Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Providence Mount St Vincent during CMS and state inspections, most recent first.
A resident with a history of smoking was not properly assessed or documented for smoking materials, another resident who continued smoking did not have a timely direct assessment of smoking safety, and a resident with a feeding tube was not protected by the ordered abdominal binder when the tube was accidentally removed. The report also found unsecured isopropyl alcohol in a resident room and accessible chemicals and razors in shower/spa areas, with staff confirming the items should not have been left open or unsecured.
Expired meds and supplies were found in storage rooms and on med carts, including expired insulin pens and suppositories, with staff confirming they should have been discarded. Surveyors also found multiple residents’ meds left unsecured at bedside or in rooms without orders or care plan authorization, including topical products, shampoo, paste, ointment, and a resident on SAM whose meds were not secured in the lock box.
Food was stored and served unsafely in the main kitchen and one neighborhood kitchen. In the main kitchen, white sauce, tomato soup, cooked bacon, and pureed cauliflower were left uncovered, and some items were undated. In the SJR kitchen and dining room, staff plated and delivered meals without hand hygiene or gloves, several dining assistants had hair not fully secured in hairnets, a volunteer entered the kitchen and served water without hand hygiene, and an LPN fed two residents with the same hand without cleaning hands between residents.
Infection control failures occurred when staff did not follow TBP or PPE requirements for residents with respiratory symptoms, contact precautions, or EBP. A resident with cough and runny nose was not placed on TBP when symptoms were present, staff entered multiple precaution rooms without the required gown, gloves, mask, or eye protection, and one RN did not perform HH during colostomy care after removing gloves. The facility also stored used toothbrushes and a hairbrush together or in shared containers in two resident rooms, with items touching each other or stored without clear separation.
A facility failed to maintain resident dignity when catheter drainage bags for two residents were left uncovered and visible during multiple observations, despite one resident having a physician order and the other having a care plan directing the bag to be covered. The facility also failed to ensure an LPN sat while feeding two residents in the dining room, as the LPN stood and alternated feeding between them.
The facility failed to ensure ADs were in place for three residents. One resident had intact cognition and multiple diagnoses, including HF and deficits after a brain bleed, but no POA paperwork was in the record despite references to a POA in care planning notes. Two other residents were their own responsible parties, had intact memory or cognition, and had no AD documentation or record of any offer or assistance to complete AD paperwork.
A resident with severe cognitive impairment, kidney disease, and a recent stroke was started on routine and PRN antipsychotic medication for restlessness and frequent falls, but the record did not show a medical diagnosis for use, consent, nonpharmacological interventions, or monitoring of adverse effects or target behaviors. The PRN antipsychotic was continued beyond the 14-day limit without a documented physician evaluation, and staff confirmed there was no appropriate indication for the medication.
Incomplete fall investigations and failure to notify provider of changes in condition. Two residents had falls that were not thoroughly investigated, with missing or incomplete witness statements, inaccurate or missed neuro checks, and no documented provider notification despite assessment findings requiring it. One resident’s fall care plan also lacked provider-notification criteria and fall monitoring interventions, and an antipsychotic was used as a fall intervention without an appropriate indication per the DON.
A resident with dementia, anxiety, and depression had worsening behaviors, including aggression and paranoia, and was receiving antipsychotic, antianxiety, and antidepressant meds. A PASRR level 1 identified serious mental health indicators and required a level 2 eval referral, but the record did not show that the determination was received or that staff followed up on the referral for several months.
Care plans were not updated for two residents with changing needs. One resident had pain, a UTI, and repeated PRN pain med use, but the CP did not include the resident’s UTI history, specific nonpharm pain interventions, or guidance for notifying the provider, and staff could not show pain reassessment or med effectiveness. Another resident with end-of-life care and mobility dependence was often left in bed, while staff said they waited for the representative and the CP did not address refusals or what to do when the representative was absent.
Pain medication orders were not clarified or followed for two residents, including one resident whose PRN pain meds lacked clear parameters and another whose ordered dose was not matched to the documented pain score. A resident with cancer and constipation also had no documented bowel movements for several days and no evidence that the bowel protocol or PRN bowel meds were used. In addition, staff did not sign out a narcotic in the ledger and did not count the cart correctly.
Failure to provide ADL assistance for grooming and bathing affected three residents. Two residents who needed staff help with hygiene had long fingernails, including debris and overgrown nails, and staff acknowledged nail care was expected on shower days or weekly as needed. Another resident who preferred showers and was scheduled for weekly bathing had no nursing shower documentation over several weeks, and the resident reported being told only OT could provide showers.
Failure to assess and document non-pressure skin conditions for two residents. One resident returned from the hospital with multiple scabs and bruises on both arms, but the readmission skin inspection and weekly skin assessment did not document the bruising, and no provider order was in place to monitor it. Another resident had a large raised bruise on the right arm while receiving blood thinner medication, but staff documented only that a bruise was present and did not record a full assessment with size, color, or swelling.
Pain Assessments and PRN Effectiveness Not Documented Two residents with significant pain needs did not have consistent pain assessments or documentation of pain medication effectiveness. One resident with generalized pain and PRN analgesics had repeated reports of pain and no documented reassessment after medication administration, while another resident with chronic pain syndrome had multiple pain medication doses given without pain scale ratings or follow-up documentation. Staff interviews confirmed pain ratings and effectiveness were not being consistently assessed or recorded.
A medication pass observation found an RN prepared and administered medications for a resident incorrectly, resulting in a 6.9% med error rate. The RN gave 1 drop of prescribed eye drops in each eye instead of the ordered 2 drops, and prepared 25 mL of a liquid supplement instead of the ordered 30 mL. The resident stated they usually received 2 drops in each eye, and the DON said staff were expected to check physician orders before giving meds.
Failure to Provide Ordered Rehabilitative Services: Three residents did not receive rehab services as assessed or ordered. One resident returned from the hospital after kidney stone surgery with PT/OT transfer orders, but no therapy orders were entered and the resident remained in bed feeling weak. Another resident with a stroke-related hand contracture and major ADL dependence had no current OT, splint, or ROM services despite prior therapy history and ongoing need. A third resident’s OT plan called for 3 to 6 sessions per week, but only 2 sessions were provided in the first week.
The facility failed to ensure 2 CNAs completed the required annual training hours. Facility policy required CNAs to complete at least 12 hours of annual training, but one CNA’s record showed only 4.3 hours completed. The DON stated the facility had difficulty getting CNAs to complete the required training and acknowledged the two CNAs did not meet the minimum requirement.
During a COVID-19 outbreak, the facility did not place required Aerosol Contact Precautions (ACP) signage on the doors of several rooms housing COVID-19 positive residents. Although staff were expected to use PPE and follow isolation protocols, there was no designated staff member to monitor signage or PPE compliance, resulting in incomplete implementation of infection control measures.
A CNA physically and verbally abused multiple residents, including one who suffered bruising and a skin tear, leading to significant distress and behavioral changes. Other residents reported rough, intimidating care and fear of the CNA. Facility staff failed to promptly report, investigate, or protect residents as required by policy, allowing the CNA to continue providing care after the initial incident.
A resident experienced physical abuse by a CNA, and multiple staff members who were aware of the incident did not report it or initiate an investigation as required by facility policy. The supervisor failed to suspend the CNA or notify the administrator and state agency, and the incident was not documented or investigated in the facility's reporting log. Additional staff reported witnessing rough and abusive behavior by the same CNA toward other residents, but did not fulfill mandated reporting duties.
A resident with severe cognitive impairment and total care needs was found with unexplained bruises and a skin tear, reportedly caused by a CNA during care. Despite staff reporting the incident, there was no documented assessment, injury report, or investigation, and the event was not logged or reported to facility leadership or the state agency, in violation of abuse prevention policies.
A resident with a chronic neurological disease was not readmitted to the facility after hospitalization for a feeding tube replacement, despite being medically cleared. The facility's internal communication indicated the resident would not return, leading to a two-week delay and psychological distress for the resident. The resident's belongings were removed, and the facility did not respond to hospital staff's attempts to arrange the resident's return.
A facility failed to enforce its non-smoking policy, allowing a resident to repeatedly vape cannabis in their room, despite being cognitively intact and aware of the rules. The resident's actions affected their roommate and posed safety risks. Staff interventions were inconsistent, and the resident continued to possess vape supplies, leading to a discharge notice.
A resident with a fractured hip and intact memory experienced psychological harm when a caregiver inappropriately touched them without consent. The resident identified the caregiver, leading to their dismissal. The incident was substantiated by the facility's investigation.
The facility failed to maintain sanitary conditions in food preparation and distribution, with staff observed not following hand hygiene protocols and using unsanitized equipment. In the main kitchen, equipment was not cleaned properly, and staff did not wash hands between tasks. On the 4th Floor North, a nutrition attendant did not sanitize a thermometer probe between uses, and on the 4th Floor South, CNAs did not secure their hair or perform hand hygiene after serving food, including in rooms with Enhanced Barrier Precautions.
The facility failed to maintain resident dignity and privacy, as observed in dining services, privacy provision, and care delivery. Staff did not consistently remove plastic wrap from drinks, administered medications in the dining room, and failed to provide privacy during care. Additionally, a resident was not promptly informed about an appeal denial, affecting their care. These actions compromised resident dignity and rights.
The facility failed to honor resident preferences for bathing frequency and type, affecting several residents who expressed dissatisfaction with their care. Despite clear communication abilities and stated preferences, residents received fewer showers or different types of baths than desired. Facility records and staff interviews confirmed these discrepancies, highlighting a lack of adherence to resident self-determination rights.
The facility failed to conduct required care conferences for two residents, leading to unmet care needs and potential frustration. One resident expressed a desire for a care conference to understand their care plan, while another was not invited to care conferences despite having communication deficits. Additionally, the facility did not update care plans for four residents to reflect changes in their care needs, including discrepancies in denture use, catheter care, and range of motion programs.
