that they had scored moderately depressed on a PHQ-9 assessment. Nursing progress notes repeatedly described the resident as anxious and/or restless on multiple occasions and at various times, yet the electronic medical record showed no evidence that the resident had been seen by any mental health provider during their stay. In an interview, the resident reported a long history of schizophrenia since their teen years, frequent hospital and facility admissions, traumatic life experiences, and concern about their future after discharge. The resident stated they believed they would benefit from mental health services and that such services had always been offered and utilized in other medical settings, but none had been offered at this facility. In a separate interview, the Social Services Director confirmed that the resident had expressed interest in mental health services and was thought to benefit from them, but stated the facility was not contracted with any mental health provider and that no mental health services were available.
Failure to Discard and Monitor PHFs During Power Outage Leads to Immediate Jeopardy
Penalty
Summary
The facility failed to maintain safe storage and handling of potentially hazardous foods (PHFs) during an extended power outage, resulting in the service of milk and other PHFs that were held above safe temperature guidelines. The power outage began early in the morning and lasted for over ten hours, during which the backup generator did not supply power to kitchen appliances, including refrigerators and freezers. Kitchen staff were instructed to keep appliance doors closed, but the refrigerator containing milk and juice was opened multiple times for meal service, and no consistent temperature monitoring was performed during the outage. After the outage, staff observed that the refrigerator temperature had risen to 50 degrees Fahrenheit, well above the safe limit for PHFs. Despite this, no food was discarded, and the milk stored in the affected refrigerator was served to residents during subsequent meal services. Staff interviews confirmed that neither the cook nor the dietary manager took or documented further temperature readings after the initial high temperature was noted, and the dietary manager acknowledged serving the milk for dinner and breakfast following the outage. Temperature logs for the day of the outage were marked as out of service, and no corrective action regarding the food was taken at that time. All 33 residents in the facility were served PHFs that had been stored above safe temperatures for an extended period. The deficiency was identified when a complaint investigator interviewed kitchen staff and reviewed records, confirming that the facility did not follow established food safety guidelines for discarding PHFs held above 45 degrees Fahrenheit for more than four hours. The incident was classified as immediate jeopardy due to the risk of foodborne illness to all residents.
Removal Plan
- Discarding affected PHFs
- Education to food service staff
- Implementing safety protocols for food temperature monitoring
- Updating policies and procedures
Failure to Complete Required PASRR Level II Evaluation Prior to Admission
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASRR) process was properly completed for a resident with a diagnosis of major depressive disorder and vascular dementia. Record review showed that a PASRR Level I screening indicated the presence of a serious mental illness (SMI) and required a Level II evaluation prior to admission. However, there was no evidence in the resident's record that a PASRR Level II evaluation was completed before the resident was admitted. Additionally, the resident's record lacked behavioral health provider notes and the required Level II evaluation summary, despite documentation of severely impaired cognition after admission. Interviews with facility staff revealed that the standard admission process was not followed for this resident, who was transferred from a sister facility. The Admissions Director and Administrator In Training both stated they did not review the resident's PASRR documentation prior to admission and were unaware that a Level II evaluation was required. The PASRR Level I was also filled out incorrectly, and the necessary referral for a Level II evaluation was not made before the resident's admission.
Failure to Maintain Safe and Comfortable Temperature During Power Outage
Penalty
Summary
The facility failed to maintain a comfortable and safe temperature for all 33 residents during an extended power outage caused by a winter storm. The backup generator in use was outdated, undersized, and only powered a limited number of lights, outlets, and the fire suppression system, but did not provide heat to the building. Staff interviews confirmed that temperatures inside the facility dropped to between 62 and 65 degrees Fahrenheit, with the coldest areas being at the ends of the hallways where residents resided. Staff responded by offering extra blankets to residents, but all areas of the building were affected by the low temperatures. Maintenance staff were aware of the limitations of the generator and had communicated the temperature readings to other staff to monitor resident safety. The administrator in training acknowledged that the generator was insufficient and that the issue had been known since the facility was acquired by the current corporation. All residents present during the outage were affected by the drop in temperature, and staff confirmed that the generator did not provide adequate heating during the incident.
