Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avamere Rehabilitation At Park West during CMS and state inspections, most recent first.
Two residents with complex medical conditions, including kidney failure, pressure ulcers, infections requiring IV antibiotics, and isolation precautions, were transferred to the ED without the required clinical documentation and notices. Despite facility policies and a discharge checklist requiring a hospital transfer form, MAR, care plan, diagnostic results, advance directives, state transfer/discharge notice, and bed-hold information, an LPN sent only a face sheet and lab results and did not call the ED to provide a report. The ED reported receiving no paperwork for one resident and was unable to reach facility staff for a medication list or status report, and the state-required transfer/discharge and bed-hold notices were not provided to either resident or their representatives.
The facility failed to provide required written transfer/discharge notices for several residents, and failed to give bed-hold information for one resident during hospital transfers. One resident was transferred twice without receiving the written notice or bed-hold policy, and the record did not show that report was called to the receiving hospital for one transfer. Staff interviews confirmed the required notices were not documented for the residents reviewed.
PASRR screening and Level 2 evaluations were not completed as required for multiple residents. Residents with diagnoses including dementia, anxiety, depression, PTSD, psychotic disorder, and mood disorder had Level 1 PASRRs that identified SMI indicators, but Level 2 referrals were missing, delayed, or not completed after admission or after an exempt hospital discharge expired. One resident’s Level 2 was not entered into the record until after admission, and another remained in the facility beyond 30 days without a new PASRR review.
Failure to provide ADL assistance including hygiene, shaving, and nail care. Several dependent residents with cognitive impairment, stroke-related weakness, heart failure, or other complex conditions were observed with long fingernails, debris under nails, unshaven facial hair, and unchanged clothing or gowns despite care plans and orders calling for staff assistance. Staff interviews confirmed expectations for routine morning care and nail/shaving assistance, but also showed these services were not consistently provided.
Failure to Provide Ordered Restorative Nursing Programs The facility did not provide RNPs as assessed for multiple residents with ROM limits, weakness, fractures, and contractures. One resident with a right-hand contracture had no documented RNP or splint/brace order, while other residents with impaired mobility and ROM were observed in bed or in wheelchairs and received AROM, passive ROM, or ambulation programs fewer times than care planned. Staff reported workload and staffing issues, and documentation showed the restorative services were not consistently delivered at the required frequency.
Staff failed to follow infection control practices for multiple residents. A resident care manager did not wear required gown and gloves during EBP care for two residents, several CNAs and an LPN did not perform HH between dirty and clean tasks or after glove removal during incontinent and wound care, TBP was not initiated for a resident with loose stools while stool testing was pending, and two residents had wheelchairs with torn, taped, or worn surfaces that staff described as difficult to clean.
Two residents did not have beds that fit their needs. One resident with obesity, chronic leg wounds, and severe mobility dependence reported a lopsided bed, and staff observed the mattress was mispositioned and the bed tilted. Another resident with dementia, stroke history, and weakness was observed scrunched in bed with feet against the footboard and stated the bed was too short to straighten their legs; staff confirmed the bed was not long enough.
The facility failed to maintain several resident rooms in a homelike condition, with observations of scratched and peeling paint, stained ceiling tiles, damaged window trim, and exposed nails in multiple rooms. Staff acknowledged the damaged areas needed repair and confirmed the broken or missing trim and sticking nails. The facility also failed to keep one resident’s personal property safe.
Failure to process grievances for missing resident property. Two residents reported missing personal items, including dentures, lotion, and a reacher, but staff did not document or resolve the grievances. One resident’s dentures were listed on the inventory and later found missing, while another resident said multiple staff were told about missing items, yet no grievance was logged and the items were not replaced.
A resident with cognitive impairment, impaired vision, and a fall history, and another resident with memory loss, unilateral weakness, and a pressure ulcer were observed with pillows placed under their mattresses. The records showed no physician orders, assessments, or consents for the under-mattress pillow use, while the DON stated this type of intervention could function as a restraint and required an order, assessment, consent, and care plan inclusion.
Unnecessary Psychotropic Medication Use and Inadequate Behavior Documentation: One resident with dementia and psychotic disturbance continued receiving an antipsychotic despite frequent refusals, a pharmacy recommendation for GDR, and limited documentation of the behaviors the order was intended to monitor. A supplemental resident with cognitive decline and a psychotic disorder had the antipsychotic restarted after an allegation and reported hallucinations, but charting showed the resident was stable, had no documented behavioral issues, and staff did not document attempts at nonpharmacological interventions before the medication was re-initiated.
Inaccurate Cognitive Assessment: A resident with severe vascular dementia, a mood disorder, and a cognitive communication deficit was assessed on the MDS with a BIMS score indicating no cognitive impairment, even though prior BIMS results showed moderate impairment or inability to complete the test. A psych eval also noted the resident was nonverbal and did not engage with questions. Staff acknowledged the BIMS and MDS were not accurate and did not reflect the resident’s cognitive decline.
Failure to provide baseline care plans after admission. Two residents and one supplemental resident with complex diagnoses, including fractures, TBI, HF, ESRD, and respiratory failure, did not receive a reviewed or provided baseline CP within the required timeframe. One resident said they had no meeting to discuss their CP, did not know their goals, and did not receive admission paperwork; staff said baseline CPs were usually reviewed at care conferences in the first week and were not routinely given to residents or representatives.
Incomplete and non-individualized care plans were identified for multiple residents. A resident with hearing aids was observed without them despite an order for daily use, a resident with dementia and malnutrition had a nutrition CP that did not reflect cognitive deficits or weight loss, a resident with dementia had no nail care addressed in the ADL CP despite overgrown nails, and a resident with dementia had no resident-specific dementia CP even though the resident could not use the call light and relied on staff passing by for help.
Care plans were not kept current for two residents with complex medical needs, including stroke-related weakness, contractures, edema, HF, and kidney disease. One resident’s CP lacked directions for a right-hand contracture, and another resident’s CP lacked interventions for edema and did not reflect refusals to wear compression socks. The facility also held incomplete care conferences for two residents: only limited staff attended, and the dietary dept. did not participate when a resident’s cultural/religious food preferences were discussed, while another resident said they did not meet with the IDT to discuss the CP and discharge goals.
Medication orders were not consistently clarified or followed. A resident had a lab task signed as completed even though no specimen was collected, two residents had PRN pain or anxiety orders that lacked clear parameters or duplicate directions, and another resident received insulin and BP meds outside ordered hold parameters. Staff also could not show required nonpharmacologic pain interventions or glucose monitoring documentation for one resident.
Failure to Monitor and Document Edema Management: The facility did not ensure edema was assessed, monitored, or documented for two residents with HF and fluid retention concerns. One resident had repeated observations of edema, a significant weight gain, and no documented provider notification, while compression socks ordered for daytime use were not worn during multiple observations and refusals were not documented. For the other resident, staff could not provide documentation of monitoring for edema or fluid retention, and the DON/administrator stated there was no edema management policy.
Unsecured chemicals were found in an unlocked soiled utility room and an unlocked storage room near a resident room. The areas contained bleach urine stain/odor remover, nail polish drying spray, rapid dissolving disinfectant spray, and bacterial drain and trap cleaner, with warning labels noting eye irritation, skin and eye contact precautions, keeping away from children, and harm if swallowed. An RCM stated the rooms should be locked and closed for resident safety.
Failure to monitor nutrition, weights, and ordered supplements for residents with malnutrition and poor intake. Staff did not complete ordered admission and weekly weights, did not consistently document meal replacements when intake was under 50%, and delayed implementation of an RD-recommended house supplement. One resident with dementia and diabetes lost significant weight, another resident with malnutrition had incomplete weight monitoring despite contact precautions, and a third resident’s supplement order was not started when the RD first recommended it.
Expired medications and medications for discharged residents were found in the First Floor Unit med room, including fish oil, stool softener, and multiple bottles left behind after residents had discharged. Staff also observed a CNA keeping antifungal powder in a resident’s nightstand and using it during care, and the RCM stated such powders should be secured and not kept at the bedside.
Antibiotic stewardship was not effectively implemented for two residents. One resident had an ABO ordered for a UTI even though a urinalysis later showed no infection, and the ABO was missed on the review list. Another resident had conflicting chest x-ray documentation for pneumonia, but the IP did not communicate the discrepancy to the facility MD or complete an ABO timeout as expected under the ABO stewardship process.
A resident at high risk for pressure ulcers developed five new PU/PIs due to the facility's failure to implement appropriate interventions and accurately assess and document skin conditions. Despite being dependent on staff for mobility and having multiple risk factors, the care plan lacked specific measures to prevent skin injuries. Upon discharge, the resident had multiple PU/PIs that were not documented or communicated to relevant parties.
The facility failed to ensure a homelike environment for residents on two floors and in one elevator. Observations revealed multiple instances of damage, including gouges and exposed drywall in resident rooms, stained ceiling tiles, and a broken trim in the elevator. Staff confirmed these issues and acknowledged the need for repairs.
The facility failed to transmit the required MDS data to CMS within the required time frames for six residents, resulting in delays in care planning and unmet care needs. The MDS assessments for these residents were transmitted between one and twelve days late, as confirmed by the MDS Coordinators.
The facility failed to update PASRR assessments to reflect changes in the mental health status of four residents. The assessments were outdated or incomplete, missing critical diagnoses such as anxiety, depression, and psychosis. The Social Services Director acknowledged the inaccuracies and the need for revisions.
The facility failed to clarify and follow physician's orders for multiple residents, leading to potential medication errors and adverse outcomes. Issues included duplicate and unclear medication orders, failure to monitor blood pressure as required, and not removing pain patches as scheduled. Additionally, orthostatic blood pressure monitoring was not conducted for a resident on antipsychotic medication, as mandated by facility policy.
