Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cherry Ridge Of Cascadia during CMS and state inspections, most recent first.
Unqualified Culinary Manager Overseeing Food and Nutrition Services: The facility failed to ensure its Culinary Manager met the required qualifications to direct food and nutrition services when a full-time qualified dietician was not employed. The CM stated she had worked at the facility since August 2025, had only cook and kitchen manager experience, and no certification documentation was provided. The CEO confirmed the CM did not have the required qualifications and was in the process of getting certified.
The facility failed to keep the kitchen hood clean, removed moldy cantaloupe from storage only after it was observed, allowed a staff drink to be stored in the kitchen freezer, and observed an employee washing hands for only four seconds with visible substance still on the arm before serving food. Food and refrigerator temperature logs were incomplete, and the activities refrigerator was found with condensation, black buildup, and temperatures above the safe range while the AD reported freezer temperatures were not being checked.
QAPI monitoring was deficient when the facility failed to ensure performance improvement activities were properly implemented and tracked for incomplete skin assessments and food labeling issues in the snack room. The CEO stated there were three PIPs, but benchmark measurements were not consistently documented, one PIP remained active after completion because the facility did not want to fall off track, and the current measurement method did not adequately track whether improvement had occurred since implementation.
Failure to obtain informed consent for ordered psychotropic and PRN meds. A resident with COPD, anxiety, and PTSD had orders for Seroquel ER, Seroquel, and lorazepam, but the record had no documentation that the resident or representative was informed of the risks and benefits or signed consent for either medication. The CRN and CNO confirmed the missing consents.
Call Light Out of Reach: A resident with acute cystitis with hematuria, DM, and cirrhosis was found sitting in a chair with the call light hanging on the wall and out of reach. The resident asked a surveyor to call staff, and later an RN and CNA entered the room after being notified. The CNA stated the resident could not reach the call light, which was on the other side of the bed and should have been within reach.
Advance Directive Not Maintained in Resident Record: A resident with dementia, muscle weakness, and protein-calorie malnutrition had documentation indicating an advance directive was in the chart, but record review did not locate a living will or DPOA for health care. The CNO confirmed the record did not include an advance directive and the facility did not have a living will on file.
A resident with COPD, anxiety, and PTSD had a PRN lorazepam order entered for palliative care related to COPD without an appropriate clinical indication documented. The care plan directed staff to give meds as ordered by the physician, and the CNO later stated the lorazepam indication should have been shortness of breath or anxiety.
Failure to report an alleged misappropriation of resident funds. A resident with COPD, anxiety, and PTSD reported $1,600 missing and believed another resident took it, but the SSD reportedly said it was too long ago to investigate. The CNO recalled hearing about missing funds from a family member but did not pursue it, and the CEO stated the allegation should have been reported to the State Agency.
Failure to Investigate Allegation of Misappropriation: A resident with COPD, anxiety, and PTSD reported $1,600 missing and believed another resident had taken the money, but the SSD told him it was too late to investigate. The grievance record and reporting portal contained no misappropriation report for the resident, and the CNO recalled hearing about missing funds from a family member but did not follow up, while the CEO stated the allegation should have been reported and investigated.
Failure to Provide Written Discharge Notice: A cognitively intact resident with osteomyelitis, paraplegia, and chronic pain syndrome was discharged AMA, but the discharge notice in the record had no resident signature confirming receipt. The SSD and CNO initialed the form, and the SSD stated the resident did not receive a copy because he left and did not return, while the CEO was unsure whether written notice was provided.
A resident with dementia, muscle weakness, and protein-calorie malnutrition had a care plan directing staff to offload his heels or use Prevalon boots while in bed. During observation, he was found in bed without the boots, and an LPN confirmed his heels were not offloaded even though they should have been.
Medication administration was not performed according to standards for two residents. One resident with dementia, anxiety, and adult failure to thrive had redness under the breasts and in the abdominal folds, and staff applied cleansing and Gold Bond powder without an active order. Another resident with glaucoma received eye drops from an LPN, but the resident rubbed his eyes afterward and the LPN did not provide the full post-administration instructions required by policy.
Failure to implement podiatry orders and document refusal for a resident with dementia, muscle weakness, and protein-calorie malnutrition. An LPN observed thick, yellow, irregular toenails and noted the resident was on the podiatry list every 3 months. A podiatry visit included an order for ammonium lactate 12% cream to the feet and callused skin, but the order was not found in the MAR/physician orders, and the CNO stated the resident refused the treatment and the refusal and provider notification were not documented.
Failure to Monitor Catheter-Associated UTI Signs: A resident with dementia, muscle weakness, and protein-calorie malnutrition had a physician order to monitor and report signs of catheter-associated UTI, but staff did not complete the ordered monitoring. The resident was observed with white, milky urine in the catheter tubing and bag on multiple days, the MAR showed the monitoring order was not completed, and the CNO stated the cloudy urine was the resident’s baseline and that no physician notification was documented.
Oxygen Concentrator Left in Room After Order Discontinued: A resident with morbid obesity with alveolar hypoventilation and diabetes was observed with an oxygen concentrator at bedside even though there was no current oxygen order. The resident stated he used oxygen only when needed, and the CNO confirmed the oxygen had been discontinued earlier and the concentrator should not have remained in the room.
A resident with COPD, anxiety, and PTSD had a PRN morphine order for severe pain related to COPD, but the CNO stated she did not know what the appropriate indication for the order should be. The facility failed to ensure the medication was administered with an appropriate clinical indication.
Food was served at unacceptable temperatures for a resident with DM, GERD, and CKD. The resident stated hot food is always cold and that this is a frequent problem, so she usually does not ask for reheating because cold food is normal in the facility. During a breakfast tray observation, the French toast, eggs, sausage, and apple juice were all documented at low temperatures, and the CM stated she was not sure what an acceptable food temperature should be upon delivery.
Incomplete and inaccurate medication orders were found for two residents after record review and staff interviews. One resident’s Toujeo insulin glargine order listed conflicting clinical indications, with staff stating the order had been mistyped, and another resident’s hydroxyzine HCl PRN anxiety order omitted the dose even though the resident had previously been receiving 25 mg tablets.