Resident Subjected to Verbal Abuse by Director of Nursing During Care Conference
Penalty
Summary
A deficiency occurred when a resident, who was cognitively intact and had multiple medical conditions including diabetes, recurrent Clostridium Difficile infection, malnutrition, and adult failure to thrive, was subjected to verbal abuse by the facility's Director of Nursing (DON) during a care conference. The resident required staff assistance with hygiene and transfers due to weakness. During the care conference, the DON made humiliating statements about the resident's bowel incontinence, told the resident they did not belong at the facility, and referred to the resident as a "nasty little man" in front of family members and other staff. Multiple witnesses, including family members, a state worker, and the Social Services Director, confirmed the DON's statements and the resident's distress as a result of the interaction. The incident was reported immediately after the care conference by the resident's family to the facility administrator, but the administrator did not address the concern at that time. The Social Services Director also reported the incident up the chain of command, expecting an investigation to begin, but found the following day that no one had spoken to the resident and the DON was still working in the building. The state worker present at the meeting did not report the incident to the required State Agency, assuming the facility would handle it. Interviews with the resident and family members revealed that the resident felt humiliated, unwanted, and disliked by the DON, and expressed a desire to remain at the facility but to have no further contact with the DON. The DON later admitted to making the derogatory statement and described the resident as acrimonious and belittling, but maintained that the conversation was not one-sided. The administrator acknowledged awareness of the incident but initially did not consider it verbal abuse, only later recognizing it as reportable and requiring investigation.
Medication Administration Errors Result in Missed Antibiotic Doses
Penalty
Summary
The facility failed to ensure that residents received their medications as ordered, resulting in significant medication errors for two residents. For one resident with osteomyelitis and sepsis, the hospital discharge order specified Vancomycin treatment for six weeks, ending on 10/13/2025. However, the medication was discontinued early on 10/03/2025 due to an error in the stop date entered by staff, which was based on a miscommunication and a typographical mistake in the order. The pharmacy confirmed the original order was through 10/13/2025, but the facility's records reflected the incorrect earlier stop date, leading to premature discontinuation of the antibiotic. Another resident with diabetes, hypertension, and an amputation had two overlapping orders for Doxycycline. The first order was for a seven-day course, and the second was to continue the medication indefinitely. The Medication Administration Record (MAR) showed that the evening dose on 11/05/2025 was not administered, as indicated by a blank entry and a red mark in the MAR, which staff confirmed meant the medication was not given. Staff interviews acknowledged the error and the importance of administering the full course of antibiotics as ordered.
Failure to Adhere to COVID-19 Testing and Respiratory Protection Guidelines
Penalty
Summary
The facility failed to adhere to federal guidelines for COVID-19 testing during an outbreak, affecting 8 out of 10 staff members. The outbreak, which lasted from December 10, 2024, to January 6, 2025, involved 10 residents and 5 staff members testing positive for COVID-19. According to the Centers for Disease Control and Prevention (CDC) guidelines, asymptomatic residents and staff with close contact to someone infected should undergo a series of three viral tests. However, the facility did not complete the required testing for the staff, increasing the risk of delayed identification and treatment of COVID-19. Additionally, the facility did not implement its respiratory protection program in a timely manner for 4 out of 10 staff members. The program required annual fit testing of N95 respirator masks, which was not conducted within the stipulated 12 months for several staff members. This lapse potentially contributed to the transmission of the virus within the facility. The staff fit testing records revealed that some staff had not been fit tested since late 2023, and one staff member had not been tested since their hire date in November 2024. The facility also failed to document COVID-19 testing results for all 29 residents during the outbreak. Despite the Director of Nursing stating that testing was supposed to occur twice weekly, there was no documentation to support this claim. The facility's leadership was inconsistent during the outbreak, as both the Administrator and Director of Nursing tested positive for COVID-19 at the beginning of the outbreak, which may have contributed to the oversight in testing and documentation.