The facility failed to provide necessary ADL assistance to several residents, including bathing, grooming, and eating assistance. Residents were observed with long, dirty fingernails, unshaved facial hair, and uncombed hair. Staff acknowledged the lack of required care and assistance.
The facility failed to ensure that three residents received the Restorative Nursing Program (RNP) services they were assessed to require, leading to inconsistencies in providing prescribed splinting and passive/active ROM programs. Observations and interviews revealed that staffing issues and workload prevented the consistent provision of these services, placing residents at risk for a decline in ROM and decreased quality of life.
The facility failed to ensure resident safety by not adequately supervising and storing smoking materials for a resident, and by not securing the Central Supply and soiled utility rooms, which contained hazardous materials accessible to residents.
The facility failed to ensure nursing staff had the appropriate competencies and skill sets to provide safe care, particularly for a resident with a tracheostomy. Staff were not trained in specialized CPR for tracheostomy care, and there was no documentation of skills verification or competency evaluations for current staff. This placed residents at risk for incompetent care and harm.
The facility failed to implement an effective Infection Prevention and Control Program, lacking a water management program, having uncleanable resident equipment, improperly handled urinary catheter bags, and inadequate hand hygiene practices. Staff confirmed these deficiencies, which left residents vulnerable to infections.
The facility failed to revise its infection prevention and control policies and implement an updated Antibiotic (ABO) Stewardship program, lacking protocols to monitor, document, and analyze ABO use. This deficiency, spanning three months, placed residents at risk for adverse outcomes and ABO-resistant organisms.
The facility failed to obtain informed consent for psychotropic medication for a resident with severe memory impairment and did not ensure adequate privacy during care for three other residents. Staff provided care without pulling privacy curtains, exposing residents to potential view from the door or other parts of the room.
The facility failed to provide required written transfer/discharge notifications to three residents, including those with kidney failure, heart failure, and malnourishment, due to a misunderstanding of the requirements. Staff interviews confirmed that no notifications were sent after June 2023.
The facility failed to provide written notice of the bed hold policy to residents and/or their representatives at the time of transfer or within 24 hours, as required by their policy. This deficiency was identified for two residents who were transferred to the hospital. Staff confirmed that the bed hold notifications were not provided as required, placing the residents and their representatives at risk of not being informed of their rights and associated costs.
The facility failed to ensure accurate MDS assessments for six residents, leading to omissions and inaccuracies in documenting refusals of care, medication administration, and resident conditions. Staff interviews confirmed these deficiencies.
The facility failed to develop and implement comprehensive care plans for four residents, leading to inconsistent and inadequate care. One resident's dental health needs were not addressed, another's toileting schedule was omitted, a third's antipsychotic medication details were incomplete, and a fourth lacked necessary CPR equipment in their room.
The facility failed to update CPs for two residents and did not provide a care conference for one resident. One resident had an outdated CP for anticoagulant therapy, another had an outdated CP for meal assistance, and a third resident did not have a care conference for over a year due to staffing issues.
The facility failed to provide consistent feeding tube care for a resident with complex medical needs, including inconsistent formula administration, inadequate documentation of fluid intake, and improper labeling of formula bags. Staff interviews confirmed a lack of adherence to facility policies and physician orders.
The facility failed to timely act on medication-related irregularities identified by the consultant pharmacist for a resident with complex medical diagnoses. Recommendations for a lipid panel blood test and a decrease in a steroid nasal inhaler were delayed by several months, placing the resident at risk for medication-related complications.
A resident with kidney failure and shortness of breath continued to receive an antibiotic medication without proper review or adjustment, despite a nephrologist's recommendation to reduce steroid dosage and a pharmacist's recommendation to clarify the necessity of the antibiotic. The facility failed to schedule a follow-up appointment and clarify the medication order.
A resident with severe memory impairment was administered an antipsychotic medication without an appropriate diagnosis. Despite a consultant pharmacist's concern, the resident continued to receive the medication until a new diagnosis was added without clear documentation of the diagnostic process. Interviews confirmed the medication was given without an adequate diagnosis for several months.
The facility failed to secure and dispose of expired medications and biologicals timely. Expired items were found in the medication room, Pyxis machine, and medication carts. Unsecured medications were also observed in resident rooms and on medication carts. Staff interviews confirmed these findings and acknowledged the lapses in protocol.
The facility failed to provide timely dental services for a resident with broken teeth and oral pain. Despite a dental consultation recommending extractions and dentures, no follow-up actions were taken due to staffing shortages, placing the resident at risk for unmet dental needs.
Failure to Provide Required Notices and Clinical Information During Hospital Transfers
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement an effective system for communication and provision of medical records when residents were transferred to the hospital, both for residents expected to return and those not expected to return. Facility policies required that residents transferred for emergency treatment receive a notice of transfer as soon as practicable, that the state agency transfer/discharge notice be completed, and that the facility’s bed-hold policy be provided. Another policy required that specific clinical information be conveyed to the receiving provider, including practitioner and representative contact information, advance directives, care plan, current status and baseline function, diagnoses, allergies, medications, diagnostic tests, and a discharge summary. A facility checklist directed staff to notify the physician, administrator, DON, and resident representative, complete a hospital transfer form, provide the state transfer/discharge notice and bed-hold policy, send a defined packet of clinical documents with the resident, and document all required elements in the medical record. For one resident, the admission MDS showed significant hearing and vision impairment, cognitive impairment, acute kidney failure, history of kidney transplant, pressure ulcers, and other complex diagnoses, with total dependence on staff for personal care and mobility. The comprehensive care plan documented an advance directive with a designated representative, an infected foot wound requiring a mid-line IV antibiotic, and detailed care for the infected pressure ulcer and IV site. The MAR and TAR contained extensive information on medications, including IV antibiotics, isolation requirements, and specific wound care instructions. On the date of transfer, a progress note recorded that the physician evaluated the resident, determined a hospital transfer was necessary, and that the resident was sent by ambulance with no bed hold desired; no additional information was documented. A hospitalist later reported that the ED received no paperwork with the resident, that multiple attempts to obtain a medication list and status report from the facility were unsuccessful, and that the facility did not inform the hospital about the mid-line IV indication or the severe infected foot wound. The hospital pharmacist ultimately had to contact the facility’s pharmacy to obtain the medication and IV information. The LPN assigned to this resident on the day of transfer stated they called the resident representative and arranged transportation, and that they sent only a face sheet and lab results with the resident. The LPN acknowledged they did not call the ED, did not send a hospital transfer sheet, did not complete or provide the state transfer/discharge notice or the bed-hold notice to the resident or representative, and did not use the discharge checklist. The LPN further stated they completed the hospital transfer form after the resident left and did not send it with the resident, and that the MAR, care plan, diagnostic results, advance directives, and change-of-condition form should have been sent but were not. For a second resident, the admission MDS documented cognitive loss, back surgery, bone infection, kidney failure requiring dialysis, and multiple pressure ulcers, with total dependence on staff for personal care and mobility. The comprehensive care plan showed the resident required a specialty mattress, was at high risk for falls, had specific behaviors with defined interventions, required medication monitoring, had an infection, was on IV antibiotics, and required specific isolation precautions. The MAR and TAR contained detailed instructions for routine and IV medications, isolation requirements, and wound care for multiple pressure ulcers. A progress note documented that the resident was sent to the hospital via ambulance for a change in condition, with multiple diagnostic tests and results, vital signs, and contact with the on-call physician who directed transfer to the ED. The LPN reported that, for this transfer, they again did not use the discharge checklist, sent only the face sheet and lab results, did not send a hospital transfer form because it was completed after the resident left, and did not provide the state transfer/discharge notice or bed-hold form to the resident or representative. The resident care manager stated that nurses were expected to follow the discharge checklist, complete the state transfer/discharge notice and bed-hold form when a resident was sent to the hospital, and call the ED to provide a report. The administrator stated that staff did not follow facility policy and that the failure in practice was identified in their system for discharging residents to the hospital. The administrator also stated that nursing staff were expected to complete the hospital transfer form, call the hospital with resident status information, complete all documentation, and send all required documents to the hospital, including the state transfer/discharge notice and bed-hold form to be provided to residents or their representatives and entered into the medical record. These expectations were not met for the two residents reviewed for hospitalization, resulting in noncompliance with WAC 388-97-0120, -0080, and -0140.
Failure to Provide Transfer/Discharge Notices, Bed-Hold Information, and Hospital Report
Penalty
Summary
The facility failed to ensure residents received required written transfer and discharge notices, and failed to provide bed-hold information for one resident, during hospital transfers and discharges. Review of records showed Resident 71 was transferred to an acute care hospital and did not receive a written transfer notification. Resident 102 was also transferred to an acute care hospital and no written transfer notification was provided to the resident or their representative. Resident 12 had discharge return anticipated MDS assessments showing hospital discharge related to a change in condition, including kidney failure and heart failure, but there was no documentation that the resident or their representative received a written notification of the reason for transfer to the hospital. Resident 6 was transferred to an acute care hospital twice, and the facility did not provide a written transfer notification or the bed-hold policy to the resident or their guardian for either transfer. The record also showed report was not called to the receiving hospital for the 02/20/2025 transfer. Staff interviews indicated the admission coordinator, social services director, RCM, and DON were involved in transfer/discharge notifications, but staff were unable to provide documentation that the required notices or hospital report were completed for the residents reviewed.