A resident with chronic kidney disease, morbid obesity, mobility limitations, and multiple active wound care needs was discharged to a homeless shelter without the facility verifying the shelter’s ability to meet ADL and wound care requirements or documenting the receiving setting’s capacity to provide needed care. The resident required supervision/touching assistance for several ADLs and substantial/maximal assistance for bathing, and had documented MASD and a chronic leg ulcer with exposed subcutaneous tissue. The shelter later reported it could not support individuals over 400 lbs, could not provide wound care or mobility assistance, and had not been contacted in advance as required by its medically fragile program. The transport company was informed on arrival that the shelter could not accept the resident, notified the facility, and the resident remained outside the shelter until transported to the ER, while facility staff had believed the resident could perform her own wound care despite the DON stating she could not apply cream to her buttocks without assistance.
A resident with chronic kidney disease, peripheral venous insufficiency, and morbid obesity had an MDS assessment documenting a foot infection and an open foot lesion, but the electronic medical record lacked documentation of wound treatment and the comprehensive care plan did not include any interventions or directions for care of the foot wound. Facility policy and CMS SOM Appendix PP require a person-centered comprehensive care plan to be developed by the IDT within a specified timeframe after assessment, yet the MDS nurse confirmed there was no care plan addressing the foot infection, despite acknowledging that one was required.
A resident with chronic kidney disease, peripheral venous insufficiency, and morbid severe obesity had a comprehensive care plan that documented a desire to remain long term but was not updated to reflect changing discharge planning goals, despite policy and CMS requirements that care plans be revised with changing needs and preferences. The MDS nurse acknowledged that the discharge plan had changed multiple times and admitted she chose not to update the care plan, resulting in a care plan that did not reflect the resident’s current discharge planning needs.
Surveyors identified that an erythromycin ophthalmic ointment and a Trelegy Ellipta inhaler on a medication cart were not labeled with an open date or date of discard. An LPN confirmed uncertainty about the duration of use for the ointment and acknowledged that both medications should have been labeled appropriately.
Surveyors found that the facility did not maintain a pest-free environment, with flies observed throughout the building, full and unemptied fly traps, and several pest control devices unplugged or non-functional. Residents reported being unable to effectively use fly swatters and expressed concern about flies, especially in the dining area. Staff and maintenance practices were inconsistent, and pest control service documentation was incomplete.
The facility did not procure food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
Deficiencies were identified in infection control practices, including unsanitary conditions in a shower room with missing grout and visible mold, as well as improper technique during medication administration when an LPN placed injection supplies directly on a sink ledge without a sanitary barrier.
A resident with complex medical and psychiatric conditions was provided THC gummies by two dietary aides after making a joking request. The facility's investigation confirmed the aides' actions through staff interviews, but failed to thoroughly question other residents about the specific incident or drug-related concerns, resulting in an incomplete investigation.
A resident with multiple mental health diagnoses and a documented PASRR Level II was inaccurately coded on the MDS assessment as not having a serious mental illness or intellectual disability. This error was confirmed by facility leadership during the survey.
The facility did not ensure that PASRR Level I screenings accurately documented mental health diagnoses or initiate required Level II evaluations for three residents with conditions such as depression, anxiety, and major depressive disorder. Staff confirmed that screenings were incomplete and referrals to the state-designated authority were not made as required.
The facility did not accurately post daily nurse staffing information, omitting the number of hours worked per shift for RNs, LPNs, and CNAs. This was confirmed by observation and staff interview, with the Staffing Coordinator acknowledging that required hours were not included in the daily postings.
Three residents experienced significant medication errors when an LPN failed to administer or document scheduled doses of morphine, oxycodone, and sliding scale insulin. The errors occurred due to staff oversight and workload, resulting in missed pain and diabetes medications for residents with chronic pain, osteoarthritis, osteoporosis, and type 2 diabetes.
Two CNAs did not have documentation of completing the required 12 hours of annual in-service education, including training in dementia care and abuse prevention. Facility leadership confirmed the absence of these records during the survey.
A resident with multiple sclerosis and Alzheimer's disease suffered fractures after falling from her bed due to staff failing to follow her care plan. The care plan required total assistance for transfers and specific interventions like fall mats and a low bed position. However, the bed was not in the lowest position, and the fall mat was missing, leading to the fall. The facility's investigation found that the CNAs involved did not provide honest or accurate reports and failed to adhere to the care plan.
The facility did not have a registered nurse (RN) on-site for 8 consecutive hours a day, 7 days a week, as required by their policy. This was discovered during a review of the nursing schedule, which showed that on five days, no RN was present for the required duration. The Director of Nursing (DON) was unaware of the need for an RN to be physically on-site, believing that being on-call was sufficient. This oversight potentially affected all 33 residents by leaving their nursing needs unmet.
The facility failed to provide clean equipment for resident care, with observations revealing dusty and soiled Hoyer lifts and mobile blood pressure machines. A CNA acknowledged the presence of dust and dirt, cleaning the equipment upon inspection. The DON confirmed that nursing staff are responsible for cleaning these items after each use.
The facility failed to provide a dignified dining experience for three residents, who were not served their meals or beverages promptly. Despite requests, a resident received a warm Pepsi without ice, which was later rectified by another resident and the Staffing Coordinator. The DON acknowledged staffing issues during mealtime.
A facility failed to provide necessary records during the transfer of a resident with multiple health issues, including diabetes and congestive heart failure, to a hospital. Despite a policy requiring specific information to be sent, there was no documentation of what records were provided. A nursing note indicated a report was given to EMTs and the receiving nurse, but the Clinical Resource Nurse could not find documentation of the records sent.
A resident with moderate persistent asthma was not instructed to rinse her mouth after using a fluticasone propionate inhaler, as observed during a medication pass by an LPN. The physician's order lacked this instruction, which was confirmed by the Clinical Resource Nurse and a pharmacist, creating a potential risk for a mouth infection.
A resident with chronic kidney disease and morbid obesity had a care plan requiring daily weight monitoring and physician notification for significant weight gain. The facility only recorded monthly weights, missing significant increases, and did not notify the physician. The DON considered the care plan a PRN order, leading to non-compliance with the care plan.
The facility failed to conduct necessary AIMS evaluations for two residents on antipsychotic medications, as required every six months. One resident, with schizoaffective disorder, had no AIMS assessments after September 2023, despite being on Depakote and Zyprexa. Another resident, also with schizoaffective disorder, had no assessments after July 2023, while on Zyprexa. This oversight created a potential for harm due to unmonitored adverse side effects.