Failure to Adhere to Food Safety Standards
Penalty
Summary
The facility failed to adhere to professional standards for food safety, as observed during a survey of the kitchen. The produce refrigerator contained three extra-large bags of shredded iceberg lettuce that were brownish, wilted, and soggy, with a use-by date that had already passed. In the dry storage room, a bag of opened crispy fried onions was found undated, and a container of flour was labeled with an expiration date that had also passed. Additionally, a second refrigerator in the common area contained several unlabeled and undated items, including a large container of diced pineapples, a full pitcher of orange juice, and a half bag of BBQ riblets. A large box of prepackaged boiled eggs was also found with an expired label. Further observations revealed that the kitchen freezer contained a half bag of unlabeled and undated sausage patties. In the nourishment refrigerator, three cups of milk with mold on the lids were labeled with an expired date, and an opened commercial pumpkin pie was found without a label or date. The Dietary Manager, Staff E, acknowledged that these items should have been labeled, dated, and discarded by their expiration dates to prevent residents from becoming ill. This oversight placed residents at risk for foodborne illness and diminished their quality of life.
Failure to Complete POLST for Resident
Penalty
Summary
The facility failed to ensure that a completed Physician's Order for Life-Sustaining Treatment (POLST) was present for Resident 6, who was cognitively intact and capable of making their own healthcare decisions. Upon admission, it was documented that Resident 6 was a full code, meaning they would receive cardiopulmonary resuscitation (CPR) if needed. However, there was no completed POLST form in the resident's medical record or in the facility's POLST binder, and no documentation indicated that any education or conversation had occurred regarding the resident's wishes for CPR or other treatments in the event of serious illness. During an interview, Resident 6 confirmed that they had not filled out a POLST form and that no one at the facility had discussed their preferences for CPR since their admission. The facility's Administrator and Director of Nursing acknowledged the absence of a completed POLST form for Resident 6 and confirmed that it was being addressed. This oversight placed Resident 6 at risk of not having their end-of-life care preferences honored.
Failure to Provide Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to provide a Notification of Medicare Non-Coverage (NOMNC) two days prior to a planned discharge for one resident, preventing the resident from exercising their right to appeal and dispute the termination of Medicare-covered services. Resident 136, who was admitted with diagnoses including Myocardial Infarction and recent Coronary Artery Bypass, was alert, oriented, and able to make their needs known. A progress note indicated the resident was to be discharged, but no NOMNC form was found in their record. The Director of Nursing confirmed that the required notice was not given.
Incomplete Documentation of Hospital Transfer
Penalty
Summary
The facility failed to ensure that a resident's medical record contained adequate documentation of a hospital transfer and that the receiving hospital received necessary information about the resident's condition. This deficiency was identified for one of the two sampled residents, who was transferred to the hospital for evaluation due to unresponsiveness. The transfer form for the resident was incomplete, lacking critical information such as the resident's care needs, treatments, or status prior to being sent to the hospital. Interviews with facility staff revealed that the expected procedure for transferring a resident to the hospital includes filling out a transfer form, notifying the hospital of the resident's status, and documenting the transfer in the resident's chart. However, in this case, the transfer form was not thoroughly completed, and no progress note was made in the resident's record. Both the Registered Nurse and the Director of Nursing confirmed the lack of documentation and incomplete transfer form after reviewing the resident's record.
Failure to Provide Bed-Hold Notice for Hospitalized Resident
Penalty
Summary
The facility failed to provide a bed-hold notice to a resident and/or their representative at the time of discharge or within 24 hours of transfer to the hospital. This deficiency was identified for one of the two sampled residents, Resident 31, who was reviewed for hospitalization. Resident 31 had cognitive impairment and diagnoses including malnutrition and a fractured left leg. On 11/04/2024, Resident 31 was transferred to the hospital for evaluation due to unresponsiveness. However, there was no documentation in the resident's record indicating that the required bed-hold notice was provided. Interviews with facility staff revealed that bed-hold notices were supposed to be given at the time of transfer or within 24 hours if the transfer was emergent. The Director of Nursing confirmed that a bed-hold notice had not been completed for Resident 31.