PASRR screenings and Level 2 evaluations were not completed for multiple residents
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed as required for 4 of 6 residents reviewed. The facility failed to ensure Level 1 PASRR screenings were accurate and/or obtained before admission, and failed to ensure Level 2 PASRR evaluations were obtained on admission or after it was identified that a Level 2 was required. The facility policy stated PASRR assessments were intended to ensure residents with mental health or intellectual disabilities were appropriately placed and received needed services, and that PASRRs would be reviewed annually or during a significant change in condition by Social Services. Resident 26 had diagnoses including severe vascular dementia with behavioral disturbance, a mood disorder, and a cognitive communication deficit, and received antipsychotic and antidepressant medications. Records showed a corrected Level 1 PASRR identified a Serious Mental Illness indicator and noted that a Level 2 was never sent, and no Level 2 referral was found in the record. Resident 7 had diagnoses including a progressive cognitive function disorder, anxiety, depression, a psychotic disorder, a chronic brain disorder, and PTSD, and received antipsychotic, antianxiety, and antidepressant medications; a corrected Level 1 PASRR identified the need for a Level 2, but no Level 2 was completed. Resident 5 admitted with multiple complex diagnoses including a mental illness characterized by extreme mood swings, anxiety, and depression, and the Level 1 PASRR identified a mood disorder and required a Level 2 referral, but the Level 2 was not entered into the record until 11 days after admission. Resident 9 admitted with anxiety and depression, had a Level 1 PASRR showing a mood disorder with an exempted hospital discharge, and the record showed the resident remained in the facility beyond 30 days without a new Level 1 or Level 2 PASRR being completed.
Failure to Provide ADL Assistance Including Hygiene, Shaving, and Nail Care
Penalty
Summary
The facility failed to provide ADL assistance, including personal hygiene, grooming, shaving, bathing-related care, and nail care, for 6 dependent residents reviewed for ADLs. The facility policy stated residents unable to perform ADLs independently would receive services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Surveyors found that staff documentation and observations did not match the residents’ needs or care plans, and multiple residents remained with long fingernails, debris under nails, unshaven facial hair, or otherwise unmet personal care needs despite being dependent on staff for these services. Resident 77 had heart failure, a history of stroke, and a progressive condition causing cognitive decline, and was dependent on staff for personal hygiene, toileting hygiene, and lower body dressing. The care plan directed one-person assistance with personal hygiene, and staff documented daily hygiene care, but observations showed long fingernails extending past the fingertips, chipped nails, and a jagged cracked thumbnail. Resident 77 stated they wanted their fingernails trimmed, and the RCM later stated nurses should provide weekly nail care, although there was no schedule for residents who were not diabetic and nail care was not on the task sheet, MAR, TAR, or care plan. Resident 31 had significant cognitive impairment and was dependent on staff for oral hygiene, toileting, bathing, dressing, and personal hygiene; an order directed licensed nurses to perform nail care every Monday. Surveyors observed long fingernails with white debris, and the resident stated they did not like their nails long and needed them cut, yet the nails remained unchanged even after the TAR showed nail care was signed as completed. Resident 99, Resident 79, Resident 8, and Resident 28 were also observed with unmet ADL needs, including long nails with debris, unshaven facial hair, and remaining in bed in the same clothing or hospital gown. Staff interviews confirmed expectations that dependent residents should receive morning care, shaving, dressing, oral care, and nail care, but staff also acknowledged these services were not consistently provided.
Failure to Provide Ordered Restorative Nursing Programs
Penalty
Summary
The facility failed to provide Restorative Nursing Programs (RNPs) as assessed for 6 of 8 residents reviewed for position and mobility. The deficiency involved residents with documented limitations in range of motion (ROM), weakness, fractures, contractures, and impaired mobility, but the restorative services recorded in care plans and task documentation were not consistently provided at the frequency directed. The report states this failure placed residents at risk for decline in mobility and ROM, functional status, and other negative health outcomes. Resident 8 had impaired functional limitation in ROM in both legs, was dependent for dressing and transfers, and required substantial assistance for rolling in bed. The care plan directed active ROM for both arms and sit-to-stand exercises for both legs three to six times weekly, but July 2025 documentation showed the resident received each assigned RNP on only 7 of 27 opportunities. The resident was observed lying in bed on multiple occasions and stated they had not gotten up in their wheelchair for a while. A restorative aide stated the programs were not provided because of workload and resident refusals, and that refusals were not documented or reported to a supervisor. Resident 11 had right-sided weakness and a right-hand contracture, but the care plan contained no documented interventions or RNP for the contracted hand, and there was no physician order for a splint or brace. The resident was repeatedly observed sitting in a wheelchair without a splint on the right hand. Staff interviews confirmed there was no documentation or RNP for the contracture, and the DON stated staff should have assessed the contracture and had a brace program in place, but did not. Resident 1 had ROM limitations in the upper and lower extremities related to multiple fractures with pain, and the care plan directed active ROM and ambulation three to six times weekly. The resident’s RNP was not offered at the minimum frequency during May, June, and July 2025. Resident 6 had ROM limitations in all extremities related to stroke, a left lower extremity fracture, and gait/mobility abnormalities, and the care plan directed passive and active ROM three to six times weekly; documentation showed the program was also not offered at the required frequency over the same three-month period. Resident 7 had weakness, contractures to both hands, and ROM limitations, with a care plan for AROM to upper and lower extremities three to six times weekly, but task records showed the program was provided fewer times than planned, including one week with no provision at all. Resident 31 had a brain bleed, one-sided weakness, required assistance with personal care, and had ROM limitations in both upper and lower extremities; the care plan directed AROM three to six times weekly, but task documentation showed the resident did not receive the program at the planned frequency across May, June, and July 2025. Staff interviews stated the restorative program was short staffed and that residents were not receiving RNPs as assessed to require.
Infection Control Failures with PPE, Hand Hygiene, TBP, and Uncleanable Equipment
Penalty
Summary
Staff failed to follow Enhanced Barrier Precautions for two residents. One resident had chronic venous ulcers, venous insufficiency, a history of a skin infection of the left lower limb, and used a wheelchair; the care plan directed staff to wear a gown and gloves during dressing, personal hygiene, and linen changes. Although an EBP sign was posted on the room door directing staff and visitors to wear gloves and a gown for high-contact care, a resident care manager was observed assisting the resident with socks without gloves or a gown. Another resident had an indwelling catheter, and the care plan directed staff to wear gloves and a gown for dressing, bathing, personal hygiene, and catheter care. An EBP sign was posted on that resident’s door, but the resident care manager was observed moving the catheter to the side of the bed without a gown. Staff did not perform hand hygiene during multiple resident care encounters. During incontinent care for one resident, a CNA wiped the resident clean, removed soiled gloves, put on new gloves without hand hygiene, continued care with the same soiled gloves, retrieved skin barrier ointment from the bedside drawer while wearing soiled gloves, applied the ointment, and assisted with turning and covering the resident while still wearing soiled gloves. During wound care for another resident, an LPN removed soiled gloves after removing an old dressing and put on new gloves without hand hygiene, then repeated glove changes without hand hygiene while cleansing the wound and applying a clean dressing. During incontinent care for a third resident, a CNA changed gloves between dirty and clean tasks but did not wash hands between those tasks. During incontinent care for a fourth resident, a CNA touched wipes, the bedside table, the door handle, and the resident’s bed controller while wearing soiled gloves, changed gloves without hand hygiene, and reapplied a bandage that had started to come off the resident’s elbow. An LPN providing wound care to two sites on that same resident changed gloves between sites but did not perform hand hygiene between glove changes. Transmission Based Precautions were not initiated for one resident who had loose, watery stools and was being tested for a colon infection. A progress note documented that the provider was notified and a stool sample was sent to the lab, but when the room was observed there was no TBP sign on the door. Staff stated the resident should have been isolated while awaiting test results, and the Infection Preventionist stated staff should have initiated TBPs for a resident with loose stools when testing was ordered. The facility also had uncleanable resident equipment. One resident’s wheelchair had torn leather armrests wrapped with tape and foam material wrapped with tape, leaving the surface uncleanable. Another resident’s motorized wheelchair had worn, torn cushions on the arm, foot, and seat areas with missing or exposed cover and cushion material, along with dirt and debris on the back of the wheelchair. Staff stated the wheelchair was difficult to clean because of its condition and could harbor infections because it could not be totally sanitized.
Beds Were Not Properly Sized or Positioned for Two Residents
Penalty
Summary
The facility failed to provide a comfortable, appropriately sized bed for two residents who were reviewed for accommodation of needs. The facility policy stated residents were to be provided a safe, comfortable, and homelike environment emphasizing comfort, personal needs, and preferences. Resident 71 had obesity, chronic lower-leg wounds, and impairments to both lower extremities, and was fully dependent on staff for bed-to-wheelchair transfers and for moving from lying to sitting. The resident stated the bed was lopsided on the left side, which made it harder to get up when transferred, and said staff had been told but the bed had not been fixed. Observation showed the bed tilted upward toward the foot of the bed, and staff later found the mattress securing bar positioned under the foot of the mattress instead of along the side, with the mattress cover not zipped properly, both contributing to the bed being lopsided. Resident 77 had non-Alzheimer's dementia, a history of stroke, muscle weakness, and needed assistance with personal care. The care plan identified limited mobility due to weakness and directed staff to assist with bed mobility and monitor for back pain. Observations showed the resident lying in bed with knees bent, feet pressed firmly against the footboard, and the head positioned above the top of the mattress. The resident stated the bed was too small, wanted to extend their legs, and needed a longer bed because of their height. Staff later confirmed the bed was not long enough for the resident to straighten their legs and stated they would ask about a longer bed or adjusting the bed length.
