Below average — CMS composite of the measures below.
The next survey window likely opens around May 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 Royal Plaza Health And Rehabilitation Of Cascadia during CMS and state inspections, most recent first.
Food safety and sanitation deficiencies were observed in the meal service area and resident freezer storage. A DM donned gloves and handled hot food and temperature checks without washing hands between tasks, physical therapy ice was stored with food ice packs, ice cubes were placed directly on resident juice cup lids, and the handwashing sink contained dirty dishes, a reusable cup, and lacked towels, a trash can, and employee handwashing signage.
Incomplete discharge transfer documentation: The facility failed to send complete hospital transfer paperwork for three residents during emergent transfers. Missing items included resident transfer forms, face sheets, care plan goals, physician H&Ps, advance directives, TARs, family/advocate notifications, verbal report with transport staff, and bed-hold notices. The CNO stated the checklist is used to show what was sent, but documents appeared to be missing for two residents, and the facility could not verify all required items were included for another resident.
Arbitration Agreement Missing Convenient Venue Requirement: The facility's arbitration agreement did not include a venue selection that was convenient to both parties, as required by CMS SOM Appendix PP and the federal regulation reviewed by surveyors. The deficiency applied to all residents who had signed an arbitration agreement, and the Administrator acknowledged that the agreement was missing this regulatory requirement.
Failure to offer a resident the opportunity to create an advance directive. Record review showed the resident had no advance directive on file, and the SS Director stated there was no documentation that education was provided or that any attempts were made to obtain one. The resident had HTN, CKD, and mild cognitive impairment.
A resident with dementia, HTN, and CKD was video recorded by one CNA while another CNA was present, and the recording showed the resident in the shower during a sensitive moment. The video was later shared with staff outside the resident’s privileged circle, and one CNA was seen laughing in the recording.
Incomplete care plans were identified for two residents. One resident with anemia, nutrition deficiency, anorexia, dementia, and depression had care plan interventions for nutrition decline, but the anemia diagnosis and related treatment interventions were not included. Another resident with PTSD, anxiety, depression, mood disorder, dementia, and Alzheimer’s disease had PTSD interventions listed, but the care plan did not identify specific PTSD triggers or the staff redirection/interventions needed to assist the resident.
Medication Administered Outside BP Parameters: A resident with HTN, chronic respiratory failure with hypoxia and hypercapnia, and a recent fracture had an order for Losartan 50 mg with hold parameters for low SBP/DBP. The MAR showed BP readings below parameter on multiple days, yet the medication was still given on several occasions despite the order to hold it.
Respiratory care was not provided as ordered for two residents. One resident with CHF, HTN, and pulmonary HTN had an order for continuous O2 at 2 LPM via NC, but the concentrator was set at 1 LPM when observed and confirmed by an RN. Another resident with CHF, COPD, and muscle weakness had an order for intermittent O2 via NC, but the NC was observed on the nightstand instead of being stored in a bag, as confirmed by an RN.
Expired liquid lorazepam was found in a medication cart during a surveyor review, and an RN acknowledged the medication was expired. The facility policy required expired or discontinued meds to be removed promptly and disposed of per policy and DEA guidelines, but the medication remained in storage for A resident.
Incomplete and inaccurate MAR documentation: A resident with CHF and bacteremia had duplicate statin orders transcribed to the MAR in error, with one statin listed as both held and administered on different shifts, and an IV Cefepime dose left unsigned on the MAR. The CNO verified the pharmacy delivery and dose counts, and stated the duplicate orders and blank MAR entry were documentation errors.
Hand hygiene and glove change practices were deficient when an RN performed a glucose finger stick on a resident with clean gloves, removed the dirty gloves, and put on clean gloves without performing hand hygiene. The resident had type 2 DM, HTN, and chronic pain syndrome. The IP stated hand hygiene should be performed when changing gloves and when moving from a dirty environment to a clean environment.