Incomplete Oxygen Orders for Resident with COPD
Penalty
Summary
The facility failed to ensure that a resident with chronic obstructive pulmonary disease (COPD) and heart failure had current and complete oxygen orders for respiratory care. The resident was observed on two occasions with varying oxygen flow rates, and at one point, the nasal cannula was not being worn despite the oxygen concentrator being on. A review of the medication administration records from July to November revealed no documentation of a physician's order for oxygen. Additionally, the resident's care plan, dated April, lacked any respiratory care plan or interventions related to the resident's COPD. Interviews with staff and the resident indicated that the resident had been experiencing shortness of breath and required supplemental oxygen for about a month. However, there were no physician orders related to oxygen until mid-November. The Physician-Nursing Communication Book and progress notes also lacked documentation regarding the resident's respiratory status or care needs. This oversight placed the resident at risk for respiratory complications and a diminished quality of life.
Deficiency in Nutritional Services Staffing
Penalty
Summary
The facility failed to employ sufficient staff with the necessary certifications to fulfill the functions of nutritional services for 30 residents. Specifically, the Dietary Manager, referred to as Staff E, did not possess the required certification for their role. During an interview, Staff E confirmed that they had not completed the necessary training to obtain the credentials required for their position. Additionally, the facility's Administrator, Staff A, acknowledged the absence of a full-time Registered Dietician and confirmed that Staff E had not completed the certification process.
Failure to Timely Assess and Treat Resident's Injury
Penalty
Summary
The facility failed to perform a timely and thorough assessment of a lower leg injury for a resident who fell on 05/01/2024. The resident, who had a history of right hip fracture with surgical repair and dementia, was at risk for falls and required extensive assistance with daily activities. Despite the fall being witnessed by the facility's administrator, there was no documentation of the incident or the resulting injury until 05/06/2024. The resident's skin tear, initially measuring 1.0 by 0.5 by 0.2 inches, was not assessed or treated promptly, leading to an increase in size and the development of a necrotic, contagious wound infection. The delay in assessment and treatment resulted in the resident experiencing harm, as the infection extended their stay in the facility. The wound was not cultured or treated with antibiotics until 05/10/2024, four days after the injury was documented. The infection was resistant to many antibiotics, necessitating a change in the resident's discharge plans to prevent spreading the bacteria to their spouse at their Adult Family Home. The facility's failure to document and address the fall and subsequent injury in a timely manner contributed to the resident's prolonged recovery and additional medical complications.
Failure to Timely Notify Resident's Representative of Fall and Injury
Penalty
Summary
The facility failed to notify a resident's representative of a change in condition in a timely manner, which was identified during a review of the medical records and interviews. The resident, who had a history of a right hip fracture with surgical repair and dementia, was admitted to the facility and required extensive assistance with daily activities. The resident was also at risk for falls. On a specific date, the resident fell after standing up from their wheelchair, resulting in a skin tear to the left lower leg. Despite the incident, the resident's representative was not informed of the fall and injury until five days later. Interviews with facility staff revealed that neither the registered nurse who assisted the resident after the fall nor the charge nurse at the time of the incident contacted the resident's representative. This lack of communication placed the resident at risk of not having their representative involved in the healthcare decision-making process for timely care and services. The delay in notification raised concerns from the resident's representative about the severity of the injury and the facility's communication practices.