Damaged Room Conditions and Unsafe Personal Property Handling
Penalty
Summary
The facility failed to ensure walls and blinds in resident rooms were maintained in a homelike condition for 6 of 19 sampled resident rooms, including Rooms 211-1, 214-1, 220, 201, 106, and 118. Observations showed scratched paint on the wall next to a resident’s bed, a scratched toilet seat cover with peeling paint and a brown-stained toilet bowl, and a bathroom ceiling tile with a large brown stain in Room 211-1. In another room, a large white paint patch did not match the surrounding wall color near a resident’s chair. In Room 220, the wood railing near the doorway had large paint gouges by a power wheelchair. In Room 201, paint was scraped off the wall behind bed B and the ceiling tiles above the window had a large brown stain. In Rooms 106 and 118, window trim was broken or missing, leaving jagged edges and small nails sticking out, and ceiling tiles above the windows had dark stains. The facility also failed to ensure one resident’s personal property was kept safe for 1 of 2 residents reviewed for personal property. The report states this failure involved Resident 8. During an observation and interview, Staff O, a Maintenance Assistant, stated maintenance issues should be reported through the facility’s in-house maintenance system so maintenance staff could address them, and identified the toilet seat, ceiling tiles, wall paint, and damaged railing as items needing repair. Staff T, the Regional Director of Quality Assurance, stated that an environment in good repair was important to ensure a homelike environment and confirmed the broken or missing trim and sticking nails in Rooms 106 and 118, stating the nails could be a potential risk for injury.
Failure to Process Grievances for Missing Resident Property
Penalty
Summary
The facility failed to initiate, investigate, and resolve grievances related to missing personal property for 2 of 2 residents reviewed. The facility administrator stated there was no grievance policy, although the resident rights policy stated residents had the right to voice grievances without discrimination or fear of discrimination, and the personal property policy stated the facility would promptly complete an investigation of misappropriation of resident property. For one resident, the record showed full upper and lower dentures were listed on the admission inventory, but a grievance form later documented that the dentures were missing and staff were unable to locate them. The form indicated the Social Service Director would contact the resident’s representative to coordinate replacement, but the resident and representative later stated they had not heard anything further and the dentures had been missing for about two and a half months. Staff later stated they did not have a copy of the grievance form and were unaware of the plan to coordinate replacement. For another resident, the resident reported that a personal bottle of lotion and a personal reacher were missing and said they had told multiple staff members, but nothing had happened. The resident care manager stated staff had been told about the missing items, the facility did not replace the lotion, and the resident did not like the plastic reacher that was provided. The grievance log contained no documentation for this resident, and staff stated they had not received a grievance for the missing items.
Unapproved Mattress and Pillow Use Functioning as Restraints
Penalty
Summary
The facility failed to ensure residents were free from physical restraints unless needed for medical treatment for 1 reviewed resident and 1 supplemental resident. For Resident 99, the record showed a history of traumatic brain dysfunction, cataracts, falls, memory problems, impaired vision, and dependence on staff for side-to-side rolling in bed. The physician’s orders included a perimeter mattress, fall mat, and later a concave mattress, but there were no orders for the pillows placed under the mattress. The care plan addressed the perimeter mattress, bed brakes, and fall mat, and staff completed assessments and consents for the bed against the wall, fall mat, perimeter mattress, and a tiltable wheelchair, but not for the pillows under the mattress. During observations, Resident 99 was seen in bed with two pillows placed between the perimeter mattress and bed frame, tilting the mattress laterally, and the DON confirmed the pillows were under the mattress and stated such use required assessment, consent, a physician’s order, and care plan inclusion. For Resident 7, the quarterly MDS showed progressive memory and cognitive loss, weakness to one side of the body, and treatment for a pressure ulcer, with no restraints in use at the time of assessment. During observation, Resident 7 was lying in bed with a pillow stuffed between the bed frame and mattress, propping the mattress up on the right side. The physician’s orders did not direct staff to place pillows under the mattress, and the revised skin breakdown care plan only directed staff to place a pillow on the open side of the mattress for right hand resting comfort, not under it. No assessment or consent was completed for the pillows under the mattress, and the DON stated pillows placed under a mattress could be perceived as a restraint and expected assessment, consent, and care plan prior to use.
Unnecessary Psychotropic Medication Use and Inadequate Behavior Documentation
Penalty
Summary
The facility failed to ensure that 1 resident with dementia and psychotic disturbance and 1 supplemental resident were free of unnecessary psychotropic medications. For one resident, the quarterly MDS showed an antipsychotic was given daily during the assessment period, while the behavior care plan called for staff to monitor behaviors, use non-pharmacological interventions, and notify the physician if behaviors interfered with medical needs. A monthly medication review recommended a gradual dose reduction of the antipsychotic, but the provider declined it and documented that the resident had stable behavior. Review of the resident’s medication records showed frequent refusals of the antipsychotic medication, including refusals on 16 of 30 days in one month and 16 of 27 days in another month. The MAR also showed staff documented non-compliance with care only two times in 27 days, despite the physician order directing staff to monitor and document behaviors every shift. Staff interviews indicated the resident refused medications and care at times, had been refusing the antipsychotic almost daily, and staff did not know whether the medication was effective. The DON stated the facility should have discontinued the antipsychotic medication but did not. For the supplemental resident, the quarterly MDS showed diagnoses including progressive cognitive decline and a psychotic disorder, but no psychosis or rejection of care during the assessment period and no antipsychotic use during that period. The resident’s care plan directed staff to monitor behavior and psychotropic side effects if applicable. After an allegation involving staff misconduct, the facility investigation concluded the allegation was not substantiated and added an intervention to re-initiate an antipsychotic due to an increase in hallucinations. However, progress notes before and after the discontinuation of the antipsychotic documented the resident was stable, had no reported auditory or visual hallucinations, tolerated the discontinuation well, and had no documented behavioral issues on multiple nursing shifts. The DON stated staff saw an increase in behaviors since the antipsychotic was discontinued, but also confirmed there was a lack of documentation describing recent behaviors and that non-pharmacological interventions were not attempted before the medication was restarted.
Inaccurate Cognitive Assessment
Penalty
Summary
The facility failed to ensure assessments accurately reflected a resident’s health status and care needs for Resident 26. The resident had diagnoses of severe vascular dementia with behavioral disturbance, a mood disorder, and a cognitive communication deficit. The facility’s dementia protocol stated that the interdisciplinary team would review the resident’s physical, functional, and psychosocial status and evaluate individuals with new or progressive cognitive impairment to help identify symptoms and findings that differentiate dementia from other causes. Resident 26’s 06/08/2025 modified MDS recorded a BIMS score of 15 out of 15, indicating no cognitive impairment. However, the resident’s 06/06/2025 BIMS evaluation showed a score of 12 out of 15, and prior BIMS evaluations on 03/11/2025 and 12/24/2024 were scored as 99 because the resident could not participate. A 06/23/2025 psychological evaluation noted the resident was nonverbal and did not engage or cooperate with questions. Staff C stated the 06/06/2025 BIMS was not accurate, Staff H stated they were supposed to interview residents before completing an MDS, and Staff HH stated they did not physically check Resident 26 when completing the MDS and relied on the BIMS completed by Staff C. The DON stated the BIMS was incorrect for Resident 26 and did not accurately reflect the resident’s cognitive decline.
Failure to Provide Baseline Care Plans After Admission
Penalty
Summary
The facility failed to provide baseline care plans to 2 residents and 1 supplemental resident within the required timeframe after admission. Resident 5 was admitted with multiple complex diagnoses including fractures, end stage kidney disease, and respiratory failure. During an interview, Resident 5 stated they did not have a meeting with staff to discuss their care plan, were unsure of their current care goals, and said they did not receive copies of any paperwork after admission. The baseline care plan evaluation form for Resident 5, signed by staff, documented that the baseline care plan was not reviewed or provided to the resident and/or representative and stated the plan would be available upon completion, without indicating it was provided within 24 hours. Resident 99 was admitted with medically complex diagnoses including fractures and traumatic brain injury, and Resident 79 was admitted with heart failure and end-stage kidney disease. For both residents, the baseline care plan evaluation forms documented that the baseline care plan was not reviewed or provided to the resident and/or representative, and instead noted that staff reviewed the plan with family or in part with the resident and that the plan would be available once completed. Resident 79 stated the facility did not provide a copy of the baseline care plan and that they were unsure of their goals while in the facility. Staff stated baseline care plans were reviewed at care conferences during the first week after admission and that it was not their standard practice to provide a copy to residents and/or representatives, and another staff member stated baseline care plans were started but not completed within 48 hours.
Incomplete and Non-Individualized Care Plans
Penalty
Summary
The facility failed to develop and/or implement comprehensive care plans for 4 of 19 sampled residents. The report cited the facility’s policy requiring a comprehensive, person-centered care plan for each resident with objective, measurable goals, and its dementia protocol requiring the resident’s condition and level of support needed to be identified and documented during care planning. For Resident 99, the 07/15/2025 MDS indicated adequate hearing with hearing aids or other hearing appliances, and a physician order dated 07/10/2025 directed staff to ensure both hearing aids were used daily during the day. The revised communication care plan dated 07/14/2025 did not address hearing aids or other hearing appliances. Observations on 07/23/2025, 07/24/2025, and 07/25/2025 showed the resident without hearing aids or other hearing appliances. The resident’s family stated the resident wore hearing aids but staff did not always help place them, and that the hearing aids were locked away when not in use. Staff N stated the care plan should address communication needs and assistance required. For Resident 26, the 06/02/2025 quarterly MDS listed severe vascular dementia with behavioral disturbance, a mood disorder, a cognitive communication deficit, and malnutrition. The revised nutritional problem care plan dated 10/22/2024 identified potential nutritional problems related to mood disorder, traumatic brain injury, swallowing difficulty, and requests for multiple snacks, but did not include dementia, malnutrition, or cognitive communication deficit. The plan did not specify when supplements should be offered, what to do if meals were refused, when to contact the provider for weight loss or meal refusal, or how staff were to explain dietary consequences given the resident’s cognitive communication deficit. The resident weighed 129 pounds on 06/01/2025 and 116 pounds on 07/28/2025, a 10.08% loss in less than two months. Staff CC stated the care plan was not updated to include supplements or the resident’s preference for noodles, and Staff E stated food alternatives were offered but not listed in the care plan. For Resident 77, the 07/08/2025 annual MDS documented a history of stroke, dementia, and cognitive deficits. The 07/21/2025 ADL performance deficit care plan addressed weakness and listed goals for improvement in transfers, dressing, toileting, and ADL scores, with one-person assistance for personal hygiene, but it did not specify fingernail care. Observations on 07/22/2025 and 07/24/2025 showed long, chipped, jagged, dry, and cracked nails extending about a quarter inch past the nail beds, and the resident stated they wanted their nails cut. Staff E stated nurses should provide weekly nail care, but there was no schedule unless a resident was diabetic and nail care was not included on the task sheet, MAR/TAR, or care plan. For Resident 1, the 04/24/2025 admission MDS identified non-Alzheimer’s dementia, and interviews showed the resident did not know how to use the call light and waited for staff to walk by for help. The resident’s representative stated the resident did not know how to use the call light due to dementia and did things on their own without asking for help. Record review showed no dementia care plan had been developed, and Staff E and Staff B stated a resident-specific dementia care plan should have been in place.