Failure to document pneumococcal vaccine offer and education for two residents. Two residents with multiple diagnoses, including PVD, DM2, vascular dementia, HTN, glaucoma, and CKD, had records showing refusal of the pneumococcal vaccine with no dates listed, but there was no documentation that they or their representatives were offered or educated on the risks and benefits. The IP stated she could not find the required documentation.
Surveyors found that kitchen equipment and food-contact surfaces were not properly cleaned or maintained, with visible accumulations of food debris and encrusted residue on ovens, grills, and dishwashing equipment. Food items served to residents were not held at safe temperatures, with several items below the required hot holding standard. Staff confirmed that cleaning routines were not followed due to short staffing, and the RDN acknowledged that food temperatures did not meet safety standards.
A resident with multiple chronic conditions and poor decision-making abilities did not receive prescribed bowel care medications for nine days despite clear physician orders. The medication administration record showed no administration of laxatives or other interventions during this period, and the DON confirmed that the protocol was not followed.
A resident with diabetes and hypertension was administered insulin Aspart on several occasions when her blood glucose was below the physician-ordered threshold, contrary to the prescribed instructions. The DON confirmed that insulin was given when it should have been held, resulting in a significant medication error.
The facility failed to address resident concerns as documented in Resident Council Meeting minutes and confirmed through interviews. Residents raised issues about staffing and call light response times, which were ongoing problems. The Activities Director did not document resolutions to these concerns, and the Administrator confirmed the absence of call light audits, indicating a failure to ensure issues were addressed.
A resident with multiple diagnoses, including quadriplegia, filed a grievance after a staff member turned off his call light and left without assisting him. The facility did not document any investigation or actions taken to address this grievance, as confirmed by the Administrator.
The facility failed to consistently calibrate glucometers in Oak Hall, Maple Hall, and the TCU, as required by the EvenCare Blood Glucose Monitoring System guidelines. The absence of a facility policy for glucometer calibration and missing logbooks contributed to this deficiency, as confirmed by staff interviews.
The facility failed to provide necessary medical information to the receiving hospital during the transfer of three residents, as required by regulations. The records lacked documentation of essential details such as the basis for transfer, practitioner contact information, and care plans. The CNO confirmed the absence of a hospital transfer policy and acknowledged the lack of documentation, which could potentially delay timely treatment.
The facility failed to notify the ombudsman of hospital transfers for three residents, including one with Alzheimer's and another with respiratory failure. The CNO and CEO confirmed the omission, which violated residents' rights to informed and safe transitions of care.
The facility failed to provide bed-hold notices to residents or their representatives during hospital transfers. This deficiency was identified for three residents, including one with Alzheimer's and another with respiratory failure, who were transferred without receiving the required notices. The CNO confirmed the lack of documentation for these notices, indicating a failure to comply with regulations.
A resident with multiple mental health diagnoses, including bipolar disorder and depression, was not referred for a required PASARR level II evaluation upon admission. The facility's initial PASARR level I screening failed to identify these conditions, and subsequent documentation was not forwarded to the appropriate authority. The Social Services Manager admitted the paperwork was incorrectly completed.
A resident's care plan for renal failure was not updated to reflect accurate monitoring, despite directives for staff to monitor for signs of hypo/hypervolemia. The MDS Coordinator acknowledged the error, as there were no physician's orders for kidney function monitoring, and the care plan was not revised after assessments.
Two residents in an LTC facility experienced medication administration errors. One resident received hydrocodone after the order was discontinued due to a failure to check the EMAR, while another was given Amoxicillin instead of Augmentin due to a transcription error in the facility's computer system. The CNO confirmed these errors and noted the need for proper medication management.
A resident with diabetes was administered 10 units of insulin Lispro on multiple occasions when their blood sugar was below the prescribed threshold of 360 mg/dl. The facility's MAR documented these errors, which were confirmed by the CNO, indicating a failure to follow the physician's order and potentially risking hypoglycemia.