Failure to Report and Address Resident Neglect
Penalty
Summary
The facility failed to report an incident of neglect involving a resident who experienced a worsening wound on their left lower leg. The resident, who had a history of a right hip fracture with surgical repair and dementia, was admitted to the facility and required extensive assistance with daily activities. On a specific date, the resident fell and sustained a skin tear on their left lower leg after hitting the footrest of their wheelchair. However, the incident was not documented or assessed until five days later, leading to a delay in medical treatment. The wound, initially measuring 1.0 by 0.5 by 0.2 inches, worsened over time, showing increased redness, pain, swelling, and slough, eventually growing to 2.0 by 1.0 by 0.5 inches. Despite the staff's awareness of the fall and injury, there was no documentation or assessment until several days later, and no treatment orders were obtained until nine days after the fall. The facility's State Reporting Log showed no reporting of staff neglect as required, indicating a failure to comply with the policy on reporting resident mistreatment and neglect.
Delayed Investigation of Resident Fall Incident
Penalty
Summary
The facility failed to conduct a timely and thorough investigation into a fall incident involving a resident, identified as Resident 1, who was at risk for falls due to a right hip fracture with surgical repair and dementia. The resident required extensive assistance with daily activities and was totally dependent on staff for eating and toilet use. On the date of the incident, the resident fell after getting out of their wheelchair unassisted, resulting in a skin tear on their left lower leg. Despite the fall occurring on 05/01/2024, the Director of Nursing was not made aware until 05/06/2024, and the investigation was not initiated until five days after the incident. The facility's policy required staff to review and investigate all allegations of abuse, neglect, and injuries of unknown source, and to complete investigation summaries and analyze occurrences to prevent further incidents. However, the investigation report was only completed on 05/06/2024, and it was noted that the resident had severe cognitive impairments, which prevented them from explaining the reason for the fall. The administrator, who witnessed the fall, confirmed the details of the incident, including the injury sustained. The delay in initiating the investigation and implementing preventative interventions was a repeat deficiency from a previous report dated 12/05/2023.
Inadequate Staffing Leads to Delayed Care and Unmet Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in delayed responses to call lights and unmet care needs. Residents reported long wait times for assistance, with some waiting up to 1.5 hours for their call lights to be answered. This lack of timely response led to residents experiencing incontinence episodes and not receiving showers as per their care plans. The facility was often short-staffed, with only one nursing assistant available for 28 or more residents during evening shifts. Resident 3, who required extensive assistance due to diabetes and cellulitis, did not receive showers as ordered by their physician, and was left sitting in urine for over an hour. Resident 1, with a serious illness affecting their nervous system, also experienced delays in receiving showers and assistance, with call light response times exceeding 30 minutes. Other residents, such as Resident 4 and Resident 5, reported similar issues with delayed care and insufficient staffing, impacting their quality of life and personal hygiene. Staff interviews revealed that the facility was chronically understaffed, with many staff members unable to take breaks and feeling overworked. The administration was aware of the staffing issues but failed to address them adequately. Staff members reported that administrative staff, including the Director of Nursing, did not assist with resident care despite being aware of the staffing shortages. The Resident Council Minutes also documented complaints about long call light wait times and insufficient nursing assistants, further highlighting the facility's failure to provide adequate care.
Deficiency in Serving Meals at Safe Temperatures
Penalty
Summary
The facility failed to serve meals at a safe temperature for two residents, leading to a deficiency in food service. Resident 1, who had no cognitive deficits and required assistance with eating due to a serious illness affecting their nervous system, reported receiving cold food multiple times. On a specific occasion, their meal was served cold, with the fish at 88 degrees Fahrenheit and the vegetables at 80 degrees Fahrenheit, despite being initially prepared at higher temperatures. The staff did not attempt to reheat the meal or offer an alternative, and the issue was only addressed after the investigator intervened. Resident 2, who had moderate cognitive deficits and a respiratory disease, also reported consistently receiving cold meals. The facility's food temperature monitoring forms were incomplete, with no documented temperatures for most of the month, indicating a lack of adherence to the facility's policy on monitoring food temperatures. The Food Service Manager acknowledged that the facility had not been using the correct form for monitoring food temperatures since the kitchen transitioned to the existing corporation.
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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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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