The facility failed to provide adequate ADL assistance, resulting in poor hygiene and grooming for several residents. A resident was observed with long fingernails and debris, while another ate without dentures due to staff oversight. Other residents experienced neglect in dressing, shaving, and bathing, with missed or unoffered care opportunities. Staff expectations for documenting refusals and reattempting care were not consistently met.
The facility failed to meet the activity needs of three residents, leading to a deficiency in care. One resident, who desired outdoor activities, was not offered any opportunities to go outside. Another resident, interested in participating in activities, was not facilitated to attend due to mobility issues. A third resident, initially isolated due to COVID-19, was not provided with in-room activities despite their preferences. Staff acknowledged the lack of documentation and effort to engage these residents.
The facility failed to secure hazardous materials across multiple units, including unlocked utility and spa rooms containing needles, chemicals, and razors. Staff confirmed these areas should have been locked to prevent resident access, but issues like broken locks and lack of keys contributed to the deficiency.
The facility failed to ensure nursing staff had the necessary competencies to provide adequate care, as required evaluations were not conducted. Interviews and record reviews revealed that the Director of Nursing could not provide documentation of competency evaluations for several staff members, despite the Facility Assessment outlining the need for such assessments. This resulted in deficiencies related to staff proficiency in critical care areas.
The facility failed to maintain effective infection control practices, as staff did not adhere to Enhanced Barrier Precautions (EBP) and Transmission-Based Precautions (TBP) for several residents. A CNA and an LPN were observed not wearing required gowns while providing care, and an LPN used contaminated tubing for a resident's tube feeding. Another LPN failed to follow proper hand hygiene and gown protocols during wound care. These actions were against the facility's infection control policies.
The facility failed to thoroughly investigate incidents involving three residents, including an allegation of inappropriate contact by a caregiver and a resident-to-resident altercation. Investigations lacked witness interviews and background checks, leading to discrepancies and potential risks to residents' well-being.
A facility failed to notify local Law Enforcement and the Department of Health after substantiating an abuse allegation involving a resident. The incident involved a CNA who allegedly kissed a resident and attempted to climb into their bed. Despite confirming the allegation and dismissing the CNA, the facility did not report the incident as required, placing residents at risk for harm.
The facility failed to provide timely written transfer notifications to two residents discharged to hospitals. For both residents, there was no documentation of the required notifications in their health records. Staff confirmed the absence of documentation and stated that notifications were expected to be provided in a timely manner. This failure placed residents at risk for discharges not aligned with their care goals.
The facility failed to provide two residents with written notification of its bed-hold policy at the time of their transfer to a hospital or within 24 hours, as required by policy. Interviews with staff revealed that the expected process was not followed, resulting in a lack of documentation for both residents.
A resident with complex medical diagnoses, including cancer, was inaccurately documented in the MDS as not being on hospice, despite receiving hospice services and medications. This discrepancy was confirmed by hospice service indicators on the resident's chart and acknowledged by a Care Manager RN, highlighting the importance of accurate documentation for aligning care plans with resident goals.
The facility failed to develop comprehensive care plans for two residents, leading to potential risks for unmet care needs. One resident with frequent diarrhea did not have a care plan addressing this issue, while another resident with lower leg edema also lacked a care plan for this condition. Staff acknowledged the importance of addressing these conditions in care plans to ensure proper management and prevent complications.
The facility failed to follow physician's orders for two residents and did not administer medications to another resident. One resident had a catheter inserted without proper orders, another had a dressing not applied as ordered, and a third missed medications due to unavailability. Staff interviews confirmed these deficiencies.
A resident with pressure ulcers did not receive necessary care as per professional standards. The resident was observed without required pressure-reducing devices, and staff failed to monitor and report changes in the resident's wound condition. Despite physician orders, interventions like floating the left foot and using boots were not consistently implemented, leading to inadequate pressure ulcer care.
A resident at risk for weight loss due to poor appetite experienced a significant unverified weight drop from 151.2 lbs. to 119.8 lbs. in three weeks. The facility failed to reweigh the resident or notify the physician or RD, contrary to their policy, placing the resident at risk for negative health outcomes.
The facility failed to provide adequate pain management for two residents. One resident did not receive thorough pain assessments before PRN narcotic administration, and another experienced a lack of availability of their PRN pain medication due to pharmacy delivery issues. Staff interviews revealed that pain assessments were not consistently documented, and facility protocols were not followed.
The facility failed to secure medications and dispose of expired items, affecting multiple units. A resident with impaired memory was left with an unsecured inhaler, and expired medications were found in several medication rooms and carts. Staff admitted to not following procedures for monitoring and disposing of expired items.
The facility failed to protect resident-identifiable information on the 5 North unit. A progress note was improperly placed in a grievance file folder accessible to anyone, and a resident roster was left exposed on a cart. Staff acknowledged the importance of maintaining confidentiality, but lapses occurred, compromising resident privacy.
A facility failed to coordinate hospice care effectively for a resident with complex medical diagnoses, including cancer. The resident's Care Plan was not updated to reflect hospice responsibilities, and there was no physician's order for hospice services. Staff were unaware of the hospice care being provided, and necessary documentation was missing from the resident's records, leading to a risk of inadequate care.
A facility failed to document and resolve grievances for a resident with a neurological disorder and mood issues, who reported feeling disrespected by a CNA. Despite the resident's complaints and a report to the ombudsman, the grievance log showed no record of these issues. Interviews revealed that grievances were not properly documented or tracked, highlighting a failure in the facility's grievance process.
The facility failed to implement its abuse prevention policies effectively, leading to incomplete investigations of incidents involving three residents. An allegation of inappropriate touching was substantiated but not reported to authorities, and investigations into other incidents lacked witness interviews, contrary to facility policy.
A facility failed to ensure the safe use of air mattresses for residents, leading to multiple falls and potential risks. The deficiency involved a lack of assessment and monitoring of air mattress settings, no informed consent from residents, and insufficient staff training. One resident experienced three falls due to the wrong size mattress and inadequate monitoring, while similar issues were noted for other residents. Interviews confirmed the absence of necessary assessments and documentation.
A resident was injured during a mechanical lift transfer when a CNA operated the lift alone, contrary to facility policy requiring two staff members. The resident suffered a severe leg laceration and was hospitalized for five days. Interviews confirmed the CNA had been trained on the policy but failed to follow it.
Failure to Assess Smoking Safety, Secure Assistive Support, and Control Hazardous Materials
Penalty
Summary
The facility failed to ensure that residents were protected from accident hazards and received adequate supervision in several situations involving smoking safety, assistive devices, and unsecured chemicals and sharps. The report states that 3 of 10 residents reviewed for accidents, plus 1 supplemental resident, were not properly assessed or protected in relation to smoking materials, an assistive device was not in place for a resident with a feeding tube, and chemicals were left unsecured in a resident room and in shower/spa areas on two units. Resident 94 had diagnoses including a recent leg amputation and respiratory issues. The resident’s records showed a non-smoking policy acknowledgement indicating the resident was a smoker or had a history of smoking, but the last-day-of-smoking section was blank. A care plan dated 04/07/2026 did not include smoking-related documentation. During observation and interview, Resident 94 stated they were currently a smoker, arranged their own transportation out of the facility, and smoked at their destination, but declined to say where smoking materials were kept. A provider note stated the resident smoked cigarettes when leaving the facility. Staff interviews showed the social worker, RN, administrator, and DON were not aware the resident was a current smoker or where smoking materials were stored, and the DON stated staff should have asked about smoking materials and the date last smoked when the resident indicated they were a smoker. Resident 24 had diagnoses including heart conditions and nicotine dependence and was documented as a current tobacco user. A smoking assessment from 09/16/2025 showed staff verbally assessed the resident in the room for ability to smoke, but there was no direct observation of the resident using a lighter or handling lit smoking materials. The assessment also showed the resident was no longer planning to smoke. A later smoking care plan stated the resident smoked one cigarette per day after lunch and that smoking materials were not to be kept in the room. Records showed no further smoking assessment until 04/06/2026, when the resident was assessed as able to smoke safely. The DON stated the resident should have been assessed for the ability to smoke safely when it was seen they were continuing to smoke, but that did not happen. Resident 3 had severely impaired cognition and was dependent on a feeding tube. The care plan showed a history of pulling out the feeding tube and included keeping an abdominal binder in place as an intervention to prevent recurrence. Physician progress notes repeatedly documented that the resident was to wear an abdominal binder to prevent accidental pulling of the feeding tube. The responsible party stated the resident was supposed to wear an abdominal binder and had received one in the hospital, and also stated the resident recently went to the hospital because the feeding tube came out when the binder was not being worn. The DON stated there was no physician order or care plan for the abdominal binder at the time the tube was accidentally removed and that staff did not know the binder should have been in place. The report also documented unsecured chemicals and sharps. A large bottle of 70% isopropyl alcohol was observed in Resident 47’s room under the sink, and staff confirmed it was a hazard and should not have been stored there. In a 4 South shower room, cleaning chemicals and a used razor were observed accessible with the door open and no staff present; staff stated the door should have been shut and locked and the razor disposed of after use. On 5 North, the spa door was observed open and unlocked with an unsecured bottle of chemical disinfectant and razors inside. Staff stated the spa door should have been locked and closed because chemicals and razors were stored there.