Food Safety and Handwashing Sink Sanitation Deficiencies
Penalty
Summary
The facility failed to follow sanitary requirements for food safety in the meal serving area and resident freezer storage. On 6/25/26 at 11:55 AM, the Dietary Manager brought in the hot food cart and donned gloves without washing hands, then moved hot food into the steam table and began taking food temperatures without washing hands between tasks or before putting on gloves. The Dietitian and Dietary Manager later stated that hands should be washed between tasks and before donning gloves. The facility also stored and handled food items improperly in resident freezer storage and during meal service. On 6/22/26, physical therapy ice was stored in Freezer #2 alongside food ice packs, and the Dietitian stated that physical therapy ice should not be stored with food ice. On 6/25/26, ice cubes were observed placed directly on resident juice cup lids, and hospitality aides removed the ice before placing the cups on meal trays; the Dietitian and Dietary Manager stated the ice should not be stored directly on the lids. In addition, the handwashing sink in the meal dispensing area contained dirty dishes, had a reusable cup stored next to it, and lacked disposable towels, a trash can, and employee handwashing signage; the Dietitian and Dietary Manager stated the sink should not contain dirty dishes or be used for storage.
Incomplete discharge transfer documentation
Penalty
Summary
The facility failed to ensure residents and/or their representatives were provided with complete discharge information during emergent hospital transfers for 3 of 6 residents reviewed for hospital discharges. For Resident #4, who was readmitted with COPD, CHF, and depression, the facility initiated an emergent discharge/transfer to the hospital on 2/10/26, but the transfer packet did not include the Resident Transfer Form, face sheet with diagnosis, care plan goals, physician H&P, advance directives, or notification of the resident family/resident advocate. On 6/26/26, the Administrator brought in the packet of paperwork sent for Resident #4 and stated that it was everything the facility sent, but the facility could not provide documentation showing the missing items were included. For Resident #5, who was readmitted with CHF, respiratory failure with hypoxia, diabetes, kidney disease, and dementia, the facility initiated an emergent discharge/transfer on 3/12/26, but the paperwork sent to the receiving hospital did not include the Resident Transfer Form, TAR, care plan goals, physician H&P, advanced directives, or notification of the resident's family and/or advocate. For Resident #46, who was admitted with CHF, hypertension, and vascular disease, the facility initiated an emergent discharge/transfer on 6/23/26, but the hospital transfer paperwork did not include the Resident Transfer Form, face sheet with diagnosis, order summary with report, care plan goals, physician H&P, advanced directives, verbal report with transport staff, notification of the resident's family and/or advocate, or notices signed for transfer and bed hold. The record for Resident #46 contained a signed Resident's Notice of Transfer and Bed Hold, but it was not checked off on the Communication for Emergent Discharge/Transfer to Acute checklist. The CNO stated the checklist is used to prove the information was sent, but it appeared documents were not sent with Residents #5 and #46.
Arbitration Agreement Missing Convenient Venue Requirement
Penalty
Summary
The facility failed to ensure its arbitration agreement included the selection of a venue that is convenient to both parties, as required by CMS SOM Appendix PP and the federal regulation reviewed by surveyors. The deficiency applied to all residents in the facility who had signed an arbitration agreement. During the survey review, the Administrator stated on 6/24/26 at 4:15 PM that the arbitration agreement was missing the regulatory requirement for a convenient location of arbitration for both parties.
Failure to Offer Advance Directive Opportunity
Penalty
Summary
The facility failed to ensure residents were offered the opportunity to create an advance directive for Resident #13, who was re-admitted with multiple diagnoses including hypertension, chronic kidney disease, and mild cognitive impairment. Record review on 6/24/26 showed that Resident #13 did not have an advance directive on file. On 6/25/26 at 2:43 PM, the Social Service Director stated there was no documentation that education was provided to Resident #13 and no attempts were made to obtain an advance directive.