Unqualified Culinary Manager Overseeing Food and Nutrition Services
Penalty
Summary
The facility failed to ensure the designated Culinary Manager met the required professional qualifications for overseeing food and nutrition services. The SOM, Appendix PP, stated that when a qualified dietician or other clinically qualified nutrition professional is not employed full-time, the facility must designate a director of food and nutrition services who meets specified qualifications, including certification or education and experience requirements. The facility’s Culinary Manager position description also required ServSafe Food Safety Certification and one of several additional credentials, such as a Certified Dietary Manager, Certified Food Protection Professional, Dietetic Technician, Registered, or certification with the American Culinary Federation. During interview, the Culinary Manager stated she had worked at the facility since August 2025 and was overseen by the facility’s RD, who worked one day per week. Documentation of the Culinary Manager’s certification was requested, but no certification was provided on multiple occasions. When asked about her background, the Culinary Manager stated she had two years of experience as a cook and one year of experience as a kitchen manager at a boarding school. The CEO later confirmed the Culinary Manager did not have the required qualifications and was in the process of getting certified.
Kitchen sanitation, food safety, and temperature monitoring failures
Penalty
Summary
The facility failed to keep the kitchen cooking hood clean. On 7/10/26 at 9:43 AM, the gray kitchen cooking hood vent was observed with a layer of brown particles on the outside of the hood vent. When asked about the kitchen cleaning schedule, the CM stated kitchen staff were to clean vents once per week, and when asked about the cooking hood vent, the CM stated she did not think the kitchen staff realized that it was also considered a vent. The facility failed to ensure food items were free from mold. On 7/10/26 at 9:16 AM, a box labeled cantaloupe was observed on a lower wire rack shelf in the dry storage area. Three cantaloupes were in the box, and one had a large oblong white fuzzy substance on it that was in contact with the other two cantaloupes. When asked about fruit ordering and inspection, the CM stated fruit was received every two weeks and inspected when staff went to use it. The CM identified the cantaloupe as bad, stated it had been ordered on 6/25/26, and removed the box from storage. The CM also stated the cantaloupe was white and moldy and should have been pulled on 6/30/26. The facility failed to prevent contamination risks related to staff practices and food safety monitoring. On 7/7/26 at 8:22 AM, a McDonald's cup containing a dark liquid was observed in the kitchen freezer, and [NAME] #1 stated the cup was theirs. The CM later stated personal drinks should not be kept in the freezer. On 7/9/26, [NAME] #2 was observed washing his hands for four seconds during tray line preparation at multiple times, and later had a cream, off-white substance stuck to the back of his right arm that was not washed off before serving food. The CM stated employees should be vigorously washing their hands for 20 seconds. The facility also failed to record required food and refrigerator temperatures. Food Temperature Logs for May 2026 through July 2026 showed missing food temperatures for multiple meals, including 5/17/26 dinner, 5/22/26 lunch, 5/23/26 breakfast, lunch, and dinner, 5/26/26 dinner, and 6/15/26 dinner. The CM stated puree food temperatures were recorded under minced and moist and that she did not catch that temperatures were not being done. The activities refrigerator temperature log for June 2026 was missing temperatures for 6/27/26 through 6/30/26, and the log had freezer sections crossed out even though ice cream bars were stored in the freezer. The AD stated he only checked refrigerator temperatures, did not check freezer temperatures, was the only staff member checking temperatures on weekdays, and temperatures were not checked on Saturdays and Sundays. On 7/9/26, the activities refrigerator was observed with condensation, black buildup on the lower shelf, and a thermometer reading above the safe line at 51 degrees; the AD later confirmed the refrigerator was at 42 degrees and stated it would not be appropriate to use anything in the refrigerator.
QAPI Monitoring Deficiencies for Skin Assessments and Food Sanitation
Penalty
Summary
The facility failed to ensure good faith efforts were made to implement and monitor performance improvement activities related to skin assessments and food sanitation. Based on the facility's QAPI Committee policy, QAPI Plan, and staff interview, the committee was expected to identify performance improvement opportunities through tracking and trending of data and to monitor progress toward goals by comparing results to benchmarks and historical performance. During interview, the CEO stated the facility had three performance improvement plans. He reported that PIP #1 addressed incomplete skin assessments and was initiated on 3/30/26 and completed the following week on 4/6/26, but it remained active because the facility did not want to fall off track. He also stated PIP #1 did not include documented benchmark measurements, although percentages were used. For PIP #2, which addressed food labeling issues in the snack room and was initiated on 5/2/26, he stated benchmark measurement was documented as improved, but percentages were not used. He stated PIP #3 was complete and no longer in place, but did not provide additional information about it. He further stated the current method used to measure performance improvement plans did not adequately track whether improvement had occurred since the date of implementation.
Failure to Obtain Informed Consent for Psychotropic and PRN Medication
Penalty
Summary
The facility failed to ensure that residents were informed in advance of the care and treatment to be furnished, including the risks and benefits of treatment, for 1 of 5 residents reviewed for informed consent. Resident #23 was admitted with multiple diagnoses including COPD, anxiety, and PTSD, and the record showed physician orders for Seroquel ER 200 mg at bedtime for schizoaffective disorder and bipolar disorder, Seroquel 100 mg daily for bipolar disorder, and lorazepam 0.5 mL by mouth every 4 hours as needed for palliative care related to COPD. A review of the record found no documentation that Resident #23 or the resident's representative were informed of the risks and benefits or provided consent for the initiation of Seroquel and lorazepam. On 7/10/26 at 10:42 AM, the CRN and CNO confirmed that Resident #23 did not have signed consents for Seroquel or lorazepam.
Call Light Out of Reach
Penalty
Summary
The facility failed to ensure Resident #38’s call light was within reach. Resident #38 was admitted with diagnoses including acute cystitis with hematuria, diabetes, and cirrhosis of the liver. On 7/10/26 at 9:14 AM, while three surveyors were passing by the resident’s room, Resident #38 asked one of them to call a staff member. The resident was sitting in a chair with a front wheel walker in front of her, and when asked where the call light was, she pointed to it hanging on the wall out of reach. Resident #38 stated she had been assisted to her room by staff after breakfast and had been sitting in the chair for a while. Later that morning, RN #1 and CNA #1 entered the room after being informed by the surveyor that the resident needed assistance. CNA #1 stated the resident was unable to reach her call light, which was on the other side of the bed, and acknowledged that it should have been within the resident’s reach.