Care plans not updated and IDT care conferences incomplete
Penalty
Summary
The facility failed to keep resident care plans updated for two residents. Resident 11 had a history of stroke with right-sided weakness and a right-hand contracture, and observations on multiple days showed the resident seated in a wheelchair with the right hand in the lap and no brace or splint in place. The revised self-care deficit care plan dated 06/16/2024 did not include documented care directions or interventions for staff to manage the right-hand contracture. The Director of Nursing stated staff should assess the resident for the contracture and update the care plan with interventions, but this had not been done. Resident 28 had diagnoses including stroke with left-sided weakness, heart failure, and kidney failure, with limited range of motion in the left arm and both legs. The resident had a physician order for compression socks to both lower legs in the morning and removal at bedtime for edema, but observations showed both feet were edematous and the resident was not wearing compression socks. The revised heart failure care plan did not include documented care directions or interventions for what staff should do if edema was noticed on the resident's legs and feet. The RN stated the resident had edema on both lower legs and sometimes refused to wear compression socks, and the DON stated the care plans were not updated according to the resident's current medical condition and refusals. The facility also failed to ensure interdisciplinary care conferences included the appropriate team members for two residents. Resident 39 had no memory impairment, received a therapeutic diet, and had diagnoses including iron deficiency, hypertension, chronic kidney disease, protein malnutrition, and adult failure to thrive. The food preferences evaluation only reflected cultural/religious restrictions and did not identify the resident's requested food preferences, including coconut. The care conference form showed only the RCM and Social Service Assistant attended, and the resident stated they had asked several staff for cultural/religious food preferences but were told the facility could not provide any. Resident 5 had multiple diagnoses including fractures, end-stage kidney disease, and respiratory failure, was able to speak clearly and understand others, and stated they did not meet with the IDT to discuss the care plan and discharge goals. The care conference form showed only the Admissions Nurse and Social Services Director attended.
Medication Orders Not Clarified or Followed
Penalty
Summary
The facility failed to ensure nurses only signed for tasks that were actually completed for one resident. For Resident 2, a pharmacist recommended bloodwork on 06/07/2025, and the June 2025 MAR showed staff signed that the bloodwork was obtained on 06/17/2025. However, the resident’s record contained no lab results for that bloodwork, and the facility’s lab binder had no receipt for June or July 2025 showing the lab obtained the specimen. The RCM reviewed the record and confirmed the lab was not collected as ordered. The facility also failed to clarify physician orders as needed for several residents. Resident 7 had orders for an OTC pain medication and an opioid pain medication, but the orders did not specify what pain level should trigger each medication. The MARs showed both medications were administered at varying pain scores across May, June, and July 2025. Resident 1 had a chronic pain care plan calling for nonpharmacological interventions before pain medication, but the physician order did not include those interventions or maximum daily dose parameters, and it did not include an order to monitor for signs of hypo/hyperglycemia. Staff E and the DON stated they expected those details to be included, but no supporting documentation was available. The facility further failed to follow physician orders for two residents. Resident 12 had an insulin order to hold the dose if blood sugar was less than 120, but the dose was given when the blood sugar was 118. Resident 5 had duplicate anxiety medication orders with different tablet amounts and no direction on which dose to use, and the duplicate orders were not clarified. Resident 5 also received blood pressure medications outside ordered parameters on multiple dates when the heart rate was less than 60. Staff N and the DON stated orders should be clarified and followed as written.
Failure to Monitor and Document Edema Management
Penalty
Summary
The facility failed to ensure edema management was assessed, monitored, documented, and carried out according to physician orders for 2 residents reviewed for edema management. One resident had diagnoses including left-sided weakness, heart failure, and kidney failure, with a care plan directing staff to monitor for dependent edema, weight gain, and other signs of fluid overload. Physician orders required compression socks during the day and weights three times weekly, but the resident’s weight increased from 230 pounds to 259 pounds over a short period, and the record did not show provider notification of the weight gain. Observations on multiple days showed edema in the left hand and both feet, and the resident was not wearing compression socks during those observations. When assessed by an RN, the resident had 3+ edema in both feet, and staff stated the resident did not like to wear the socks. For the second resident, the record showed diagnoses including heart failure and shortness of breath, and the resident was receiving diuretic therapy. The resident’s representative stated the resident often had significant swelling in the lower legs due to fluid retention and that the swelling had been very bad recently. Staff were unable to provide documentation that the resident’s fluid retention or edema was being monitored, and the facility administrator stated the facility did not have an edema management policy. Staff also stated they expected monitoring for signs of fluid retention/edema, but no documentation was provided to show that this monitoring occurred.
Unsecured Chemicals in Utility and Storage Areas
Penalty
Summary
The facility failed to maintain an environment free from accident hazards by leaving chemicals unsecured in 1 of 3 soiled utility rooms and 1 of 2 storage rooms. On the second floor, the soiled utility room door was observed unlocked, and the room contained an unsecured bottle of bleach urine stain/odor remover that was one quarter full, a bag of fingernail polishes, a bottle of nail polish drying spray with a warning to prevent contact with skin and eyes, and a bottle of rapid dissolving disinfectant spray with a caution label to keep away from children. A second-floor storage room near a resident room was also observed unlocked and led through another door to a bathroom where a bottle of bacterial drain and trap cleaner for slow drains was found with about one quarter of its contents remaining and a warning label stating it was harmful if swallowed. Staff E stated the soiled utility room and storage rooms should be locked and closed for resident safety.
Failure to Monitor Nutrition, Weights, and Ordered Supplements
Penalty
Summary
The facility failed to monitor and report nutritional care for residents with identified nutritional risk, failed to provide weight monitoring as ordered, and failed to obtain supplements as ordered for three residents. The report states the facility did not consistently monitor residents who ate less than 50% of meals, did not collect timely and accurate weights as ordered and per policy, and did not ensure ordered supplements were initiated or offered as directed. The cited policy required staff to monitor and document weight and intake in a way that allowed comparison over time and to notify the provider of abrupt or persistent changes from baseline appetite or food intake. Resident 79 had diagnoses including malnutrition, was on a mechanically altered diet, and had no natural teeth. The resident stated staff had not weighed them recently and expressed concern about weight loss. Records showed the resident was identified as nutritionally at risk with documented weight loss, had an order for admission weights for three days, but only two were completed. A later order required weekly weights and provider notification for a gain or loss of five pounds or more, yet the scheduled weight was not completed because the resident was on contact precautions. The next documented weight showed a loss of 17.2 pounds in 16 days. Resident 26 had diagnoses including dementia, mood disorder, cognitive communication deficit, malnutrition, and diabetes. The care plan called for monthly weights, prescribed diet, and snacks, but the resident lost weight from 129 pounds to 116 pounds. Staff documented multiple meals as none to less than 25% eaten, but meal replacement percentages were not documented on several occasions as required by the task sheet. The resident also had an appetite stimulant order, but the record did not show instructions for missed meals or provider notification when intake was poor. Resident 1 had malnutrition and diabetes with poor intake noted on nutrition assessment, and a house supplement was recommended twice daily, but the supplement order was not initiated until more than one month later.
Expired, Discharged, and Unsecured Medications Found
Penalty
Summary
The facility failed to ensure drugs and biologicals were labeled and stored in accordance with policy and accepted professional principles. In the First Floor Unit medication room, surveyors observed expired medications, including a bottle of fish oil that expired in 3/25, two bottles of stool softener that expired in 4/25, and two gallon-sized storage bags containing multiple expired medication bottles. Staff AA, an LPN, acknowledged the medications were expired and stated they should be removed from the medication room and discarded. Surveyors also observed multiple medications still present in the First Floor Unit medication room for discharged residents, including residents who had discharged over five months, over two months, almost two months, and over a month earlier. Staff AA stated discharged residents' medications should be sent with the resident or returned to the pharmacy after discharge. In addition, during observation of Resident 31, a CNA removed a bottle of antifungal powder from the resident's nightstand drawer and applied it during incontinence care, then returned it to the drawer. The Resident Care Manager stated antifungal powders should be secured and not kept at the resident's bedside.