Expired Medications and Unsecured Bedside Storage
Penalty
Summary
The facility failed to ensure that expired medications and expired medical supplies were removed from storage areas and medication carts, and failed to ensure that medications were properly secured in resident rooms when there was no order or care plan direction allowing bedside storage. Surveyors observed expired items in the Saint [NAME] Residence medication storage room, including 100 sterile cotton tipped applicators and a COVID test, and in the 2 North medication storage room, where multiple expired supplies were present, including wound dressings, blood collection tubes, specimen kits, colostomy dressings, IV supplies, tube feeding kits, and sterile specimen collection kits. Staff confirmed the expiration dates and stated the items should have been discarded before expiration, and the DON stated staff were expected to discard supplies before the expiration date on the packaging. Surveyors also found expired medications on medication carts. The 4 South medication cart contained two insulin pens that had been opened in February 2026 without a specific open date documented, and staff stated the pens expired 28 days after opening and should have been labeled with the date opened and discarded. The 5 North medication cart B contained three packages of pain-relieving suppositories with an expiration date of 11/2025 and eight packages of laxative suppositories with an expiration date of 03/2026. Staff confirmed expired medications should not be present in the cart and stated administering expired medications could compromise resident safety. In addition, surveyors observed unsecured medications in resident rooms on multiple units without physician orders or care plan interventions authorizing bedside storage. On 4 South, a bottle of topical powder and a bottle of antiseptic skin cleanser were left on a resident’s bedside table, and staff confirmed they were unsecured and should have been in the medication cart. On 3 South, a resident who was asleep had a medication cup with a pink tablet left on the overbed table, and staff stated medications should remain with the resident until fully taken. On 5 Central, a resident had a sealed stool softener powder and a half-empty bottle of medicated cream on the bedside table, and staff stated the medications should have been stored in a secured medication cart. On 2 North, one resident on the SAM program had several medications unsecured in the room despite a lock box being present, and staff stated the resident needed reassessment for SAM appropriateness. Additional unsecured medications were found in other resident rooms, including medicated shampoo, topical paste, and topical ointment, with staff confirming there were no orders allowing those items to remain in the rooms.
Unsanitary food storage and improper hand hygiene during meal service
Penalty
Summary
Food was not stored and served under sanitary conditions in the main kitchen and one neighborhood kitchen. In the main kitchen refrigerator, a large sheet pan of white sauce and two large sheet pans of tomato soup were observed dated 04/05/2026 and left uncovered. A plastic container with cooked pieces of bacon was undated and uncovered. In the main freezer, two muffin pans containing 12 servings of pureed cauliflower in each pan were also undated and uncovered. The Interim Dining Services Manager stated the white sauce and tomato soup should have been covered, and that the bacon pieces and cauliflower cups should have been dated and covered, but they were not. In the SJR kitchen and dining room, staff were observed plating food and delivering meals without performing hand hygiene or putting on gloves before returning to the steam table. Three dining assistants were observed plating food with hair loosely pulled back and not fully secured in a hairnet while serving food. A volunteer touched residents' clothing, entered the kitchen without hand hygiene or a hairnet, served water to a visitor, and went through the kitchen to the refrigerator. An LPN adjusted one resident's clothing while feeding them and then used the same hand to feed another resident without performing hand hygiene between residents. The DON stated volunteers should not have been in the kitchen area around food or serving water, and that staff should perform hand hygiene between feeding two residents when using the same hand.
Infection Control Failures With Precautions, PPE, Hand Hygiene, and Hygiene Item Storage
Penalty
Summary
The facility failed to ensure Transmission Based Precautions were implemented or followed for residents with respiratory symptoms or documented precautions. Resident 12 had droplet and contact precaution signage posted, but staff entered the room without PPE and without sanitizing hands, and the record review showed no physician order directing isolation precautions. Resident 157 was coughing and gurgling, was documented as being placed on droplet precautions for fever and cough, and had droplet signage and an isolation cart outside the room; however, a contracted staff member entered without a mask, eye protection, or gown. Resident 33 also had contact precaution signage on the door, but a CNA entered without gown and gloves. Resident 212 had EBP and contact precaution signs posted, yet a RN entered without gown or gloves, and the infection preventionist stated the room should have had only one sign indicating the highest level of precautions. The facility also failed to initiate TBP for residents with respiratory symptoms. Resident 156 reported a cough and runny nose and was waiting for respiratory testing results, but there was no TBP signage outside the room at the time of observation. Staff stated TBP should begin as soon as a resident presents with respiratory symptoms, and later noted the resident had pending RSV testing and a pending chest x-ray, with droplet precautions not placed until later. Staff also stated they expected TBP for residents with respiratory symptoms and for residents being tested for RSV. The facility failed to ensure appropriate PPE and hand hygiene during resident care. For Resident 201, who had end stage kidney disease and gangrene to the left foot and was on EBP, an environmental services technician removed dirty bedding, cleaned the bed, bedside table, sink, vacuumed the floor, and cleaned the bathroom while wearing the same gloves and without a gown, changing gloves, or performing hand hygiene until the end of the task. For Resident 93, a RN provided colostomy care while double gloved, removed glove layers during care, and did not perform hand hygiene after removing the second layer of gloves before continuing the procedure. The facility also failed to store resident hygiene items properly in two rooms. In one room, a bin next to the sink contained an uncovered used toothbrush stored on top of other items with a hairbrush containing strands of hair stored on top of the toothbrush. In another shared room, an emesis basin contained a used toothbrush and another used toothbrush was laid across the top of the basin without identification, while a third used toothbrush was stored vertically in a labeled bin with the bristles touching the wall. Staff confirmed the toothbrush and hairbrush were stored together and stated the items should have been stored separately for infection control.
Dignity Concerns With Uncovered Catheter Bags and Standing Feeding Assistance
Penalty
Summary
The facility failed to ensure catheter drainage bags were covered to obscure their contents for two residents. Resident 202 was admitted with diagnoses including urinary infection, enlarged prostate, and obstructive uropathy, and had a physician order dated 03/29/2026 directing staff to cover the catheter bag to ensure dignity. During observations on 04/06/2026 and 04/07/2026, Resident 202 was seen with the catheter bag hanging from the wheelchair and then from the bedrail without a cover. Staff H stated the bag should have been covered to maintain dignity, and the DON stated staff were expected to use dignity covers for drainage bags. Resident 3 was admitted with diagnoses including stroke, high blood pressure, and kidney disease, and had an indwelling urinary catheter. The care plan directed staff to keep the urinary catheter drainage bag covered to promote dignity. However, observations on 04/06/2026, 04/07/2026, and 04/08/2026 showed the catheter bag was not covered and was visible to others in the dining room and from the hallway. The facility also failed to ensure staff sat while providing feeding assistance: during an observation in the SJR dining room, Staff D stood next to the table and fed two female residents by alternating between them. Staff D stated they were not aware that dignity was an issue when standing to feed residents, while other staff stated staff should sit down while assisting residents with feeding for dignity.
Missing Advance Directive Documentation for Three Residents
Penalty
Summary
The facility failed to implement a system to ensure Advanced Directives (AD) were in place for 3 of 8 residents reviewed for ADs: Residents 188, 189, and 7. The facility policy stated staff would determine on admission whether a resident had an AD and, if not, determine whether the resident wished to formulate one, then obtain and maintain a copy in the resident record for staff access. However, record review showed no AD or POA paperwork available in the records for these residents, and there was no documentation that the facility offered or assisted them to complete AD paperwork. Resident 189 had intact cognition and diagnoses including heart failure, difficulty speaking following a brain bleed, and weakness to one side of the body. The resident stated their sister used to be their POA but was not any longer, yet the record contained no POA paperwork despite a care plan conference form and social services note referencing a POA. Resident 7 had no impaired memory and was their own responsible party, but there was no AD in the record and no documentation that the facility attempted to offer or assist with completion. Resident 188 had intact memory, clear speech, and the ability to understand others, was their own responsible party, and likewise had no AD in the record and no documentation of an offer or assistance to complete AD papers.
Unnecessary Antipsychotic Use Without Diagnosis, Consent, or Monitoring
Penalty
Summary
The facility failed to ensure that Resident 3’s medication regimen was free of chemical restraints and unnecessary psychotropic use. Resident 3 was admitted with diagnoses of high blood pressure, kidney disease, and a recent stroke, and the admission MDS showed severely impaired cognition, no indicators of psychosis, and no behaviors in the look-back period. The facility’s psychotropic medication policy stated that behavioral and non-pharmacological approaches should be used to minimize psychotropic use, that alternatives and risks/benefits should be reviewed before starting such medication, and that PRN antipsychotics should only be used for 14 days unless evaluated by a physician for continued use. After an unwitnessed fall, a nursing note documented that the physician was called, but there was no documentation of the circumstances of the fall or behaviors reported to the on-call provider. The physician later documented that Resident 3 was more restless with frequent falls and started an antipsychotic medication in the evening routinely and also as needed, but the note did not identify a medical diagnosis for the antipsychotic use. A later physician note did not update the indication for the routine antipsychotic and did not evaluate the PRN antipsychotic use. The medication orders showed the routine antipsychotic was started, discontinued, restarted, and discontinued again with the same indication of restlessness, and the PRN antipsychotic was also discontinued and restarted with the same indication, without a documented medical diagnosis. The record also showed no physician order to monitor adverse side effects or target behaviors, no documented non-pharmacological interventions before the antipsychotic was prescribed, and no signed or verbal consent for the antipsychotic medication. A pharmacy consultant recommended discontinuation of the antipsychotic and noted that PRN antipsychotic orders are limited to 14 days unless the prescriber directly examines the resident and assesses the resident’s condition and progress, but there was no signature or note showing the physician saw the recommendation. Staff interviews confirmed there was no appropriate indication for the antipsychotic, and staff were unable to locate consent or documentation of adverse side effect monitoring or behavior monitoring.
Incomplete fall investigations and failure to notify provider of changes in condition
Penalty
Summary
The facility failed to thoroughly investigate falls, notify the provider of changes in condition, implement appropriate fall interventions, and rule out abuse or neglect for two residents reviewed for investigations. The cited policy required fall investigations to include interviews with residents, staff, and others, assessment for injuries, and neurological assessments for unwitnessed falls with physician notification as needed. The report also states the facility failed to thoroughly investigate, notify provider of changes in condition, implement appropriate fall interventions, and rule out abuse/neglect for 2 of 11 sampled residents reviewed for investigations. Resident 3 was admitted with kidney disease, stroke, high blood pressure, and recent brain surgery, and was dependent on staff for ADLs. The resident’s fall care plan identified fall risk and included room close to the nursing station and anticipating needs, but did not include provider-notification criteria or fall monitoring interventions. For multiple falls, the investigation summaries lacked witness statements or other documentation supporting when care was provided or the circumstances leading to the falls. One unwitnessed fall had a neurological assessment with missing vital signs, missing observation of neurological changes, and late nurse initials; another fall had no documentation that the resident’s condition was reported to the provider despite neurological assessments indicating symptoms requiring notification. Staff B stated the investigations should have included witness statements and that the neurological assessments were inaccurate, and also stated there was not an appropriate indication for the resident’s antipsychotic medication used as an intervention for falls due to restlessness. Resident 27 was admitted with heart failure, an abnormal heart rhythm, and a urinary tract infection and required supervision with ADLs. After a fall at home while out of the facility, neurological assessments were initiated and repeatedly marked to indicate symptoms requiring physician notification, but there was no documented evidence that the provider was notified. After an unwitnessed fall in the resident’s room, staff witness statements were incomplete, with key questions left blank regarding whether the care plan was followed, toileting, changes during the shift, and the potential cause of the fall. The attached neurological assessments also showed missed assessments, and Staff B stated the assessments were inaccurate and not completed and that the witness statements should have been further investigated but were not.