Advance Directive Not Maintained in Resident Record
Penalty
Summary
The facility failed to ensure that a copy of a resident's advance directive was maintained in the medical record for Resident #32, who was admitted with multiple diagnoses including dementia, muscle weakness, and protein-calorie malnutrition. The resident's care plan, revised 5/12/22, documented that the resident and appointed healthcare representative were to receive education regarding advance directives as needed, and a care conference evaluation dated 6/26/26 documented that the resident had an advance directive in the record. However, on 7/8/26, review of the medical record did not locate a living will or durable power of attorney for health care, and the CNO later confirmed that the record did not include an advance directive and the facility did not have a living will on file.
Inappropriate Indication for PRN Lorazepam
Penalty
Summary
The facility failed to ensure medications were administered with an appropriate clinical indication for Resident #23, who was admitted with diagnoses including COPD, anxiety, and PTSD. The resident’s care plan, revised 5/27/26, directed staff to give medications as ordered by the physician. Physician orders showed lorazepam 2 mg/mL, 0.5 mL by mouth every 4 hours as needed, ordered for palliative care related to COPD and initiated on 6/29/26. During review on 7/9/26 at 2:45 PM, the CNO reviewed the lorazepam order and stated the indication should be shortness of breath or anxiety.
Failure to Report Alleged Misappropriation
Penalty
Summary
The facility failed to ensure an allegation of misappropriation was reported to the State Agency as required for Resident #23, who was admitted with diagnoses including COPD, anxiety, and PTSD. Resident #23 stated that approximately two months before the survey, he reported $1,600.00 missing to the Social Services Director and believed another resident had taken the money. He reported that the SSD asked how long ago it happened, and when he said about one and a half months earlier, he was told it had been too long ago to investigate. During the survey, the SSD did not respond to a call for interview, the CNO stated she recalled a family member mentioning the missing funds but did not ask further questions, and the CNO said the allegation was never made directly to her or facility staff. The CEO stated the allegation should have been reported to the State Agency.
Failure to Investigate Allegation of Misappropriation
Penalty
Summary
The facility failed to ensure an allegation of misappropriation was investigated as required for Resident #23, who was admitted with diagnoses including COPD, anxiety, and PTSD. Resident #23 stated that approximately two months earlier he reported $1,600.00 missing to the SSD and told the SSD he believed another resident had taken the money. He reported that when he explained the incident had occurred about one and a half months earlier, the SSD told him it had been too long ago to investigate. Review of the facility grievance records from February 2026 through June 2026 showed no documented allegation of misappropriation involving Resident #23, and review of the Long-Term Care Reporting Portal showed no report of misappropriation involving him. The CNO stated she recalled a family member mentioning Resident #23's missing funds but did not ask further questions, and the CEO stated the allegation should have been reported and investigated for potential misappropriation.
Failure to Provide Written Discharge Notice
Penalty
Summary
The facility failed to ensure that a written notice of discharge was provided to Resident #37, who was discharged from the facility. The facility’s policy required written notice of transfer or discharge to the resident, the resident’s representative, and the Office of the State Long-Term Care Ombudsman, and required the notice to include the reason for discharge, the effective date, the destination, and ombudsman contact information. Resident #37 was admitted with diagnoses including other chronic osteomyelitis, paraplegia, and chronic pain syndrome, and an admission MDS documented that he was cognitively intact. The Notice of Discharge or Transfer form in the resident’s record was dated 5/21/26, but there was no resident signature in the verification of receipt section. Instead, the form stated that Resident #37 left the facility against medical advice (AMA) and included the initials of the SSD and CNO. The CEO stated the SSD was responsible for discharges and transfers and that the facility had obtained a current address for Resident #37, but did not know whether he received written notice. The SSD stated that Resident #37 did not receive a copy of the notice because he left the facility and did not return, and there was no address to mail it to him.
Failure to Offload Heels as Directed
Penalty
Summary
Resident #32, who was admitted with diagnoses including dementia, muscle weakness, and protein-calorie malnutrition, had a care plan revised on 6/18/21 directing staff to offload his heels or use Prevalon boots when he was in bed, as he allowed. During observation on 7/9/26 at 11:22 AM, Resident #32 was found in bed without Prevalon boots in place. At 11:23 AM, an LPN stated the resident should have had his boots on, then lifted the blanket and observed the resident's legs resting on a pillow. When asked whether the resident's heels were offloaded, the LPN stated they were not and confirmed they should have been offloaded.
Medication Administration Not Performed According to Standards
Penalty
Summary
The facility failed to ensure medications were administered according to professional standards of practice for Resident #30 and Resident #9. Resident #30, who was admitted with diagnoses including dementia, anxiety, and adult failure to thrive, was observed with redness to the lower abdomen and under the breasts. CNA #2 stated she assisted with keeping the areas clean twice daily, and later stated she cleansed the affected areas with warm soapy water and patted them dry before the nurse applied powder. However, the resident’s skin evaluation documented redness to the abdominal folds and under the breasts with treatment in place, while the physician orders and MAR/TAR contained no orders for skin treatment to those areas. LPN #2 later stated Gold Bond powder was being applied and acknowledged there was no active order for it. Resident #9, who had diagnoses including unspecified glaucoma, hypertension, and prostate cancer, had physician orders for Brimonidine Tartrate ophthalmic solution one drop in both eyes three times daily and Dorzolamide HCL ophthalmic solution one drop in both eyes two times daily. During observation, an LPN handed the resident a tissue, administered the eye drops, and the resident rubbed both eyes with the tissue after each administration. The LPN told the resident not to rub his eyes, but was not heard instructing him to close his eye gently, encourage gentle eye movement, blot excess medication, or press a finger between the eye and the top of the nose after administration. The LPN later stated she told the resident to dab his eyes and not rub them, but did not educate him on the importance of not rubbing his eyes after the eye drops were given.