Resident Video Recorded During Sensitive Moment
Penalty
Summary
The facility failed to ensure a resident was free from abuse when a staff member video recorded Resident #63 during a sensitive moment in the shower and another staff member was present. The video, about seven seconds long, showed the resident standing fully clothed in the shower, holding the shower head and spraying water into the bathroom and adjoining room, while CNA #5 was visible laughing during the last couple seconds of the recording. The investigation identified CNA #10 as the person who recorded the video, and the video was later shown to the Administrator by a staff member from the neighboring Assisted Living unit. Resident #63 was admitted with multiple diagnoses including dementia with behavioral disturbances, hypertension, and chronic kidney disease. During the investigation, Resident #63 was interviewed but was unable to recall the incident. The state agency attempted to contact CNA #5 and CNA #10, but neither returned calls, and the facility could not provide the name or phone number of the Assisted Living staff member who presented the video for interview.
Incomplete Care Plans for Residents With Anemia and PTSD
Penalty
Summary
The facility failed to create a comprehensive care plan for 2 of 18 residents reviewed for care plan development. Resident #19 was admitted and readmitted with multiple diagnoses including anemia, nutrition deficiency, anorexia, dementia, and depression. A review of the care plan dated 1/7/26 showed interventions for nutrition decline, but it did not include treatment or interventions related to the resident’s diagnosis of unspecified anemia. On 6/25/26 at 3:01 PM, the CNO stated the anemia diagnosis and treatment interventions were not included in the care plan and should have been. Resident #9 was admitted with multiple diagnoses including PTSD, anxiety, depression, mood disorder, dementia, and Alzheimer’s disease. A review of the care plan dated 6/6/23 documented mood problems due to past trauma, depression, and anxiety, and included PTSD interventions, but did not address specific PTSD triggers or identify what interventions or redirections were needed by staff to assist the resident. On 6/25/26 at 3:09 PM, the CNO stated the care plan was not comprehensive and did not include specific PTSD triggers or education/redirection for staff, the resident, or the resident’s representative.
Medication Administered Outside Blood Pressure Parameters
Penalty
Summary
The facility failed to ensure quality care was provided related to medication administration for Resident #35, who was admitted following a fall with fracture and had diagnoses including chronic respiratory failure with hypoxia and hypercapnia and hypertension. The resident had a physician order dated 6/12/26 for Losartan Potassium 50 mg by mouth in the morning, with instructions to hold the medication for SBP less than 100 or DBP less than 60. The resident’s blood pressure records showed readings below those parameters on June 13, 14, 17, 18, 20, 21, 22, 23, 24, and 25, and the MAR documented that Losartan was administered on June 20, 22, and 23 despite the blood pressures being out of parameter. On 6/25/26, the CNO stated the doses on June 20, 22, and 23 should have been held and were administered in error.
Respiratory Care and Oxygen Storage Deficiencies
Penalty
Summary
The facility failed to ensure respiratory services were provided in accordance with professional standards of practice for two residents. One resident had diagnoses including congestive heart failure, hypertension, and pulmonary hypertension, and had a physician order for oxygen at 2 LPM continuously via nasal cannula through an oxygen concentrator. During observation, the resident was found with the nasal cannula in place while the oxygen was set at 1 LPM. An RN later verified the setting was 1 LPM and stated the resident’s oxygen should have been set at 2 LPM. Another resident, who had diagnoses including CHF, COPD, and muscle weakness, had a physician order for oxygen at 1-3 LPM intermittently via nasal cannula to maintain oxygen saturations above 88%, using an oxygen concentrator or tank with humidification. During observation, the resident was in bed with the nasal cannula placed directly on the nightstand. An RN confirmed the cannula was on the nightstand and stated it should have been stored in a bag.