PASRR Level 2 Referral Not Followed Up Timely
Penalty
Summary
The facility failed to ensure that a PASRR level 2 referral was followed up on in a timely manner for one resident. Resident 16 had diagnoses including a progressive, irreversible brain disorder that affected memory, thinking skills, and the ability to perform simple tasks, along with anxiety and depression. The resident’s MDS showed use of an antipsychotic, antianxiety, and antidepressant medication during the assessment period. A social services care conference note documented worsening behaviors, including aggression, paranoia about money being stolen, and paranoia about food and drinks. The physician was present, a psychiatric consult was completed, and medication changes were made. A PASRR level 1 completed later identified serious mental health indicators and stated that a PASRR level 2 evaluation referral was required, but the resident’s record and social services notes did not show that a level 2 determination was received or that staff followed up on the referral from January through April. The social worker stated the process was to follow up quarterly and confirmed the determination was not received and follow-up was not completed.
Care Plans Not Updated for Pain, Mobility, and Psychosocial Needs
Penalty
Summary
The facility failed to keep care plans updated and revised for two residents. For Resident 82, the 11/10/2025 MDS showed muscle weakness, a urinary tract infection, and a need for pain management. The 08/20/2024 care plan for risk for pain related to decreased physical mobility directed staff to provide nonpharmacological pain interventions and assess pain medication effectiveness, but it did not include the resident’s history of urinary tract infections, specific nonpharmacological interventions for pain relief, or when to notify the provider for ongoing pain needs. Resident 82’s April 2026 MAR showed PRN pain medication given on multiple occasions for pain, flank pain, groin pain, and pain related to a urinary tract infection, but there was no documentation that staff assessed whether the medication was effective or that nonpharmacological interventions were provided. During observations, the resident stated they had pain in the back, stomach, and head, and yelled from the room that they were in pain. Staff interviews confirmed they could not find documentation of recent pain assessment or pain medication effectiveness, and the DON stated pain should be checked every shift and the source and daily monitoring should be included on the care plan, but it was not. For Resident 18, the 03/15/2026 annual MDS showed end-of-life care, one-sided physical impairment, and dependence on staff for mobility. The 08/19/2024 care plan directed staff to check with the resident and involve them in activities of interest, and the 04/10/2026 Kardex directed staff to assist the resident out of bed at least once daily and report refusals. However, observations showed the resident remained in bed in the room on multiple occasions, and the resident’s representative stated the resident was often left in the room instead of being assisted to the dining room or activities. Staff stated they waited for the representative to take the resident out, were not notified of refusals, and the care plan did not include instructions for refusals or what to do when the representative was not present.
Pain Orders, Bowel Protocol, and Narcotic Ledger Errors
Penalty
Summary
Physician’s orders for pain management were not clarified or followed for two residents. One resident had diagnoses including chronic kidney disease, arthritis, and high blood pressure, and a quarterly MDS showed frequent pain that almost constantly interrupted sleep and frequently affected daily activities. That resident had orders for a narcotic pain medication twice daily as needed and a non-narcotic pain medication every eight hours as needed, but the orders did not include directions identifying which medication should be given based on pain level. The DON stated pain medication orders should include parameters according to pain intensity and that the orders should have been clarified with the provider, but they were not. Another resident with diagnoses including cancer, an anxiety disorder, and constipation had an order for an as-needed narcotic pain medication with directions to give one tablet for pain levels four to six out of ten and two tablets for pain levels seven to ten out of ten. The February MAR showed the resident received one tablet for a pain level of seven on multiple occasions. The same resident also had no documented bowel movements for several days in February, and the MAR showed no documentation that the bowel protocol was initiated or that as-needed stool softeners or laxatives were given. In addition, on the fourth-floor south medication cart, a narcotic was present in the ledger but not in the cart, and staff confirmed it had been administered earlier but was not signed out of the narcotic ledger. The DON stated staff should have signed for the medication when given and counted the cart correctly, but they did not.
Failure to Provide ADL Assistance for Grooming and Bathing
Penalty
Summary
The facility failed to provide assistance with activities of daily living related to cleanliness and grooming for 3 of 7 sampled residents. The deficiency involved failure to provide nail care for two residents and failure to provide bathing for one resident. The facility policy stated residents were to receive care and services for ADLs, including bathing and grooming. Resident 39’s admission MDS showed no memory impairment, clear speech, and ability to make independent daily decisions, but also showed the resident required maximal assistance with transfers, personal hygiene, and bathing. The care plan called for an appropriate level of staff assistance with ADLs, and the resident preference checklist showed a preference for staff-provided nail care. Observations on multiple dates showed long fingernails with black debris underneath. The resident stated they needed help clipping their fingernails, and a CNA confirmed the fingernails were long with debris and said they should have been clipped on the resident’s shower day, but they were not. Resident 189’s quarterly MDS showed cognitive intactness, impairment of one arm and one leg, dependence on staff for personal hygiene, and a blood sugar control disorder. The resident stated they could not use their right hand from the elbow down and used the left hand to open contracted fingers on the right hand; fingernails on both hands were long. A weekly skin check documented fingernail length as within normal limits per resident preference, but later observation showed the contracted right pinky and ring fingernails were over a half inch long. Resident 189 stated staff did not offer to clip the fingernails and that they wanted them shorter. Staff later confirmed the nails needed trimming and stated nail care should be offered weekly, with the nurse responsible for checking and trimming nails for residents with a blood sugar control disorder. Resident 156’s admission MDS showed no memory impairment, that it was very important for the resident to choose among bathing options, no rejection of care, and occasional urinary incontinence. Review of bathing documentation for several weeks showed no showers were offered or provided. The resident stated staff told them only OT could give showers and that they preferred showers at least three times a week, but OT had only assisted with one or two showers since admission. Rehab staff reviewed OT notes and stated the resident only had showers on two occasions with OT, while nursing staff were expected to provide bathing per the bathing schedule. The LTC RN reviewed the bathing schedule and documentation and stated the resident was scheduled for weekly showers, but there was no documentation showing showers were offered or provided.
Failure to Assess and Document Non-Pressure Skin Conditions
Penalty
Summary
The facility failed to ensure that residents’ skin was assessed, documented, monitored, and treated as required for 2 of 4 residents reviewed for non-pressure skin conditions. Facility policy required skin conditions to be assessed, documented with location, description, and interventions, and followed up to evaluate progression or resolution. Resident 188 was readmitted after a scheduled hospital procedure, and a comprehensive skin inspection on readmission did not document bruises on the skin map. On observation, Resident 188 had multiple open scabs on the face, arms, and lower legs, along with dark purple bruises on both arms, which the resident said occurred in the hospital during blood draws and IV medication administration. The April 2026 physician orders contained no orders to monitor the bruising, and a weekly skin assessment also did not document bruising on both arms. Staff V stated they noticed the bruises but did not notify the provider because they believed regular staff already knew about them. Resident 214 was admitted with no memory impairment and was receiving blood thinner medication during the assessment period. On observation, Resident 214 had an 8 x 4.5-centimeter dark purple raised bruise on the right arm, and the resident stated it had become larger and more swollen after receiving a blood transfusion in the hospital. Review of the skin assessments showed staff documented only that there was a bruise, but did not document an assessment of the bruise. The DON reviewed the record and stated staff were expected to complete an accurate and thorough skin assessment documenting the appearance, including size, color, and any swelling, to establish a baseline and determine whether the skin issue was improving or worsening.
Pain Assessments and PRN Medication Effectiveness Not Documented
Penalty
Summary
The facility failed to provide pain management consistent with its pain management policy for two residents by not completing pain assessments, not using pain scales, and not documenting whether PRN pain medications were effective. The report states that the facility policy required residents with pain to be assessed using a numeric pain rating scale or Wong-Baker FACES scale to support consistent evaluation and clinical decision-making. Resident 82 had multiple medical conditions including a bladder infection, cognitive impairment, and muscle weakness, and the MDS identified generalized pain and pain medication use. The care plan directed staff to assess pain medication effectiveness, use a pain scale, and monitor side effects, but the record did not show a recent pain assessment or provider notification for ongoing pain needs. The April 2026 MAR showed PRN pain medication given on multiple days, including medication for a urinary tract infection, but there was no documentation that staff reassessed pain for effectiveness or used a pain scale after administration. During observations and interviews, Resident 82 repeatedly stated they had pain in the back, stomach, and head, and was observed yelling from the room that they were in pain. Resident 52 had diagnoses including heart issues, cancer, wounds, and chronic pain syndrome, and the MDS showed frequent pain with worst pain rated 5 out of 10 and that the resident could understand and be understood. The care plan directed staff to monitor pain, report unresolved or worsening pain, and use the pain scale with follow-up assessments. However, the MAR and progress notes did not document pain levels for multiple administrations of suboxone, and no pain scale rating was documented for most administrations or for the results of any of them. Physician visit notes also lacked pain scale documentation. In interviews, Resident 52 reported pain levels of 8 to 9 out of 10, said pain medication was often too soon to receive, and stated staff rarely asked for a pain rating; staff acknowledged that ongoing pain assessments and documentation of pain severity and medication effectiveness were expected but were not done.