Failure to Implement Podiatry Orders and Document Refusal
Penalty
Summary
The facility failed to ensure podiatry treatment orders and care plan interventions were implemented as written for Resident #32, who was admitted with diagnoses including dementia, muscle weakness, and protein-calorie malnutrition. The resident’s care plan, initiated on 4/11/24, directed staff to provide podiatry evaluation and treatment as needed. On 7/9/26, an LPN observed that the resident’s toenails needed trimming and described them as chunky, yellow, and irregular, and later stated the resident was on the podiatry list to be seen every three months. A review of the resident’s podiatry visit dated 5/19/26 documented a physician order for ammonium lactate 12% cream to be applied to bilateral feet and callused skin as needed for 180 days, but the resident’s physician orders from 05/01/26 through 07/09/26 contained no order for ammonium lactate. The CNO stated on 7/10/26 that when the ammonium lactate order was received, the resident was asked if he wanted the treatment and he said no, and that the provider notification of the refusal and the resident’s refusal were not documented in the medical record.
Failure to Monitor Catheter-Associated UTI Signs
Penalty
Summary
The facility failed to ensure proper monitoring was conducted to identify potential catheter-associated urinary tract infections for Resident #32, who was admitted and later readmitted with diagnoses including dementia, muscle weakness, and protein-calorie malnutrition. A physician order dated 2/14/25 directed staff to monitor, record, and report signs and symptoms of catheter-associated urinary tract infection, including pain, burning, blood-tinged urine, cloudiness, no output, deepening urine color, increased pulse, increased temperature, urinary frequency, foul-smelling urine, fever, chills, altered mental status, changes in behavior, or changes in eating patterns. Resident #32 was observed with white, milky urine in the catheter tubing flowing into the catheter bag on 7/7/26, 7/8/26, and 7/9/26. The MAR for 7/1/26 through 7/10/26 documented "No" for completion of the physician order to monitor, record, and report signs and symptoms of catheter-associated urinary tract infection. On 7/10/26 at 10:29 AM, the CNO stated she would not document a change when the urine appeared milky white because this was the resident's baseline, said the monitoring order was not appropriate because cloudiness would be normal for him, and confirmed the record did not include documentation of physician notification regarding urine changes.
Oxygen Concentrator Left in Room After Order Discontinued
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not maintained when the facility failed to remove an oxygen concentrator from Resident #12's room after the physician discontinued the oxygen order. Resident #12 was admitted and later readmitted to the facility with diagnoses including morbid obesity with alveolar hypoventilation and diabetes. On 7/7/26, the resident was observed sitting in his power chair with an oxygen concentrator at his bedside. When asked about oxygen use, the resident stated he only used oxygen when he needed it. Review of the resident's physician orders showed no current oxygen order, and the CNO stated on 7/8/26 that the oxygen concentrator should not have been in the room because oxygen had been discontinued on 6/17/26.
Unclear Clinical Indication for PRN Morphine Order
Penalty
Summary
The facility failed to ensure medications were administered with an appropriate clinical indication for one resident reviewed for unnecessary medications. Resident #23 was admitted with multiple diagnoses including COPD, anxiety, and PTSD. The resident’s care plan, revised 3/2/26, stated to give medications as ordered by the physician. The physician orders included Morphine Sulfate 20 mg/mL, 0.25 mL by mouth every 6 hours as needed for severe pain related to COPD, initiated on 7/7/26. During interview on 7/9/26 at 2:45 PM, the CNO stated she did not know what the appropriate indication for the morphine order should be.
Food Served at Unacceptable Temperatures
Penalty
Summary
Food was not served at palatable temperatures for Resident #31, who was admitted with multiple diagnoses including diabetes, gastroesophageal reflux, and chronic kidney disease. During an interview, the resident stated that hot food is always cold, that she generally eats in the dining room, and that most of the time this is a problem. She also stated that she normally does not ask for her food to be reheated because cold food is normal in the facility. On a later observation, a breakfast tray was requested from the kitchen and delivered by the CM, and the food temperatures were documented as French toast at 84 F, eggs at 93 F, sausage at 79 F, and apple juice at 51 F. When the temperatures were reviewed, the CM stated she was not sure what an acceptable food temperature should be upon delivery.
Incomplete and inaccurate medication orders in resident records
Penalty
Summary
The facility failed to ensure a physician order was clarified for its clinical indication and medication dosage, resulting in inaccurate documentation in the resident medical record. The deficiency was identified through record review and staff interviews and involved 2 of 2 residents reviewed. The facility’s documentation policy stated that the resident medical record should be accurate, objective, and clinically relevant. One resident was admitted and readmitted with diagnoses including morbid obesity with alveolar hypoventilation and diabetes. A physician order listed Toujeo SoloStar insulin glargine 300 units/ml as 120 units subcutaneously one time a day related to morbid obesity with alveolar hypoventilation, and also listed Toujeo SoloStar insulin glargine 300 units/ml as 120 units subcutaneously at bedtime related to type 2 diabetes. During interview, the CRN stated the evening dose was for diabetes and the morning dose was for obesity, then later stated the insulin glargine order should have been for diabetes and not obesity and had been mistyped by the nurse. Another resident was admitted and readmitted with diagnoses including quadriplegia, depression, and anxiety disorder. That resident’s MAR showed an order for hydroxyzine HCl every 8 hours as needed for anxiety, but the order did not include a dose. The CNO confirmed the dose was missing and stated the resident had previously been receiving hydroxyzine 25 mg tablets and the person entering the order did not catch the 25 mg.
Failure to Assess and Coordinate Safe Discharge to Homeless Shelter
Penalty
Summary
The deficiency involves the facility’s failure to consider the availability, capacity, and capability of a caregiver/support setting to meet a resident’s care needs prior to discharge. The facility’s policy required that information necessary to meet a resident’s needs be provided upon transfer, but for one resident with chronic kidney disease, morbid obesity (BMI >70), muscle weakness, difficulty walking, anxiety/adjustment disorders, and multiple active wound care orders, this did not occur. A Discharge MDS documented the resident was cognitively intact but required supervision/touching assistance for eating, hygiene, dressing, toileting, and footwear, and substantial/maximal assistance for bathing. The TAR and wound care note showed ongoing wound care needs, including a chronic ulcer with exposed subcutaneous tissue and MASD requiring topical treatment, and documented that refusal of care and garments could lead to unhealable wounds, sepsis, and death. The discharge evaluation noted a follow-up medical appointment but the record lacked a referral to a wound care clinic, documentation that the receiving setting could meet ADL or wound care needs, and a signed discharge plan. The resident was discharged to a homeless shelter without prior contact from the facility to verify the shelter’s ability to meet her care needs. The homeless shelter’s case manager reported their cots could not support individuals over 400 lbs and that they could not provide wound care or mobility assistance, and confirmed the facility had not contacted them before dropping off the resident. The shelter’s medically fragile program requirements specified that individuals must be independent with ADLs, that LTC facilities must provide advance notification to verify bed availability and care capability, and that an in-person assessment is required prior to acceptance. Transportation records showed the resident was offloaded at the shelter, which then informed the driver they could not accept her; the transport company left a message for the facility and later informed the facility that the shelter could not accept the resident, but the facility did not request the resident be returned. The resident remained outside the shelter until transported to the ER. The Social Services Director stated she did not notify the shelter because it was a homeless shelter and did not refer the resident to a wound clinic because she believed the resident could perform her own care, while the DON stated the resident could not apply cream to bilateral buttocks without assistance. Cross-references were made to F656 and F657.