Antibiotic Stewardship Program Not Effectively Implemented
Penalty
Summary
The facility failed to implement an effective Antibiotic (ABO) Stewardship Program for 2 of 3 residents reviewed for ABO stewardship, Resident 9 and Resident 53. According to the facility policy, when an ABO was prescribed the primary care practitioner was to assess the resident within 72 hours, and diagnostic results were to be communicated to the resident’s primary care provider to determine whether ABO therapy should be continued, modified, or discontinued. Staff D, the Infection Preventionist, stated the facility used McGeers criteria to review ABO use and expected staff to obtain the diagnosis, start and stop dates, supporting lab results, and other data when a resident was admitted with an infection, or to ensure symptoms met McGeers criteria when an infection was acquired in the facility. Resident 9 had a June 2025 physician order for an ABO course to treat a UTI, but the 07/16/2025 urinalysis reported no infection present, and Staff D stated Resident 9’s ABO was missed and not reviewed on the June line listing. Resident 53 had a 07/07/2025 Infection Screening Evaluation noting a recent chest x-ray consistent with pneumonia, but the H&P showed a 07/01/2025 chest x-ray negative for pneumonia. Staff D stated they knew about the conflicting hospital documentation but did not communicate it to the facility physician, and they did not conduct an ABO timeout for Resident 53 as expected. Staff D also stated Resident 53 was not on the June 2025 ABO line listing and the July 2025 line listing had not yet been started.
Failure to Prevent and Document Pressure Ulcers
Penalty
Summary
The facility failed to implement appropriate interventions to protect a resident's skin from injury, leading to the development of five new pressure ulcers/pressure injuries (PU/PIs) and associated pain. The resident, who was admitted for rehabilitation with multiple diagnoses including a brain disorder, dementia, and diabetes, was assessed at high risk for developing PU/PIs due to factors such as limited mobility, inadequate nutrition, and risk for skin friction and shearing injuries. Despite these risk factors, the facility did not include specific interventions in the care plan to prevent friction and shearing, nor did they accurately assess and document the resident's skin condition. The facility's policy required nursing staff to recognize, assess, and document significant risk factors for developing PUs, as well as to conduct weekly skin assessments. However, the weekly skin assessments for the resident showed no skin impairments, even though the care plan noted redness on the left heel. Additionally, documentation revealed that bed mobility assistance was often provided by only one staff member instead of the required two, and there were instances of incomplete documentation regarding staff assistance with bed mobility. Upon discharge, the resident was found to have multiple PU/PIs, including an unstageable PU/PI on the coccyx and stage two PU/PIs on the buttocks and ankle. The facility failed to document these skin impairments in the discharge notes or communicate them to the resident's representative or the receiving community home. Interviews with facility staff confirmed that the care plan did not address individualized risk factors for PU/PIs, and the nursing staff did not accurately identify, assess, or document the resident's skin injuries, nor did they notify the practitioner or the resident's representative about the PU/PIs.
Failure to Maintain Homelike Environment
Penalty
Summary
The facility failed to ensure a homelike environment for residents on two of its floors and in one of its elevators. Observations revealed multiple instances of damage and disrepair, including deep gouges and exposed drywall in resident rooms, falling and stained ceiling tiles, and scratched paint. Specifically, rooms on the 200 and 300 floors had walls with gouges and missing paint, and ceiling tiles with brown stains. Staff confirmed these observations and acknowledged that the damage should be repaired. Additionally, the elevator had a broken trim with a sharp, jagged edge at thigh level, posing a potential risk to residents, particularly those in wheelchairs. Interviews with staff, including the Director of Nursing, confirmed that the facility's policy was to provide a safe, clean, and homelike environment, and that the observed damages were not in line with this policy. The staff acknowledged the need for repairs and maintenance to ensure the environment met the expected standards. The failure to address these issues left residents at risk for a less-than-homelike environment, contrary to the facility's stated policy and regulatory requirements.
Failure to Timely Transmit MDS Data
Penalty
Summary
The facility failed to transmit the required Minimum Data Set (MDS) data to the Center for Medicare and Medicaid Services (CMS) within the required time frames for six residents. Specifically, the MDS assessments for Residents 33, 69, 57, 17, 73, and 51 were not completed or transmitted within the mandated 14-day period after the Assessment Reference Date (ARD). This delay in submission was confirmed by the MDS Coordinators, Staff J and Staff Q, during an interview, where they acknowledged the failure to meet the required timelines for MDS completion and transmission. Resident 33 had a Significant Change MDS and a Quarterly MDS that were both transmitted late. Resident 69 and Resident 57 each had a Quarterly MDS that was transmitted 12 and 11 days late, respectively. Resident 17's Annual MDS was transmitted two days late, while Resident 73's Quarterly MDS was also two days late. Resident 51 had two Quarterly MDS assessments that were transmitted one and three days late. These delays in MDS submission placed residents at risk for delays in care planning and unmet care needs.
Failure to Update PASRR Assessments
Penalty
Summary
The facility failed to ensure that Pre-Admission Screening and Resident Review (PASRR) assessments were updated to reflect changes in the mental health status of four residents. Resident 30's Level 1 PASRR, dated 11/28/2023, did not include diagnoses of anxiety or depression, despite these being noted in the resident's medical records. Staff M, the Social Services Director, acknowledged that the PASRR was inaccurate and needed revision. Similarly, Resident 37's PASRR, dated 10/19/2022, did not reflect the resident's diagnoses of psychosis and difficulty adjusting to changes with mixed anxiety and depressed mood, which were documented in the resident's medical records and medication administration records. Staff M confirmed that the PASRR should have been updated to include these diagnoses. Resident 13's PASRR, completed on 02/20/2024, was found to be incomplete, with one of the three required questions left unanswered. Staff M admitted that all questions should have been answered. Lastly, Resident 69's PASRRs, dated 01/06/2023 and 03/25/2024, did not identify the resident's anxiety disorder, despite this being documented in the resident's medical records and medication orders. Staff M acknowledged that the PASRRs should have reflected the anxiety diagnosis. These deficiencies indicate a failure by the facility to ensure that PASRR assessments were accurately and timely updated to reflect residents' current mental health statuses. This oversight could potentially lead to inappropriate placement and inadequate mental health care services for the affected residents. The facility's policy, dated 03/22/2024, mandates periodic reviews of PASRRs to capture any changes in residents' mental health conditions, a responsibility assigned to the Social Services department. However, the policy was not adhered to in these cases, as evidenced by the outdated and incomplete PASRR assessments for Residents 30, 37, 13, and 69.
Failure to Clarify and Follow Physician's Orders
Penalty
Summary
The facility failed to ensure that physician's orders (POs) were clarified as needed for six residents, leading to potential medication errors and adverse outcomes. For instance, Resident 17 had duplicate orders for a powdered laxative medication, and Resident 33 had a high blood pressure medication order without documentation of blood pressure monitoring prior to administration. Additionally, Resident 13's pain medication patch order lacked specific instructions on the location of application, and Resident 57's high blood pressure medication order did not include parameters for when to hold the medication based on blood pressure or heart rate readings. These unclear and duplicate orders were not clarified with the provider by staff, as confirmed by interviews with staff members. The facility also failed to follow physician's orders for two residents. Resident 69 had a pain medication patch that was not removed as scheduled, and Resident 57's insulin medication was not held when blood sugar levels were below the specified threshold. Furthermore, Resident 57 received a pain medication outside the ordered parameters on multiple occasions. Staff interviews revealed that the expectation was for nursing staff to follow, clarify, and document orders as directed, but this was not consistently done. Additionally, the facility did not ensure that orthostatic blood pressure monitoring was conducted as required for Resident 2, who was on antipsychotic medication. The facility's policy mandated monthly orthostatic blood pressure checks for residents on psychoactive medications, but there was no documentation to show that this monitoring was performed for Resident 2. Staff interviews confirmed that the orthostatic blood pressure checks were not completed and documented as required, indicating a lapse in adherence to the facility's policy and physician's orders.
Failure to Provide Necessary ADL Assistance
Penalty
Summary
The facility failed to ensure residents who were dependent on staff for assistance with Activities of Daily Living (ADLs) received the necessary care. Resident 61, who required substantial to maximal assistance with bathing and personal hygiene, was not provided a shower since admission, and their fingernails were observed to be long and dirty on multiple occasions. The care plan did not include specific instructions for bathing preferences, and there was no documentation of refusals. Staff confirmed the lack of showers and nail care for Resident 61 since admission. Resident 51, who had impaired memory and was totally dependent on staff for personal hygiene, was observed with long, dirty fingernails and facial hair on several occasions. Staff acknowledged that ADL assistance, including personal grooming, was not provided as required. Similarly, Resident 58, who had diagnoses including Parkinson's disease and required maximal assistance with transfers and personal hygiene, was observed lying in bed with long facial hair and wearing a hospital gown. The resident expressed a desire to be out of bed and in their wheelchair, but staff did not assist with transfers or grooming as care planned. Resident 73, who had impaired memory and required maximal assistance with personal hygiene, was observed with long fingernails and facial hair. There was no documentation of the resident's preferences or refusals for care. Staff confirmed the lack of ADL assistance. Resident 55, who had severe memory impairment and required assistance with personal hygiene and eating, was observed with long, dirty fingernails, uncombed hair, and a beard. The resident struggled to open food containers without staff assistance. Staff acknowledged that the resident did not receive the required assistance with grooming and eating as documented in their care plan.