Medication Administration Error Rate Exceeded 5 Percent
Penalty
Summary
The facility failed to ensure a medication error rate of less than 5 percent. During a medication pass observation, Staff W, a Long Term Care Registered Nurse, prepared morning medications for Resident 56 and measured 25 milliliters of a liquid supplement and prepared prescription eye drops. Staff W administered 1 drop of the eye drops into each eye, while the resident stated they usually received 2 drops in each eye from other nurses. Staff W initially stated the physician order directed 1 drop in each eye. When Staff W reviewed the resident’s physician orders, they confirmed the order actually directed 2 eye drops in each eye and 30 milliliters of the liquid supplement, not 25 milliliters. Staff W stated they should check the orders for all residents before administering medications. The facility’s Medication Administration policy stated staff should verify the resident name, medication name, strength, dosage, time, and route before administration. The Director of Nursing stated the expectation was for staff to check physician orders before administering medications, but they did not.
Failure to Provide Ordered Rehabilitative Services
Penalty
Summary
The facility failed to ensure specialized rehabilitative services were provided as assessed for three residents reviewed for skilled therapy services. The deficiency involved Resident 188, Resident 189, and Resident 156, and the report states this failure prevented residents from attaining, maintaining, or restoring their highest practicable level of physical, mental, functional, and psycho-social well-being. Resident 188 returned to the facility after a hospital stay for a scheduled kidney stone removal procedure. The hospital transfer orders required PT and OT evaluation and management to resume previous activity level, but the facility’s March and April 2026 physician orders contained no PT or OT orders. The resident was observed lying in bed in a hospital gown on two occasions and stated they felt weak and wanted therapy to help them sit on the edge of the bed. The Rehab Director stated therapy staff missed the hospital therapy orders and did not evaluate or treat the resident for PT and OT needs. Resident 189 had diagnoses including weakness to one side of the body and was dependent on staff for multiple ADLs, with substantial/maximal assistance needed for bed mobility and dependence for wheelchair transfers. The resident had a right hand contracture and no brace or splint in place, and stated staff had been talking about therapy but no one had started it and that staff were not working with them to stretch or provide ROM. The last OT services for the hand contracture were nearly two years earlier, and there was no documentation explaining the resident’s refusal of the splint, alternate therapies, or restorative nursing options. Resident 156’s OT evaluation called for therapy three to six times per week for four weeks, but the treatment record showed only two OT sessions during the first week, and the Rehab Director confirmed the resident should have received at least three sessions that week but did not.
Failure to Ensure CNA Annual Training Requirements Were Met
Penalty
Summary
The facility failed to ensure nurse aides completed the required annual training for 2 of 5 nurse aides reviewed, Staff J, CNA, and Staff K, CNA. The facility policy stated that CNAs must complete a minimum of 12 hours of annual training, and review of Staff J’s training records for their last full year of employment showed only 4.3 hours of education and training completed, which did not meet the requirement. In interview, the DON stated the facility had difficulty encouraging CNAs to complete the required training because of the size of the facility and the format of the education modules provided by ownership/foundation, and acknowledged that Staff J and Staff K did not complete the minimum 12 hours of annual training.
Failure to Implement COVID-19 Transmission-Based Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program to prevent the transmission of communicable diseases, specifically COVID-19. During a COVID-19 outbreak, 16 residents on the third floor south tested positive for the virus. According to facility policy, residents with confirmed or suspected COVID-19 infections were to be placed on Aerosol Contact Precautions (ACP), which included placing signage on the resident's door to inform staff and visitors of required Personal Protective Equipment (PPE) and actions to take before entering. However, observations revealed that four rooms housing COVID-19 positive residents did not have the required ACP signage on their doors. Interviews with staff, including the Infection Control Preventionist, LPN, and DON, confirmed that ACP signage was expected to be present and that staff were required to wear PPE when entering the rooms of isolated residents. Despite this, there was no specific staff member assigned to routinely monitor for ACP signage or staff use of PPE, with oversight being shared among all managers and the Infection Control Preventionist. The lack of proper signage and monitoring led to a failure in fully implementing the facility's infection control protocols as outlined in their policy.
Failure to Protect Residents from Abuse and Inadequate Response to Allegations
Penalty
Summary
The facility failed to protect multiple residents from abuse, as evidenced by physical, verbal, and psychological harm caused by a CNA. One resident, who was severely cognitively impaired and dependent on staff for all care, was physically injured when the CNA grabbed their arms, resulting in fingerprint bruises and a nail-inflicted skin tear. This resident subsequently exhibited significant mood changes, including frequent crying, increased distress behaviors, multiple days of refused care and medications, and repeated verbalizations of fear of being physically hurt. Documentation showed that the injuries and behavioral changes were not promptly assessed, reported, or investigated by nursing or management staff, despite being observed and reported by other CNAs. Other residents, most of whom were cognitively intact but physically dependent, reported or were observed to experience rough, hurried, or intimidating care from the same CNA. Several residents described being treated roughly during transfers or personal care, being spoken to in a demeaning or intimidating manner, and feeling fearful or anxious about receiving care from the CNA. Some residents reported changes in their behavior, such as avoiding common areas or losing sleep, to avoid interactions with the CNA. Despite these reports and observations, the CNA continued to provide care to residents for an extended period after the initial incident. The facility's policies required immediate reporting, investigation, and protection of residents from abuse, but these procedures were not followed. The responsible nurse manager did not suspend the CNA, did not initiate an investigation, and did not report the suspected abuse to facility leadership or the state agency as required. Injuries and behavioral changes were not documented or monitored in a timely manner, and residents were not protected from further potential abuse during the period in question.
Failure to Implement Abuse Prevention Policy and Mandated Reporting
Penalty
Summary
The facility failed to implement its abuse prevention policy for a resident who sustained injuries of unknown origin. The policy required that all allegations or suspicions of abuse be promptly investigated, that the alleged victim be protected, and that the alleged perpetrator be suspended during the investigation. However, after an incident in which a CNA physically abused a resident, multiple staff members who were aware of the incident did not report it as required. The supervisor who was informed of the abuse did not initiate an investigation, did not report the incident to the administrator or the state agency hotline, and did not suspend the alleged perpetrator immediately. The CNA continued to work for several days after the incident before being suspended. Record review showed that the facility did not document or investigate the incident in its reporting log, and there was no evidence that the required screenings for abuse or neglect were completed with the CNA's prior employers or references. Staff interviews revealed that several staff members witnessed or were aware of rough and abusive behavior by the CNA toward multiple residents, including physical injuries and verbal mistreatment, but failed to act as mandated reporters. The facility's mandated reporter training attendance records indicated that not all relevant staff had received the required training. The facility had previously been cited for similar failures to protect residents from abuse, prevent further abuse, complete investigations, and report to the state agency. Despite staff being aware of their responsibilities as mandated reporters, they did not report the incidents, relying instead on supervisors who also failed to act according to policy and regulatory requirements.
Failure to Investigate and Report Potential Abuse Incident
Penalty
Summary
The facility failed to identify and investigate a potential abuse incident involving a resident who was severely cognitively impaired, dependent on staff for all care, and diagnosed with dementia. The resident was found with bruises in the shape of fingers on both arms and a significant skin tear on the left arm. Staff interviews revealed that a CNA admitted to grabbing the resident's arms during care, which was reported to a licensed nurse and the resident care manager. Despite this, there was no documentation of a thorough assessment, injury report, or investigation into the cause of the injuries, as required by both state guidelines and the facility's own abuse prevention policy. Review of the resident's records showed no adequate description or measurement of the injuries, and the incident was not logged in the facility's incident and accident log. The administrator confirmed that the required steps, including reporting to the administrator, DON, and state agency, were not taken. The facility's failure to follow its abuse prohibition and prevention policy, as well as state reporting guidelines, resulted in a lack of protection for the resident and potentially others from further abuse or neglect.
Facility Fails to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after a hospitalization, resulting in psychological harm. The resident, who had a chronic, progressive neurological disease and required assistance for all personal care and mobility, was sent to the emergency room (ER) for a possible abdominal infection and feeding tube replacement. Despite being medically cleared for discharge, the facility did not allow the resident to return, leading to a two-week hospitalization delay while another nursing facility was arranged. The facility's internal communication indicated that the resident would not be readmitted, and the admissions assistant informed the hospital of this decision. The resident's belongings were packed and removed from their room, which was not occupied by another resident until 12 days after the resident was sent to the ER. The facility's staff, including the administrator and admissions assistant, were aware of the situation but did not facilitate the resident's return. Interviews with the resident's representative and hospital staff revealed that the resident experienced significant distress, expressing feelings of homelessness and hopelessness. The resident's representative reported that the resident was discouraged and talked about suicide. The hospital discharge coordinator and physician attempted to communicate with the facility, but the facility did not respond to their calls. The facility's failure to readmit the resident after hospitalization led to the resident being transferred to a different nursing facility.
Failure to Enforce Non-Smoking Policy and Prevent Cannabis Vaping
Penalty
Summary
The facility failed to maintain a safe environment free from hazards for two residents, specifically concerning Resident 2's use of cannabis through a vape pen. Despite the facility's non-smoking policy, Resident 2, who was cognitively intact but required maximum assistance for personal care and mobility, repeatedly vaped cannabis in their room. This behavior was documented in multiple nursing progress notes, indicating that Resident 2 used air freshener to mask the smell and was found with vape supplies on several occasions. The facility's staff intervened by removing the vape supplies and reporting the incidents to management, but Resident 2 continued to vape, leading to a 30-day discharge notice. The facility's records showed that Resident 2 had acknowledged the non-smoking policy upon admission and was aware of the consequences of non-compliance. Despite this, Resident 2 continued to vape, affecting their roommate, Resident 3, who was non-responsive during an interview. The facility's care plan for Resident 2 included reminders of the non-smoking policy and discussions about alternatives, but these measures were ineffective in preventing further incidents. Interviews with facility staff revealed that there was a lack of consistent action in addressing the ongoing issue. Although the nurse was expected to remove vape materials and report to the supervisor, there were instances where this did not occur. Additionally, there was no evidence of an assessment being conducted to evaluate the safety of Resident 2's vaping behavior. The facility's management acknowledged that Resident 2 still had vape supplies in their possession, which were eventually surrendered to the facility.