Failure to Develop Comprehensive Care Plan for Foot Infection
Penalty
Summary
Surveyors found that the facility failed to ensure a resident-centered, comprehensive care plan was written to address an identified foot infection and open foot lesion. CMS SOM Appendix PP requires each resident to have a person-centered comprehensive care plan that addresses medical, physical, mental, and psychosocial needs, and the facility’s RAI & Comprehensive Care Plans policy requires the IDT to develop such a plan within 7 days of completing the comprehensive assessment. Resident #1, who had multiple diagnoses including chronic kidney disease, peripheral venous insufficiency, and morbid obesity, had a Quarterly MDS assessment documenting an infection of the foot and another open lesion on the foot. Despite this, the resident’s electronic medical record did not contain documentation indicating treatment for wounds, and the care plan initiated and later revised did not include any directions for care of the foot wound or infection. During interview, the MDS nurse confirmed that the resident did not have a care plan for the foot infection and acknowledged that there should have been one. This deficient practice was cited for 1 of 3 residents whose care plans were reviewed and was noted by surveyors as creating the risk of adverse outcomes if comprehensive care plans did not reflect the necessary care for each resident.
Failure to Update Care Plan for Changing Discharge Planning Needs
Penalty
Summary
The facility failed to ensure a resident’s comprehensive care plan was revised to reflect current discharge planning needs and goals as required by CMS SOM Appendix PP and the facility’s RAI & Comprehensive Care Plans Policy and Procedure. The policy, revised on 9/3/25, required that the care plan reflect discharge planning goals, and CMS guidance required review and revision of the care plan after each assessment based on changing goals, preferences, and needs. Resident #1, initially admitted and later readmitted with multiple diagnoses including chronic kidney disease, peripheral venous insufficiency, and morbid severe obesity, had a care plan initiated on 3/1/24 and revised on 9/29/25 that documented the resident wanted to stay at the facility long term. However, the care plan was not updated to include current discharge planning that reflected the resident’s evolving goals, preferences, and care needs. During an interview on 2/3/25 at 2:00 PM, the MDS Nurse acknowledged that there was no updated care plan reflecting discharge planning and stated that because the resident’s discharge plan kept changing, she chose not to update the care plan. This deficient practice created the risk of adverse outcomes if care and services were not provided due to care plans not being revised as residents’ needs changed.
Medications Not Properly Labeled or Dated on Medication Cart
Penalty
Summary
During a medication cart inspection, surveyors found that certain medications available for residents were not labeled or dated as required. Specifically, an erythromycin ophthalmic ointment and a Trelegy Ellipta inhaler were discovered without an open date or date of discard. When interviewed, an LPN stated she was unsure how long the ophthalmic ointment was good for and acknowledged that both medications should have been labeled with the open date. This issue was identified on one of two medication carts inspected.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain a pest-free environment and implement an effective pest control program, as evidenced by multiple observations of flies throughout the building and inadequate maintenance of pest control devices. Surveyors observed full fly traps hanging outside the facility, fly swatters in most resident rooms, and flies landing on residents' food in the dining room. Several pest control devices, such as air curtains and insect catchers, were found unplugged, turned off, or non-functional, with some traps full and not emptied for several weeks. The Director of Maintenance confirmed that some devices had not been operational for an extended period and that exterior fly traps had not been emptied in 6-8 weeks. Documentation of pest control services was incomplete, with no record for one of the months reviewed. Residents reported being offered fly swatters, but many were unable to use them effectively and expressed concern about the presence of flies, particularly in the dining area. During a Resident Council meeting, residents indicated they were unaware of the facility's pest control measures and noted that outdoor fly traps appeared full. Staff were observed entering and exiting the facility without ensuring air curtains were functioning, further contributing to the pest issue. The deficiency was identified through direct observation, record review, and interviews with residents and staff.
Failure to Follow Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Infection Control Deficiencies in Shower Room Sanitation and Medication Administration
Penalty
Summary
The facility failed to implement effective infection control practices in two key areas: shower room sanitation and medication administration. During an inspection of a shower room with the Director of Maintenance, it was observed that the shower floor lacked grout between the tiles, creating uneven and potentially unsanitary conditions. Black mold-like substances were visible along the bottom edges of the shower walls, and an adhesive trim on the lower portion of the shower walls was peeling away, with additional black mold-like material found underneath. The Director of Maintenance confirmed the lack of grouting contributed to the unsanitary environment. Additionally, the CEO stated there was no log of who was responsible for cleaning the shower rooms, although they should be cleaned daily. During a medication administration observation, an LPN was seen preparing a subcutaneous injection. After performing hand hygiene and gathering supplies, the LPN placed the injectable pen and alcohol wipes directly on the sink ledge without using a sanitary barrier. She then washed and dried her hands, applied gloves, and administered the injection. The LPN later acknowledged that a paper towel should have been used as a barrier instead of placing the supplies directly on the sink. These actions demonstrate lapses in infection control protocols during both environmental cleaning and direct resident care.
Incomplete Investigation of Abuse Allegation Involving Psychoactive Substance
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of abuse involving a resident with multiple diagnoses, including schizophrenia, auditory hallucinations, and chronic pain syndrome. The incident involved two dietary aides who provided the resident with THC gummies on two separate occasions after the resident had jokingly requested them. The facility's investigation included interviews with the involved resident and two unidentified dietary staff, both of whom confirmed the aides' actions. Additionally, three other residents were interviewed, but they were only asked general safety questions and not specifically about the incident or drug-related concerns. The investigation substantiated the allegation, as evidenced by the termination of the two dietary aides. However, the investigative process was incomplete because resident interviews did not address the specific incident or related drug concerns, limiting the scope and thoroughness of the inquiry. This incomplete approach created the potential for undetected harm due to the lack of comprehensive investigative procedures.