Failure to Provide Required Restorative Nursing Program Services
Penalty
Summary
The facility failed to ensure that three residents received the Restorative Nursing Program (RNP) services they were assessed to require. Resident 57, who had multiple medically complex diagnoses including stroke with impairment of functional limitation in range of motion (ROM) to the upper arm and both lower legs, did not receive the prescribed splint and passive ROM to their right hand daily or three to six times per week as per the care plan. Additionally, the active ROM program for Resident 57's lower legs was not provided as frequently as required. Observations confirmed that the resident was not wearing the hand splint, and interviews with staff revealed that the RNP services were not consistently provided due to staffing issues after the departure of another restorative aide in February. Resident 69, who had functional limitations in ROM to both upper arms and lower legs, also did not receive the recommended RNP programs three to six times per week. Observations showed that the resident was not wearing a splint on their left arm, and documentation indicated that the RNP programs were provided less frequently than required. Interviews with staff confirmed the inconsistency in providing the RNP services and the need for a better restorative system. Resident 51, who had paralysis on one side of their body, a contracture to their right hand, and impairment to both legs, did not receive the prescribed splinting and passive ROM programs as required. Observations showed that the resident was not wearing the splint on multiple occasions, and documentation indicated that the RNP programs were provided less frequently than required. Interviews with staff revealed that the workload with other residents' RNPs prevented the consistent provision of the required services. The facility's failure to provide the necessary RNP services as assessed and documented placed the residents at risk for a decline in ROM, increased dependence on staff, and a decreased quality of life.
Failure to Ensure Safety and Supervision
Penalty
Summary
The facility failed to ensure the safety of its residents by not adequately supervising and storing smoking materials for a resident who smoked, and by not securing the Central Supply and soiled utility rooms. Resident 83, who had impaired vision, used a wheelchair, and required substantial assistance with daily activities, was found to be storing cigarettes in their pocket despite the facility's policy requiring such materials to be stored with the facility. This discrepancy was observed during an interview where the resident admitted to smoking outside the designated smoking times and areas, contrary to the facility's smoking policy and their signed agreement. The facility's staff, including the Director of Nursing and the Administrator, acknowledged the need for better organization and supervision of the smoking process but had not effectively enforced the policy with Resident 83. Additionally, the facility's Central Supply room was observed to be unlocked and unsupervised on multiple occasions, containing potentially hazardous materials such as medical supplies, over-the-counter medications, and chemicals. Staff acknowledged the importance of keeping the room secured but failed to do so consistently. Similarly, the soiled utility rooms on the 1st and 3rd floors were found unsecured, with dangerous chemicals accessible to residents. Staff confirmed that these rooms should be locked at all times to prevent access to hazardous materials, but observations showed that the doors did not secure properly, posing a risk to resident safety.
Failure to Ensure Nursing Staff Competency in Tracheostomy and Stoma Care
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies and skill sets to provide nursing care and related services that assured resident safety and attained or maintained the resident's highest practicable physical, mental, and psychosocial well-being. This deficiency was identified through observation, interview, and record review, revealing that the facility did not verify skills competency for five Certified Nursing Assistants (CNAs) and one Registered Nurse (RN) interviewed for special focused training for tracheostomy and stoma care. Specifically, the facility did not provide specialized CPR training for staff working with Resident 91, who had a tracheostomy, and staff were unable to explain the specific CPR requirements for this resident. The Director of Nursing acknowledged that the facility policy did not include emergency care for choking or CPR for residents with a tracheostomy and that specialized CPR training should have been provided before staff worked with Resident 91. Additionally, the Staff Development Coordinator, who had been in the position for two months, stated that there was no documentation for skills verification or competency evaluations for any current staff, and no process for staff skills evaluations on hire or annually. The Human Resources staff confirmed that there were no skills verification documents on file for a sample of five staff. The Resident Care Manager also stated that no special focus training was performed for staff on how to care for a tracheostomy or stoma routinely or in an emergency. The facility's failure to validate their nursing staff's knowledge, skills, abilities, behaviors, and other characteristics necessary to perform job-related functions safely and successfully placed residents at risk for incompetent care and harm, specifically placing Resident 91 at risk for injury, harm, and death.
Infection Control Deficiencies
Penalty
Summary
The facility failed to implement an effective Infection Prevention and Control Program, as evidenced by the lack of a water management program, uncleanable resident equipment, improperly handled urinary catheter bags, and inadequate hand hygiene practices. During an interview, the Environmental Director and Administrator confirmed that there was no current water management program to monitor and prevent waterborne pathogens like Legionella. Observations revealed multiple instances of resident equipment, such as mattresses, wheelchairs, walkers, and dining room chairs, with damaged surfaces that were uncleanable, posing a risk for infection spread. Staff interviews corroborated that these items should be intact and cleanable to reduce infection risks. Specific observations included a CNA handling Resident 66's morning hygiene care without changing gloves or performing hand hygiene between dirty and clean tasks, and another CNA providing care to Resident 51 without changing gloves or washing hands between different care activities. These lapses in hand hygiene were acknowledged by the staff involved, who admitted to not following proper hand hygiene protocols. Additionally, Resident 61's catheter bag was observed lying on the floor and dragging on the hall carpet, which was confirmed by staff to be improper handling that could compromise the catheter's integrity and contaminate the environment. The facility's failure to maintain cleanable surfaces on resident equipment and ensure proper hand hygiene practices, along with the absence of a water management program, left residents vulnerable to infections and other negative health outcomes. Staff interviews consistently highlighted the importance of these measures in preventing the spread of infections, yet the observations indicated a significant lapse in adherence to these protocols.
Failure to Implement Updated Antibiotic Stewardship Program
Penalty
Summary
The facility failed to revise its infection prevention and control policies and develop and implement an updated Antibiotic (ABO) Stewardship program to comply with the 10/24/2023 federal requirements. Specifically, the facility did not implement protocols and a system to monitor, document, and analyze the appropriate use of ABOs. This failure included the lack of leadership support and accountability for three months (January, February, and March 2024). The facility did not have an infection surveillance process that gathered data on residents' symptoms, the type of infectious organism, assessment of infections to meet specific criteria for ABO treatment, and tracking the spread of infection through tracing similar organisms. This placed residents at risk for potential adverse outcomes associated with the inappropriate or unnecessary use of ABOs and an increased risk for ABO-resistant organisms. The facility's policies on Surveillance for Infections and Antibiotic Stewardship were outdated and not revised to meet the new federal requirements. The Infection Control Preventionist (ICP), who started in February 2024, was unable to provide infection control surveillance, analysis, data reports, or Quality Assurance Policy Improvement leadership review for January and February 2024. During an interview, the ICP and other staff members acknowledged that the ABO stewardship program was not intact and did not meet the required standards. The surveillance log provided by the ICP lacked documentation on the organism, symptoms, and criteria for ABO use, further indicating the deficiency in the facility's infection control and ABO stewardship program.
Failure to Obtain Consent and Ensure Privacy
Penalty
Summary
The facility failed to obtain informed consent prior to administering psychotropic medication to Resident 37. The resident, who had severe memory impairment and exhibited verbal behaviors, was given an antipsychotic medication without proper consent. The consent form in the resident's record was not correctly filled out, as it did not specify which medication the resident was consenting to. The Director of Nursing confirmed that the form should have been properly completed to indicate the specific medication, but it was not, resulting in a lack of informed consent for the treatment provided to Resident 37. Additionally, the facility did not ensure adequate privacy during the provision of care for Residents 3, 76, and 69. Observations showed that staff members provided care without pulling privacy curtains, exposing the residents to potential view from the door or other parts of the room. This lack of privacy was noted during various care activities, including dressing and incontinence care. Staff interviews revealed a lack of awareness about the importance of using privacy curtains to protect residents' dignity and privacy during care. The Resident Care Manager acknowledged the importance of privacy and stated that curtains should be used to ensure residents' rights are protected.
Failure to Provide Required Transfer/Discharge Notifications
Penalty
Summary
The facility failed to ensure that residents received the required written notices at the time of transfer or discharge, or as soon as practicable, for three residents reviewed for hospitalization. Resident 66, who had kidney failure and was on dialysis, was transferred to the hospital from the Kidney Center without receiving a written notification regarding the reason for the transfer. Staff interviews revealed that the Medical Records Assistant stopped sending these notifications after June 2023, mistakenly believing they were no longer required. The Social Services Director acknowledged that the required written notices were not provided to Resident 66 or their representative, nor was the Long-Term Care Ombudsman notified as required. Similarly, Resident 30, who had complex medical diagnoses including heart failure and a vertebrae infection, was transferred to the hospital twice for blood transfusions without receiving written notifications. Resident 97, who had diagnoses including malnourishment, gout, and nausea, was also transferred to the hospital without receiving the required written notification. Staff interviews confirmed that no transfer notifications were sent after June 2023 due to a misunderstanding of the requirements. The facility's failure to provide these notifications was not in alignment with the residents' stated goals for care and preferences.