Resident Experienced Psychological Harm Due to Inappropriate Staff Conduct
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse, resulting in psychological harm to a resident who was touched inappropriately without consent by a staff member. The incident involved a resident with intact memory and a history of social isolation, who required assistance with mobility due to a fractured right hip. The resident reported that a male caregiver entered their room, kissed them, and attempted to climb into their bed. The resident was able to identify the caregiver from a photo array, leading to the caregiver's removal from the schedule. The facility's investigation confirmed the resident's account, noting the resident's alert and oriented status, intact memory, and daily journaling as factors supporting the reliability of their report. The investigation concluded that the incident occurred in the early morning, and the caregiver involved was dismissed following the substantiation of the claim. The resident continued to recall the incident unprompted in subsequent interviews, indicating ongoing psychological impact.
Sanitation and Hand Hygiene Deficiencies in Food Service
Penalty
Summary
The facility failed to ensure that food and drinks served to residents were prepared and distributed under sanitary conditions. Observations in the main kitchen revealed several pieces of equipment, such as a meat slicer and food processor bases, were not maintained in a sanitary manner, with visible dust and food residue. During lunch preparation, a cook was observed handling food without proper hand hygiene, changing gloves without washing hands, and touching various surfaces and food items without sanitizing hands in between tasks. In the 4th Floor North Unit, a nutrition attendant was observed checking food temperatures with a thermometer probe that was not properly sanitized between uses. The attendant used a paper towel to wipe the probe instead of using alcohol swabs, as expected by the facility's standards. Additionally, the attendant's hair was not fully covered, which is against the facility's policy for food preparation. On the 4th Floor South Unit, CNAs were observed serving food without securing their hair and failing to perform hand hygiene after delivering trays to residents' rooms, including those under Enhanced Barrier Precautions. One CNA entered a resident's room without donning the required protective equipment and continued to serve food without washing hands. These actions were contrary to the facility's policy and placed residents at risk of exposure to contaminants.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to uphold resident rights and dignity for 10 out of 35 sampled residents, as observed during dining services, privacy provision, and care delivery. During meal services, staff did not consistently remove plastic wrap from residents' drinks, despite residents expressing a preference for uncovered drinks. This was observed with several residents, including one who preferred to drink without a straw, yet staff routinely punctured the plastic wrap with a straw. Additionally, medications were administered in the dining room, which was identified as a dignity concern by staff, as it compromised the privacy and dignity of residents. Privacy issues were also noted, with staff failing to close doors or curtains during care provision. For instance, a resident receiving tube feeding was left exposed to the hallway, and another resident's catheter bag was visible from the hallway without a privacy cover, contrary to the care plan directives. These lapses in privacy were acknowledged by staff as not meeting the expected standards of care. Furthermore, care was not always provided in a dignified manner. A resident was subjected to a sign outside their room regarding food delivery, which they found bothersome and unclear. Another resident experienced a delay in being informed about the denial of their rehabilitation services appeal, which was crucial information affecting their care and mobility. The social worker admitted to not notifying the resident promptly, which was against the expected process. These incidents collectively highlight the facility's failure to maintain and promote resident dignity and rights.
Failure to Accommodate Resident Bathing Preferences
Penalty
Summary
The facility failed to honor and facilitate resident self-determination by not accommodating the bathing preferences of several residents, which is a violation of their rights. Resident 22, who had a history of stroke and was dependent on staff for bathing, expressed a preference for more frequent tub baths. However, the facility's records showed that Resident 22 received only one shower in December and a bed bath instead of a tub bath on multiple occasions, contrary to their stated preference and the instructions on their care plan. Similarly, Resident 142, who had intact memory and clear communication abilities, expressed a desire for more frequent showers. Despite this, the facility's documentation indicated that Resident 142 received fewer showers than scheduled and preferred. The care plan for Resident 142 also showed unanswered questions regarding their bathing preferences, indicating a lack of attention to their personal choices. Resident 170, who also had clear communication abilities, reported dissatisfaction with the frequency of their bathing, stating they only received one bath per week. The facility's records lacked specific instructions for bathing frequency or type for Resident 170, and the unit's shower schedule confirmed that all residents were scheduled for only once-a-week bathing. Additionally, Resident 100, who was dependent on staff for transfers and bathing, was not offered their preferred type of bath, receiving only bed baths instead. These failures to accommodate resident preferences were confirmed through interviews with staff and review of facility documentation.
Failure to Conduct Care Conferences and Update Care Plans
Penalty
Summary
The facility failed to conduct care conferences as required for two residents, leading to unmet care needs and potential frustration. Resident 427, who was admitted without memory impairment, reported not having a care conference scheduled since their admission, despite expressing a desire for one to understand their care plan. Staff M, a social worker, confirmed that care conferences were scheduled as needed or upon request, but since Resident 427 did not request one, it was not scheduled. Similarly, Resident 28, who had medically complex conditions and a communication deficit due to hearing loss, was not invited to care conferences held on two separate occasions. Staff K, a manager, acknowledged that the facility's process for inviting residents to care conferences was not followed for Resident 28. The facility also failed to update care plans to reflect changes in residents' care needs for four residents. Resident 22, who had multiple medically complex diagnoses, was noted to have discrepancies in their care plan regarding denture use, with the Kardex indicating the use of lower dentures instead of the upper dentures specified in the care plan. Staff K acknowledged the inaccuracy and the need for updates. Resident 142, who had malnutrition and recently had all teeth extracted, was using dentures, but their care plan and Kardex did not reflect this change. Staff K confirmed that the care plan and Kardex should be updated to address the resident's denture use. Resident 170, who had multiple medically complex diagnoses including cancer, had an indwelling catheter removed, but their care plan and Kardex still indicated the need for catheter care. Staff K confirmed that the care plan and Kardex should be updated to reflect the resident's current toileting status. Additionally, Resident 7, who had a history of stroke and one-sided limitations to their range of motion, was receiving a bed mobility restorative nursing program but no range of motion programs, despite the care plan indicating the need for a passive range of motion program. Staff B confirmed that the care plan was not up to date.
Deficiencies in ADL Assistance and Hygiene in LTC Facility
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADLs) for several residents, leading to deficiencies in personal hygiene and grooming. Resident 14, who was dependent on staff for personal hygiene due to weakness on the left side of their body, was observed with long fingernails and black debris under them. Despite the care plan indicating the need for extensive assistance, staff did not provide the necessary nail care. Interviews with staff revealed an expectation for staff to check resident preferences and provide assistance, yet this was not documented or followed through. Resident 22, who required setup assistance for eating and was dependent on staff for dressing, was observed eating without dentures on multiple occasions. The resident expressed a desire to wear dentures, but staff failed to provide them, leaving the dentures in a cup across the room. This oversight was contrary to the care plan, which directed staff to ensure the resident wore dentures. Staff interviews confirmed the expectation for daily assistance with dentures, especially before meals. Other residents, such as Resident 170, 93, 112, 120, 126, and 82, experienced similar neglect in ADLs, including dressing, shaving, and bathing. Resident 170 was left in a hospital gown without being offered to get dressed, while Residents 93 and 112 were not assisted with shaving, resulting in long chin hairs. Residents 120, 126, and 82 did not receive regular bathing as per their preferences and schedules, with documentation showing missed or unoffered bathing opportunities. Staff interviews highlighted the expectation for documenting refusals and reattempting care, which was not consistently practiced, leading to these deficiencies.
Failure to Provide Meaningful Activities for Residents
Penalty
Summary
The facility failed to provide meaningful activity programs that met the needs of three residents, leading to a deficiency in their care. Resident 110, who had intact memory and sometimes experienced social isolation, expressed a strong desire to go outside, which was not facilitated by the staff. Despite the resident's care plan indicating the importance of outdoor activities, the activity flow sheets showed no offers to take the resident outside since their admission. The recreation therapist confirmed that no such offers were made, highlighting a gap in meeting the resident's preferences. Resident 170, who required substantial assistance for mobility and expressed a keen interest in participating in activities, was not facilitated to attend any since their admission. Despite the resident's care plan encouraging activity attendance and an interest in bingo, the activity flow sheets documented minimal offers and no refusals, indicating a lack of effort to engage the resident in meaningful activities. The recreational therapist acknowledged the oversight in documentation and the failure to provide adequate activity opportunities. Resident 171, who was initially on isolation due to COVID-19, was not provided with in-room activities despite their preferences for reading, music, and religious services. Observations showed a lack of engagement materials in the resident's room, and staff admitted to not providing activities due to infection control concerns. Even after the resident tested negative for COVID-19, the facility did not adjust their approach to meet the resident's activity needs, as confirmed by the administrator and recreation therapist assistant.
Unsecured Hazardous Materials in Facility
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards across multiple units, including 2 North, 4 South, St Joseph's Residence (SJR), and 5 North. On the 2 North unit, the clean utility room was found unlocked with eight blood collection kits containing needles uncontained on a shelf. Staff confirmed the absence of a locking mechanism on the utility room door, which should have been secured to prevent resident access. Similarly, on the 4 South unit, the clean utility room was unlocked, allowing access to various personal care products, and the spa room was propped open with a bottle of disinfectant cleaner accessible, despite warnings to keep it out of reach of children. On the SJR unit, the laundry room door was left open, and an unlocked cabinet inside contained hazardous chemicals, including disinfectants and laundry detergent, which were accessible to residents. The 5 North unit also had unsecured areas, with the spa room and clean utility room left unlocked, containing a skin disinfectant solution, facility cleaning solutions, and razors. Staff interviews confirmed that these areas should have been locked to prevent resident access to potentially dangerous items, but issues such as broken locks and lack of keys contributed to the deficiency.