Inaccurate MDS Coding for PASRR Status
Penalty
Summary
The facility failed to ensure the accuracy of a resident's Minimum Data Set (MDS) assessment, specifically in Section A1500 regarding PASRR (Preadmission Screening and Resident Review) status. A resident admitted with diagnoses including major depressive disorder, anxiety disorder, and alcohol dependence had a PASRR Level II documented in the electronic medical record. However, the admission MDS assessment incorrectly indicated that the resident was not considered by the state Level II PASRR process to have a serious mental illness or intellectual disability. This inaccuracy was confirmed by the Director of Clinical Services, who acknowledged the MDS was coded incorrectly. The deficiency was identified through review of the RAI Manual, record review, and staff interview, and was found to be true for one of three residents whose records were reviewed for assessment accuracy.
Failure to Complete Accurate PASRR Screenings and Referrals for Mental Health Diagnoses
Penalty
Summary
The facility failed to refer residents with diagnosed mental disorders to the appropriate state-designated authority for evaluation and determination, as required by PASRR (Preadmission Screening and Resident Review) regulations. For three residents reviewed, the facility did not ensure that PASRR Level I screenings accurately reflected their mental health diagnoses, nor did they initiate PASRR Level II evaluations when indicated. Specifically, one resident with multiple sclerosis, Alzheimer’s disease, and depression was admitted without a PASRR Level II, and their Level I screening did not document the depressive disorder despite the use of an antidepressant. Another resident with quadriplegia, depression, and anxiety was admitted and readmitted without a PASRR Level II, and their Level I screening omitted documentation of depression and anxiety. Additionally, a third resident with major depressive disorder, anxiety disorder, and alcohol dependence had a Level I screening that only noted mild or situational depression, omitting the major depression and anxiety diagnoses. Staff interviews confirmed that the PASRR Level I screenings were incomplete or inaccurate and that Level II evaluations were not completed when required. The Social Services Director acknowledged that the screenings should have included all relevant diagnoses and that Level II evaluations were necessary but not performed. These findings were based on record reviews and staff interviews, demonstrating a pattern of failure to properly identify and refer residents with mental health needs for appropriate evaluation.
Failure to Accurately Post Daily Nurse Staffing Hours
Penalty
Summary
The facility failed to ensure that nurse staffing information was accurately posted each day, specifically omitting the number of hours worked per shift for registered nurses, licensed practical nurses, and certified nursing assistants. Observations conducted from 8/4/25 through 8/6/25 revealed that the daily postings did not include the required hours for each shift. During an interview on 8/6/25, the Staffing Coordinator confirmed that the hours worked for nursing staff were not posted as required for the number of covered positions on the daily staff postings.
Failure to Prevent Significant Medication Errors
Penalty
Summary
The facility failed to prevent significant medication errors for three residents, as evidenced by missed or undocumented administration of prescribed medications. One resident with chronic pain and a history of left hip joint absence and shoulder deformity did not receive a scheduled dose of morphine sulfate because the LPN forgot to retrieve the medication while assisting another resident. Documentation indicated the resident was alert and able to verbalize pain, and the error was discovered during a narcotic count at the end of the shift. Another resident with back pain, osteoarthritis, and osteoporosis did not receive a scheduled dose of oxycodone due to the LPN being overwhelmed by the number of residents waiting for medication. The resident's pain level increased during this period, and the incident was documented as a medication error. A third resident with type 2 diabetes and morbid obesity did not have documentation of receiving prescribed sliding scale insulin after a blood sugar reading that required administration. Review of the Medication Administration Record confirmed the absence of documentation for the insulin dose. In all three cases, the medication errors were attributed to staff oversight or workload, and the facility's policy on medication errors was not followed as required.
Failure to Provide Required Annual In-Service Education for CNAs
Penalty
Summary
The facility failed to provide the required minimum of 12 hours of in-service education per year for two of three Certified Nursing Assistants (CNAs) reviewed for sufficient and competent staffing. Record reviews showed that both CNAs had been employed at the facility for over 12 months, but their training records did not document completion of the required annual in-service hours for the evaluation period. During staff interviews, facility leadership confirmed that they were unable to produce any records showing that these CNAs had completed the mandated training for the specified period. This lack of documented in-service education included essential topics such as dementia care and abuse prevention, as required for CNA competency. The absence of these records was identified during the review of staff files and confirmed by the CEO during the survey process.
Failure to Follow Care Plan Results in Resident Fall and Injury
Penalty
Summary
The facility failed to ensure a resident's care plan was followed to prevent falls, resulting in harm to the resident. The resident, who had multiple sclerosis and Alzheimer's disease, required total assistance for transfers with two staff and a mechanical lift, as documented in her care plan. Additionally, interventions such as using fall mats and keeping the bed in the lowest position were specified. However, on the day of the incident, the resident fell from her bed, resulting in fractures to her right lower leg. The facility's investigation revealed that the bed was not in the lowest position, and the fall mat was not in place at the time of the fall. The incident occurred when CNA #1 and #2 were involved in transferring the resident. After placing a sling under the resident, CNA #1 lowered the bed and left the room to retrieve the mechanical lift and CNA #2. Upon returning, they found the resident had rolled over the bolster and fallen to the floor. The facility later determined that the reports provided by the CNAs were not honest or accurate, and they did not follow the resident's care plan, leading to the fall and subsequent injury.
Failure to Ensure RN On-Site 8 Hours Daily
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on-site for 8 consecutive hours a day, 7 days a week, as required by their policy. This deficiency was identified during a review of the nursing schedule for a three-week period, where it was found that on five specific days, there was no RN present for the required duration. The Director of Nursing (DON) admitted to being unaware of the requirement for an RN to be physically on-site and believed that being on-call was sufficient. This oversight had the potential to affect all 33 residents in the facility by leaving their routine and emergency nursing needs unmet.