Failure to Provide Bed Hold Notification
Penalty
Summary
The facility failed to provide written notice of the bed hold policy to residents and/or their representatives at the time of transfer or within 24 hours, as required by their policy. This deficiency was identified for two residents, Resident 66 and Resident 97, who were transferred to the hospital. Resident 66, who had kidney failure and was undergoing dialysis, was transferred to the hospital from the Kidney Center due to a change in condition. The medical record did not show any evidence that the bed hold policy was discussed or offered to Resident 66 or their representative during the transfer. Staff K, responsible for offering bed holds, confirmed that the bed hold was not provided as required. Resident 97, who had diagnoses including malnourishment, gout, and nausea, was transferred to the hospital after experiencing a sudden headache and nausea. The facility did not provide a bed hold due to the resident's altered mental state at the time of transfer. Resident 97 returned to the facility eight days later. Staff M from Social Services stated that nursing typically handled the bed hold process and confirmed that Resident 97 should have received a bed hold, but the resident's record did not show that it was provided. This failure to provide the required bed hold notification placed the residents and their representatives at risk of not being informed of their rights and the cost associated with holding the resident's bed while hospitalized.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments for six residents accurately reflected their conditions. For Resident 7, the MDS did not capture the resident's refusal of a knee brace program on two occasions. Similarly, Resident 57's MDS did not reflect the resident's refusal of a Range of Motion (ROM) program and bathing assistance. Staff interviews confirmed that these refusals should have been documented accurately in the MDS assessments. Resident 69's MDS inaccurately indicated that the resident did not receive antianxiety medications, despite the Medication Administration Record (MAR) showing regular administration of such medication. Resident 81's MDS was incomplete and inaccurate, failing to include a resident interview for mood and pain assessment, and incorrectly noting the presence of natural teeth when the resident had none. Staff interviews revealed that the MDS was completed remotely by a corporate nurse, which may have contributed to these inaccuracies. Resident 37's MDS did not include an active psychotic disorder diagnosis, despite the resident receiving antipsychotic medication. Similarly, Resident 2's MDS failed to document the administration of antipsychotic medication for Obsessive-Compulsive Disorder (OCD) and did not include the resident's weight, as staff failed to weigh the resident during the assessment period. Staff interviews confirmed these omissions and inaccuracies in the MDS assessments.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure a person-centered comprehensive care plan (CP) was developed and implemented for four residents, leading to inconsistent and inadequate care. Resident 66, who had kidney and heart failure, and high blood pressure, was observed to have missing teeth and required staff assistance for oral care. However, no CP was developed to address the resident's dental health needs. Staff K confirmed that an oral/dental CP should have been initiated but was not. Resident 73, who had impaired memory and was frequently incontinent, was observed to smell like urine. Despite being a candidate for a scheduled toileting program, no bowel and bladder CP was developed to instruct staff on the toileting schedule. Staff K confirmed the omission of the necessary CP for Resident 73's incontinent care needs. Resident 37, who had severely impaired memory and took antipsychotic medication, had a CP that did not specify which antipsychotic medication was prescribed or the behaviors it was meant to treat. Staff B emphasized the importance of comprehensive and accurate CPs. Resident 91, who had a tracheostomy and required specialized CPR equipment, did not have the necessary Ambu bag or pediatric CPR mask available in their room as directed by their CP. Staff O confirmed the absence of these critical items, which were eventually found on the medical crash cart. Staff B stated that the required suction machine and supplies should have been in the room per the CP directions.
Failure to Update Care Plans and Schedule Care Conferences
Penalty
Summary
The facility failed to ensure Care Plans (CP) were updated and/or revised as needed for two residents and did not provide an opportunity for a care conference for one resident. Resident 83 had a CP that inaccurately included an intervention for anticoagulant therapy, despite not receiving any anticoagulant medication. This discrepancy was confirmed by the Resident Care Manager (RCM) during an interview. Resident 51's CP indicated a need for one-to-one assistance during meals, but observations showed the resident eating without staff assistance. The RCM acknowledged that the CP was outdated and needed revision. Additionally, Resident 59 did not have a care conference for over a year, despite the facility's policy to hold such conferences quarterly and annually. The resident confirmed not having a care conference in a long time, and the Social Services Director admitted to being behind in scheduling due to staffing issues. The last documented care conference for Resident 59 was over a year ago, which was confirmed by staff during interviews and record reviews.
Failure to Implement Proper Feeding Tube Care
Penalty
Summary
The facility failed to implement proper care for a resident with a feeding tube, leading to several deficiencies. The resident, who had multiple medically complex diagnoses including malnutrition, required the use of a feeding tube for more than 51% of their total caloric and fluid intake. The facility did not provide a consistent formula or rate of administration, failed to document the total intake provided over 24 hours, did not clarify and administer the correct amount of water flushing required, and did not label and date the feeding tube formula as required by the facility's policy. These actions were observed over several days, with inconsistencies in the type of formula used, the rate of administration, and the labeling of the formula bags. The resident's physician orders included specific instructions for water flushing and formula administration, but these were not consistently followed. For example, the orders directed staff to flush the feeding tube with 300 mL of water three times a day and to provide a 300 mL bolus feeding four times a day of Isosource formula. However, observations showed that the formula bags were sometimes unlabeled or incorrectly labeled, and the administration rates varied. Additionally, during a medication pass, a nurse administered a total of 238 mL of water, which was not in accordance with the physician's orders. Interviews with staff revealed a lack of adherence to the facility's policies and physician orders. The Resident Care Manager acknowledged that there should be an order identifying the nutritional intake needs for the resident and that the total amount of fluid intake should be documented every 24 hours. The Director of Nursing also stated that feeding tube orders should be followed consistently, with formula bags labeled and dated as required. The failure to follow these protocols placed the resident at risk for complications related to their feeding tube and hydration status.
Failure to Act on Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure timely action on medication-related irregularities identified by the consultant pharmacist for one resident. Resident 33, who had complex medical diagnoses including high blood pressure and hyperlipidemia, had a medication order for hyperlipidemia that required periodic monitoring through a lipid panel blood test. Although the consultant pharmacist recommended this test in October 2023 and the provider agreed, the lipid panel was not obtained until January 2024, three months later. Additionally, a recommendation to decrease a steroid nasal inhaler due to lack of symptoms was made in November 2023 but was not addressed until March 2024, after repeated recommendations and delays in provider approval. The Director of Nursing (Staff B) acknowledged that pharmacy recommendations should be completed and implemented by the end of the month they are made and should be readily available in the resident's records. However, the facility's failure to act on these recommendations in a timely manner placed Resident 33 at risk for medication-related complications. The pharmacy's pending response lists for November and December 2023 showed that the facility had not addressed the recommendations, and the records confirmed the delays in obtaining necessary lab tests and adjusting medication orders.
Failure to Review and Adjust Medication Regimen
Penalty
Summary
The facility failed to ensure that Resident 58's drug regimen was free from unnecessary medications. Resident 58, who had diagnoses including kidney failure and shortness of breath, was receiving an antibiotic (ABO) medication every 48 hours for long-term use of systemic steroids since November 2023. Despite a nephrologist's recommendation in January 2024 to reduce the steroid dosage and follow up in eight weeks, the facility did not schedule the follow-up appointment or clarify the necessity of the ABO medication with the nephrologist. Additionally, a pharmacist's recommendation in February 2024 to clarify the ABO medication with the nephrologist was not followed by the staff. Staff K, the Resident Care Manager, acknowledged that they were responsible for following up with the nephrologist's recommendations but admitted to missing the follow-up appointment and failing to clarify the ABO medication order. This oversight resulted in Resident 58 continuing to receive the ABO medication without proper review or adjustment, contrary to the nephrologist's instructions and the pharmacist's recommendations.
Failure to Ensure Appropriate Diagnosis for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure residents were free of unnecessary medications, specifically for one resident who was administered an antipsychotic (AP) medication without an appropriate diagnosis. The resident, who had severe memory impairment and verbal behaviors, was given an AP medication for vascular dementia with behavioral disturbance and psychosis. However, the facility's consultant pharmacist noted that dementia was not an appropriate indication for the use of an AP medication and that the resident did not have a documented psychosis diagnosis. Despite this, the resident continued to receive the medication until a new diagnosis of unspecified psychosis was added by the facility's medical supply clerk, without clear documentation of who diagnosed the resident or the diagnostic process followed. Interviews with the Director of Nursing and the Regional Nurse Consultant confirmed that the resident received the AP medication without an adequate diagnosis from September 2022 until February 2024. The facility's policy required that psychoactive medications be provided at the lowest effective dose and only with supporting diagnoses. The lack of proper documentation and adherence to this policy left the resident at risk for adverse side effects and unnecessary medication use.
Failure to Secure and Dispose of Expired Medications
Penalty
Summary
The facility failed to ensure drugs and biologicals were secured and expired medications and biologicals were disposed of timely in accordance with professional standards. In the first floor medication room, expired ostomy pouches, IV tubing, and IV fluid were found, along with expired IV antibiotic medication and liquid antacid medication in the refrigerator. Additionally, the refrigerator contained medications for discharged residents that had not been removed. The Pyxis machine also contained expired IV fluid and electrolyte solution. Medication carts on the third and first floors had loose pills and an opened nasal spray with no open date or resident name. Staff interviews confirmed these findings and acknowledged that expired medications should not be kept and that medications for discharged residents should be destroyed within one to two days after discharge, but this was not done. Unsecured medications were also observed in resident rooms and on medication carts. A steroid inhaler, analgesic lotion, and antifungal powder were found unsecured on a resident's bedside table, and a pain patch was left unsecured on another resident's bedside table. Additionally, an unsecured, opened pain patch was observed on top of a medication cart without staff present. Staff interviews confirmed that medications should not be left unsecured at a resident's bedside or on top of medication carts without staff present.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to ensure prompt dental services were provided for Resident 57, who was cognitively intact and had obvious dental issues, including broken teeth and oral pain. Despite a dental consultation in June 2023 recommending x-rays, evaluation, and extraction of all upper and lower teeth, followed by the provision of dentures, no follow-up actions were taken. The resident expressed interest in obtaining dentures, but the necessary dental services were not coordinated or provided in a timely manner. Interviews with staff revealed that the Medical Records Director, responsible for coordinating dental appointments, cited staffing shortages as a reason for the delay in scheduling these appointments. The Director of Nursing stated that referrals should be followed up within a week, but this did not occur for Resident 57. The lack of timely follow-up placed the resident at risk for unmet dental needs and diminished quality of life.
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Illustrative
What surveyors actually found near you
We read the 1,412 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Seattle
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Providence Mount St Vincent | 2.1 mi | ★★★★★ | 0 | 0 |
| The Terraces At Skyline | 3.1 mi | ★★★★★ | 1 | 0 |
| Mirabella | 3.5 mi | ★★★★★ | 2 | 0 |
| Seattle Medical Post Acute Care | 3.9 mi | ★★★★★ | 71 | 0 |
| Transitional Care Of Seattle | 4.2 mi | ★★★★★ | 49 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.