Deficiency in Nursing Staff Competency Evaluation
Penalty
Summary
The facility failed to ensure that nursing staff, including Certified Nursing Assistants and Registered Nurses, possessed the necessary competencies and skills to provide adequate care and ensure the safety and well-being of residents. This deficiency was identified through interviews and record reviews, which revealed that the facility did not conduct the required competency evaluations for four staff members. The 2024 Facility Assessment indicated that skills assessments were to be completed upon hire and annually, covering areas such as abuse and neglect, resident rights, dementia care, infection control, and specific resident needs. However, the Director of Nursing was unable to provide documentation verifying the competency evaluations for the staff in question. Interviews with the Director of Nursing and the Administrator confirmed that the facility did not perform the necessary evaluations to assess the competencies, skills, and knowledge of the nursing staff. This lack of assessment resulted in deficiencies related to the competency of nursing staff, as the facility did not adhere to its own policies outlined in the Facility Assessment. The failure to ensure proficiency in critical areas such as personal care skills, vital sign monitoring, and emergency protocols compromised the ability of the staff to provide safe and effective care to residents.
Inadequate Infection Control Practices
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of staff not adhering to Enhanced Barrier Precautions (EBP) and Transmission-Based Precautions (TBP). Resident 14, who had intravenous access and was dependent on staff for personal hygiene, was observed receiving care from a CNA who did not wear the required isolation gown. The CNA acknowledged forgetting to put on the gown, which was a breach of the facility's infection control policy. Resident 85, who was primarily fed through a tube and had severely impaired vision, was also subject to inadequate infection control measures. A Licensed Practical Nurse (LPN) was observed administering tube feeding without wearing a gown, as required by the EBP sign on the resident's door. Additionally, the LPN used tubing that had fallen on the floor, which was against the facility's policy for maintaining cleanliness and preventing contamination. The LPN admitted to being nervous and forgetting to replace the tubing. Resident 15, who had a pressure ulcer requiring skin treatments, was another case where infection control protocols were not followed. An LPN providing wound care did not wear a gown, failed to perform proper hand hygiene, and used ungloved hands to handle used wound supplies. The facility's Director of Nursing and other staff members acknowledged that the expected infection control protocols were not followed, placing residents at risk for healthcare-associated infections.
Inadequate Investigation of Abuse and Resident Interactions
Penalty
Summary
The facility failed to thoroughly investigate reportable incidents involving three residents, leading to deficiencies in handling allegations of abuse and resident-to-resident interactions. Resident 110 reported an incident where a caregiver kissed them and attempted to climb into their bed. The facility's investigation substantiated the allegation but lacked thoroughness, as it did not include interviews with other potential witnesses or victims, nor did it verify if the caregiver had worked on other units. Additionally, the investigation did not include a background check to determine if the caregiver had any disqualifying history. Resident 95 experienced a fall after intervening in a resident-to-resident altercation involving a hot beverage. The facility's investigation categorized the incident as a non-injury fall and did not include witness interviews from other staff or residents. This lack of thorough investigation led to discrepancies in the characterization of the incident, which Resident 95 feared could negatively impact their independence. Resident 124 reported an incident where they backed their wheelchair into another resident, who then cussed at them. The investigation ruled out abuse but did not include witness statements from other staff or residents who may have been present. The investigation was completed by multiple staff members but lacked signatures to confirm its completion. These deficiencies in the investigation process placed residents at risk of verbal and mental abuse, psychosocial harm, and diminished quality of life.
Failure to Report Abuse to Authorities
Penalty
Summary
The facility failed to notify local Law Enforcement (LE) and the Department of Health (DOH) after substantiating an allegation of inappropriate touch/abuse involving a resident, identified as Resident 110. The incident occurred on December 24, 2024, when a Certified Nursing Assistant (CNA), referred to as Staff I, allegedly kissed Resident 110 and attempted to climb into their bed. The facility's investigation confirmed the allegation, and Staff I was immediately dismissed. However, the facility did not report the incident to LE or DOH, as required by Washington State's Department of Social & Health Services guidelines and the facility's own Abuse Prohibition and Prevention policy. Resident 110, who had intact memory and required assistance with mobility due to a fractured right hip, reported the incident during an interview on January 2, 2025. The Director of Nursing, identified as Staff B, acknowledged using the Purple Book for guidance on investigation and reporting but failed to notify the appropriate authorities. Additionally, a follow-up report filed with the Department of Social & Health Services' Complaint Resolution Unit contained errors in Staff I's name, further complicating the reporting process. This oversight placed residents at risk for verbal and mental abuse, psychosocial harm, and diminished quality of life.
Failure to Provide Timely Written Transfer Notifications
Penalty
Summary
The facility failed to ensure that residents or their representatives received the required written notices at the time of transfer or discharge, or as soon as practicable, for two residents reviewed for hospitalizations. Resident 14 was discharged to an acute care hospital, and there was no documentation in their health records indicating that the required written transfer notification was provided within 24 hours. Staff D, the Social Services Director, confirmed the absence of such documentation and stated that their process was to provide written notification the same day or email it the next day. However, they were unable to locate a copy of the notification for Resident 14. Similarly, Resident 120 was discharged to an acute care hospital, and their health records also lacked documentation of the required written transfer notification. Staff D reviewed Resident 120's records and confirmed the absence of documentation showing that the notification was provided as required. Staff A, the Administrator, stated that they expected staff to provide written notifications in a timely manner during hospitalizations. The failure to provide these notifications placed residents at risk for discharges that were not aligned with their stated goals for care and preferences.
Failure to Provide Bed-Hold Notification
Penalty
Summary
The facility failed to provide written notification of its bed-hold policy to two residents, Resident 14 and Resident 120, or their representatives, at the time of their transfer to an acute care hospital or within 24 hours as required. According to the facility's policy, residents and their representatives should receive bed-hold information at admission and before a hospital transfer or therapeutic leave. For emergency transfers, the facility is expected to contact residents or representatives to offer bed-hold information within 24 hours. However, for Resident 14, who was discharged to a hospital on November 14, 2024, there was no documentation indicating that a bed-hold notification was provided. Similarly, for Resident 120, who was transferred to a hospital on August 15, 2024, there was no record of a bed-hold notification being given. Interviews with facility staff revealed a lack of adherence to the policy. Staff N, a Social Services Assistant, stated that the facility's process was to offer bed-hold information on the same day residents were sent to a hospital. Staff A, the Administrator, and Staff D, the Social Service Director, both acknowledged the expectation that bed-hold notifications should be provided in a timely manner, either at the time of transfer or shortly thereafter. Despite these expectations, the absence of documentation for both residents indicates a failure to comply with the facility's policy, potentially leaving residents and their representatives uninformed about their rights and the costs associated with holding a bed during hospitalization.
Inaccurate MDS Documentation for Hospice Resident
Penalty
Summary
The facility failed to ensure an accurate assessment for Resident 170, as evidenced by discrepancies in the Minimum Data Set (MDS) documentation. Resident 170, who had multiple medically complex diagnoses including cancer, was inaccurately documented in the 12/11/2024 Admission MDS as not being on hospice, despite being on hospice services since 12/06/2024. This was confirmed by the presence of hospice service stickers on the resident's chart and the resident receiving an antianxiety medication as part of a hospice comfort kit. Staff SS, a Care Manager and Registered Nurse, acknowledged the inaccuracy in the MDS, emphasizing the importance of capturing hospice care to ensure the resident's care plan aligned with their comfort-focused goals.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, leading to potential risks for unmet care needs and inappropriate care. Resident 428, who was admitted to the facility with a history of frequent bowel incontinence and diarrhea, did not have a care plan addressing these issues. Despite being ruled out for infectious causes, the resident continued to experience diarrhea, which was unmanaged and not documented in the care plan. This oversight was confirmed by the Infection Preventionist, who acknowledged the importance of a care plan to manage the resident's condition and prevent complications such as dehydration and skin breakdown. Similarly, Resident 93, who was at risk for pressure ulcers and required assistance with mobility and personal hygiene, was observed to have edema in both lower legs. However, the resident's care plan did not address this condition, despite it being identified in a progress note. The Director of Nursing and the Manager of Long Term Care both stated that it was expected for staff to develop care plans that address current resident conditions, including monitoring and documenting interventions for edema. The lack of a comprehensive care plan for Resident 93's edema was a clear deficiency in the facility's care planning process.
Failure to Follow Physician Orders and Administer Medications
Penalty
Summary
The facility failed to follow physician's orders for two residents, leading to potential risks for the residents involved. Resident 22, who had a neurogenic bladder and required an indwelling catheter, was observed with a catheter bag hanging from the bed frame. The physician's orders specified the removal of the catheter for a trial and replacement with a size 16 FR catheter if necessary. However, staff inserted a size 14 FR catheter without a physician's order, and there were no directions for the duration of its use. Staff K acknowledged that the physician's orders were not followed. Resident 85, who had severe cognitive impairment and was at risk for pressure ulcers, had a physician's order for a dressing to be applied to a sacral wound every three days. The Treatment Administration Record indicated that the resident refused treatment on one occasion, and staff documented that the dressing was applied as ordered. However, observations showed that the resident had no dressing on the sacral area, and staff interviews confirmed the absence of a wound or dressing. Staff E stated that the physician's orders should have been clarified if there were changes, but this was not done. Resident 28, with medically complex conditions including unstable blood sugars and high blood pressure, did not receive prescribed medications due to unavailability. The resident reported missing medications and expressed distress over the situation. Staff J confirmed the medications were unavailable and did not notify the provider or document the issue. Staff K stated that the nurse should have sought further instructions from the provider and documented the situation, but this was not done.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary care and services for a resident with pressure ulcers, consistent with professional standards of practice. The resident, who had impairments to both sides of their lower body and was dependent on staff for activities of daily living, was observed without the required pressure-reducing devices while in a wheelchair. Despite physician orders to float the resident's left foot and use boots, staff interviews revealed that these interventions were not consistently implemented. Observations showed the resident's left foot hanging down while seated, contrary to the care plan instructions. Additionally, the facility did not adequately monitor and report changes in the resident's wound condition. A dressing on the resident's left foot was observed to be saturated with blood, yet staff failed to report this bleeding to the nurse or document it in the progress notes. The lack of communication and documentation regarding the resident's wound condition, as well as the failure to follow physician orders and care plan interventions, contributed to the deficiency in providing appropriate pressure ulcer care.