Deficiency in Equipment Cleanliness
Penalty
Summary
The facility failed to ensure that residents were provided with clean equipment for obtaining vital signs and performing transfers, which could potentially lead to psychosocial harm. Observations made on two separate occasions revealed that two Hoyer lifts were visibly dusty, with a clear dried brown substance on their bases and thick white or gray material, resembling hairs, wrapped around the wheels. Additionally, the control wand for electric lifting on one of the Hoyer lifts was smeared with a light brown substance. Three mobile blood pressure machines were also found to be noticeably dusty on their reading screens, tops, legs, and bases, with one blood pressure cuff smeared with a light brown substance. During an interview, a CNA stated that he cleans the mobile blood pressure machines after each resident use, focusing on parts that touch the resident, such as the blood pressure cuff. However, he acknowledged the presence of dust and dirt on the machines and proceeded to clean them with a disinfectant wipe. The CNA also identified the material on the Hoyer lift wheels as hairs and removed them. The DON confirmed that nursing staff are responsible for cleaning the mobile blood pressure machines and Hoyer lifts after each use, indicating a lapse in adherence to the facility's cleaning protocols.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to treat residents with respect and dignity during mealtime, as observed on August 19, 2024. Three residents were affected by this deficiency. Resident #24 was seated alone at a table in the back corner, while Residents #26 and #29 were seated at the end of the main table with two other residents. Despite the facility's Dining Policy, which emphasizes a pleasant dining atmosphere and adequate staffing, these residents were not served their meals or beverages promptly. The meal service began at 12:25 PM, but by 12:31 PM, the tray cart was removed without serving these residents. Resident #26 requested a cold Pepsi three times between 12:35 PM and 12:41 PM, but CNA #3, who was assisting another resident, deferred the request. Eventually, the Staffing Coordinator brought a warm can of Pepsi at 12:41 PM, which was opened by Resident #29. The Staffing Coordinator returned with a cup of ice at 12:46 PM and poured the Pepsi for Resident #26. The meal trays for Residents #24, #26, and #29 were finally served at 12:48 PM. The Director of Nursing (DON) acknowledged that sometimes there is insufficient staff to assist with meals, as staff may be redirected to pass out hall trays.
Failure to Provide Resident Records During Hospital Transfer
Penalty
Summary
The facility failed to ensure that necessary resident records were provided to the hospital upon the transfer of a resident, identified as Resident #16. This deficiency was identified through a review of records, policies, and staff interviews. According to the facility's Transfer and Discharge policy, specific information should be provided to the receiving provider, including contact information for the resident's practitioner, resident representative information, advanced directive information, special instructions for ongoing care, the resident's comprehensive care plan goals, and all information necessary to meet the resident's needs. However, there was no documentation indicating what records were sent to the hospital when Resident #16 was transferred. Resident #16, who had multiple diagnoses including diabetes, legal blindness, congestive heart failure, and chronic respiratory failure with hypoxia, was transferred to the emergency room after being found hard to arouse. A nursing progress note documented that a report was given to the EMT and the nurse at the receiving facility, but there was no documentation of the specific records sent. The Clinical Resource Nurse confirmed the absence of documentation and noted that a checklist should have been used to document what was sent, but it was not found.
Failure to Instruct Resident on Proper Medication Administration
Penalty
Summary
The facility failed to ensure medication was administered according to professional standards of practice for one resident. During an observation of medication administration, a resident with a diagnosis of moderate persistent asthma was given fluticasone propionate inhalation without being instructed to rinse her mouth afterward. This omission was noted during a medication pass by an LPN, who did not provide the resident with instructions to rinse and spit after using the inhaler. The Clinical Resource Nurse confirmed that the physician's order for the medication did not include instructions to rinse and spit, which should have been included. Additionally, a pharmacist confirmed that residents should be instructed to rinse their mouths after taking fluticasone propionate to prevent mouth infections. The lack of proper instruction created the potential for the resident to develop a yeast infection.
Failure to Follow Care Plan for Weight Monitoring
Penalty
Summary
The facility failed to adhere to professional standards of practice for a resident with chronic kidney disease and morbid obesity. The resident's care plan required staff to monitor and report specific signs and symptoms, including a weight gain of over 2 pounds per day, to the physician. However, the resident's weight was only recorded monthly, showing significant increases of 13.2 pounds from June to July and 10.4 pounds from July to August. There was no documentation that the physician was notified of these weight gains, nor was there evidence that daily weight checks were conducted to monitor for a 2-pound daily increase as directed by the care plan. During an interview, the Director of Nursing (DON) indicated that the care plan was considered a PRN order, to be activated only if there was a problem, and confirmed that the resident was not weighed daily. An email from the Administrator further clarified that the checks were to be performed when the patient exhibited general signs of illness or clinical changes, which would then trigger further assessment. This approach led to a failure in following the care plan as directed, creating a potential for harm to the resident.
Failure to Conduct AIMS Evaluations for Residents on Antipsychotic Medications
Penalty
Summary
The facility failed to ensure that residents taking antipsychotic medications received the necessary Abnormal Involuntary Movement Scale (AIMS) evaluations, as recommended by the American Psychiatric Association. This deficiency was identified for two residents who were reviewed for unnecessary medications. Resident #5, who was admitted with multiple diagnoses including schizoaffective disorder, was prescribed Depakote and Zyprexa. Although his care plan required AIMS evaluations every six months, the last documented assessment was in September 2023, with no evaluations conducted in March 2024. Clinical Resource Nurse #1 confirmed the absence of the required assessments. Similarly, Resident #16, also diagnosed with schizoaffective disorder, was prescribed Zyprexa. His care plan also mandated AIMS evaluations every six months. However, the last recorded AIMS assessment was in July 2023, with no subsequent evaluations in January and July 2024. Clinical Resource Nurse #1 was unable to locate any AIMS assessments for Resident #16 after July 2023. The lack of these evaluations created a potential for harm as residents were not monitored for adverse side effects of antipsychotic medications.
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Illustrative
What surveyors actually found near you
We read the 208 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Emmett
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| River's Edge Rehabilitation & Living Center | 1.3 mi | ★★★★★ | 13 | 0 |
| Caldwell Care Of Cascadia | 18.2 mi | ★★★★★ | 18 | 0 |
| Canyon West Of Cascadia | 18.9 mi | ★★★★★ | 13 | 0 |
| Creekside Transitional Care And Rehabilitation | 20.1 mi | ★★★★★ | 0 | 0 |
| Karcher Post Acute | 20.8 mi | ★★★★★ | 23 | 0 |
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