Failure to Monitor Resident's Weight Accurately
Penalty
Summary
The facility failed to accurately monitor the weight of a resident, identified as Resident 14, who was at risk for weight loss due to poor appetite. According to the facility's Weight and Nutrition Monitoring Policy, changes in residents' nutritional status and weight should be routinely discussed by clinical staff and the Registered Dietician. Resident 14, who had diagnoses including anemia and malnutrition, was dependent on staff for various needs and required assistance with meals. The resident's weight records showed a significant drop from 151.2 lbs. on December 13, 2024, to 119.8 lbs. on January 3, 2025, indicating a potential weight loss of over 30 lbs. in three weeks. The facility did not reweigh Resident 14 to verify the accuracy of the recorded weight loss, nor did they notify the physician or the Registered Dietician about this significant change. Staff E, the Director of Long Term Care and a Registered Nurse, acknowledged that the facility's process was to weigh residents weekly unless otherwise ordered by a provider, and that the staff should have reweighed Resident 14 due to the improbability of such a drastic weight loss. The failure to follow these procedures placed the resident at risk for negative health outcomes.
Inadequate Pain Management for Residents
Penalty
Summary
The facility failed to provide adequate pain management for two residents, leading to deficiencies in care. Resident 120, who had no cognitive impairment and a diagnosis of chronic pain, was not given a thorough pain assessment before the administration of PRN narcotic pain medication. The Medication Administration Records for November 2024, December 2024, and January 2025 showed incomplete documentation of pain assessments, including pain level, location, and non-pharmacological interventions. Interviews with Resident 120 and staff revealed that pain medications were not administered timely, and pain assessments were not consistently documented, contrary to the facility's expectations. Resident 28, who suffered from chronic pain due to chronic wounds, experienced a lack of availability of their PRN pain medication. The facility ran out of the medication, and the pharmacy did not deliver it as expected. The resident was given over-the-counter medication for breakthrough pain, but the facility's emergency medication supply kit did not contain the necessary pain medication. Staff interviews indicated that the recent switch to another pharmacy might have contributed to the delay, and the facility's protocol for handling such situations was not followed, as the nurses failed to notify management or the provider and did not document the issue in progress notes.
Medication Security and Expiration Oversight
Penalty
Summary
The facility failed to ensure the security and proper disposal of medications and biologicals across multiple units and medication storage areas. On the 300 South unit, a resident with severely impaired memory and a chronic respiratory disease was left unsupervised with an unsecured and unlabeled inhaler. The nurse responsible, who was new to the unit, admitted to not verifying the resident's ability to self-administer the medication. This oversight placed the resident at risk of receiving incorrect or expired medications. Additionally, expired medications and supplies were found in several medication rooms and carts, including the 5 North, 5 South, 4 South, and 3 South medication rooms, as well as the 5 South Medication Cart 1. Items such as urinary catheter kits, wound dressings, injectable medications, and various medical supplies were past their expiration dates. Staff interviews revealed a lack of adherence to the facility's policy on monitoring and disposing of expired items, with staff acknowledging the oversight and the potential harm to residents from using expired products.
Failure to Protect Resident Information on 5 North Unit
Penalty
Summary
The facility failed to maintain the confidentiality of resident-identifiable information on the 5 North unit, as observed during a survey. A paper copy of an interdisciplinary team progress note was found in a grievance file folder accessible to anyone near the elevator on the fifth floor. Staff E, a Resident Care Manager, acknowledged that the progress note should not have been placed there, as it compromised resident confidentiality. Additionally, a resident roster/report sheet was left exposed on top of a cart, visible to anyone passing by. Staff UU, an LPN, admitted to forgetting to cover the sensitive information before leaving the cart unattended. The Director of Nursing, Staff B, confirmed that staff were expected to keep resident information covered and out of sight to protect resident rights.
Deficient Coordination of Hospice Services
Penalty
Summary
The facility failed to ensure effective coordination of care between the facility and hospice staff for a resident receiving hospice services. The resident, who had multiple medically complex diagnoses including cancer, was admitted to hospice services, but the facility did not update the resident's Care Plan to reflect which agency was responsible for hospice care. Observations showed that the resident's chart indicated hospice services, but there was no physician's order for hospice, and the Care Plan lacked detailed interventions and collaboration notes. Additionally, the Kardex used by staff for care instructions did not indicate the resident was on hospice or specify the care to be provided by the facility or hospice. Interviews with facility staff revealed a lack of awareness and understanding of the hospice care being provided to the resident. The Certified Nursing Assistant responsible for the resident's care was unsure of the hospice providers' role, and the Manager of Long Term Care acknowledged the records were lacking in necessary documentation and collaboration. The facility's Administrator also expected hospice services to be coordinated with the facility, including ensuring orders, Care Plans, and progress notes were readily available in the resident's records. These deficiencies in communication and documentation placed the resident at risk of not receiving necessary care and services.
Failure to Document and Resolve Resident Grievances
Penalty
Summary
The facility failed to identify and resolve grievances for Resident 70, who was reviewed for grievances. According to the facility's Resident Grievance Policy, residents have the right to file grievances verbally or in writing and receive a written decision. However, the facility did not document any grievances from Resident 70, despite the resident expressing issues with a staff member, Staff ZZ. Resident 70, who has a progressive neurological disorder, depression, and a mood disorder, reported feeling disrespected by Staff ZZ, who did not respect their boundaries and was not patient during care. The resident had also reported these issues to the ombudsman. Interviews with staff revealed that grievances were not documented or tracked properly. Staff ZZ acknowledged the accusations made by Resident 70 and reported them to their nurse and the Director of Nursing, Staff B. However, the grievance log did not reflect any grievances from Resident 70. The Social Services Director, Staff D, stated that grievances should be documented, especially when residents complain about staff. Despite this, there was no record of grievances from Resident 70, indicating a failure in the facility's grievance process.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to effectively implement its abuse prohibition and prevention policies, resulting in deficiencies related to the handling of incidents involving three residents. For Resident 110, an investigation substantiated an allegation of inappropriate touching by a Certified Nursing Aide, Staff I. However, the investigation did not include necessary actions such as notifying law enforcement or the Department of Health, conducting a background check on Staff I, or interviewing potential witnesses or other residents who might have been affected. This lack of thoroughness in the investigation process was acknowledged by the Director of Nursing and the Administrator. For Resident 95, an incident initially categorized as a non-injury fall was later described by the resident as a slip on liquid thrown by another resident. The investigation did not include interviews with witnesses, which was a deviation from the facility's policy. Similarly, for Resident 124, an incident involving verbal abuse was reported, but the subsequent investigation failed to include witness statements from staff or residents who were present. Both the Director of Nursing and the Administrator recognized that these investigations were incomplete and did not adhere to the facility's established procedures.
Deficiency in Safe Use of Air Mattresses
Penalty
Summary
The facility failed to ensure the safe use of air mattresses for four residents, leading to multiple falls and potential risks for other residents using similar equipment. The deficiency was identified through observations, interviews, and record reviews, which revealed that the facility did not implement a comprehensive system for assessing and monitoring the use of air mattresses. Specifically, there was a lack of assessment regarding the type, size, and settings of the air mattresses, and no informed consent was obtained from residents or their representatives. Additionally, staff training on the use and monitoring of air mattresses was not provided, and care plans were not updated to include necessary interventions. Resident 1, who was admitted with a history of falls and pressure injuries, experienced three falls from the bed while using an air mattress. The facility's records showed that the wrong size air mattress was initially delivered, and there was no documentation of a safety assessment or discussion of risks and benefits with the resident or their representative. The Treatment Administration Record (TAR) lacked specific parameters for air mattress settings, and staff were only directed to monitor the mattress for function and comfort, without assessing or documenting the pump settings. Similar deficiencies were noted for Residents 2, 3, and 4, who also used air mattresses without proper safety assessments or documentation of settings. Interviews with facility staff confirmed that the necessary assessments and monitoring were not conducted, and no documentation was provided to show that staff were trained on the use and monitoring of air mattresses. The facility's failure to implement a system for the safe use of air mattresses placed residents at risk for falls, injury, and other negative outcomes.
Failure to Follow Mechanical Lift Policy Results in Resident Injury
Penalty
Summary
The facility failed to ensure an environment free of avoidable accidents and injuries for a resident who required mechanical lift transfers. The facility policy mandated that two staff members operate the mechanical lift to ensure resident safety. However, a Certified Nursing Assistant (CNA) transferred the resident alone, resulting in a severe laceration on the resident's right leg. The resident, who had limited mobility and fragile skin, was hospitalized for five days due to the injury, which required surgical intervention. The resident's care plan and Kardex clearly indicated the need for two staff members during mechanical lift transfers to prevent injuries. Despite having attended training that reinforced this policy, the CNA proceeded with the transfer alone. During the transfer, the resident's leg was cut by the wheelchair's footrest, causing a deep laceration that exposed connective tissue and resulted in significant bleeding. The CNA then transferred the resident back to bed without assistance, further violating the facility's policy. Interviews with facility staff confirmed that the CNA had previously used the mechanical lift without a second person on multiple occasions. The Director of Clinical Operations and the Director of Nursing both stated that the CNA had been trained and was aware of the policy requiring two staff members for mechanical lift transfers. The incident report and hospital records detailed the extent of the resident's injury and the subsequent medical treatment required, including surgery and a five-day hospital stay.
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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.
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Nursing homes near Seattle
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avamere Rehabilitation At Park West | 2.1 mi | ★★★★★ | 1 | 0 |
| Washington Care Center | 3.8 mi | ★★★★★ | 29 | 0 |
| The Terraces At Skyline | 4 mi | ★★★★★ | 1 | 0 |
| Transitional Care Of Seattle | 4.5 mi | ★★★★★ | 2 | 0 |
| Seattle Medical Post Acute Care | 4.7 mi | ★★★★★ | 7 | 0 |
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