Expired Medication Found in Medication Cart
Penalty
Summary
Expired medication was found in a medication storage area during a surveyor observation and cart review, and the facility failed to ensure it was removed and discarded in accordance with professional standards and facility policy. The facility policy titled Medication Storage and Labeling stated that medications must be stored and labeled in accordance with CMS regulations, state law, and acceptable professional principles, and that expired or discontinued medications must be removed promptly and disposed of per facility policy and DEA guidelines to prevent diversion. During the medication storage and cart review, the surveyor and RN #3 found a bottle of liquid lorazepam for Resident #2 that was dated with an expiration date. RN #3 acknowledged that the medication was expired and stated that it must be removed from the cart and discarded immediately.
Incomplete and inaccurate MAR documentation
Penalty
Summary
Resident #68’s medication record was incomplete and inaccurate. The resident was admitted with multiple diagnoses including CHF and bacteremia. The June 2026 MAR documented duplicate physician orders for Crestor 10 mg at bedtime and rosuvastatin calcium 10 mg at bedtime, both related to hyperlipidemia. The MAR showed Crestor signed as administered on June 20, 21, 22, 23, and 24, while rosuvastatin was signed as held due to duplicate therapy on June 20, 21, and 24, and signed as administered on June 22 and 23. The CNO verified that the pharmacy had delivered one card of rosuvastatin on 6/20/26 and that the card had 5 doses administered, indicating the resident had not received the same medication twice on June 22 and 23. The CNO stated the two same medication orders were transcribed to the MAR in error and that the MAR documented the medication twice in error on June 22 and 23. Resident #68’s June 2026 MAR also documented an order for Cefepime HCl 2 grams IV every 8 hours related to bacteremia for 30 administrations until finished. The MAR showed that the 9:00 PM dose on June 21 was not signed as administered and was left blank. The CNO verified the number of Cefepime doses delivered from the pharmacy and confirmed the correct number of doses had been administered based on the number of doses remaining. The CNO stated the nurse who administered the 9:00 PM dose on June 21 should have signed for it, and the MAR was left blank in error.
Hand Hygiene Not Performed During Glove Change
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when facility staff did not follow proper infection control practices and glove change protocols. Resident #6, who was re-admitted with multiple diagnoses including type 2 diabetes, hypertension, and chronic pain syndrome, was observed on 6/24/26 at 12:17 PM while RN #3 performed a glucose finger stick using clean gloves, then removed the dirty gloves and put on clean gloves without performing hand hygiene. The facility policy titled Hand Hygiene stated that hand hygiene should be performed at critical moments during resident care, including immediately before and after touching a resident, before moving from a soiled body site to a clean body site on the same resident, and after contact with objects or surfaces in the resident's environment. On 6/26/26 at 10:02 AM, the IP stated hand hygiene should be performed when changing gloves and when going from a dirty environment to a clean environment.
Failure to Document Pneumococcal Vaccine Offer and Education
Penalty
Summary
The facility failed to ensure pneumococcal immunizations were offered and/or provided as indicated for 2 of 5 residents reviewed for pneumococcal immunization. Resident #2 was re-admitted with diagnoses including peripheral vascular disease, diabetes type 2, and vascular dementia, and the record documented that the resident refused the pneumococcal vaccine, with no dates listed. The record did not include documentation that the resident and/or representative was offered or educated regarding the risks and benefits of pneumococcal vaccination. Resident #13 was admitted with diagnoses including HTN, glaucoma, and chronic kidney disease, and the record also documented refusal of the pneumococcal vaccine with no dates listed. There was no documentation that the resident and/or his representative was offered or educated regarding the risks and benefits of the pneumococcal vaccination. On 6/26/26 at 10:01 AM, the IP stated she was unable to find documentation that Resident #2 and Resident #13 were offered or educated about the risks and benefits of the pneumococcal vaccination.
Deficient Kitchen Sanitation and Food Temperature Control
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's kitchen related to cleanliness, maintenance, and food safety. The floor in the walk-in freezer had not been swept, with visible accumulations of onion peelings and other food debris. The convection oven doors and interior, two ovens, the flat top grill, and cooking skillets all had thick layers of dark or black encrusted residue. The dishwashing machine had a thick accumulation of dust and food particles on top, and a significant buildup of white lime or hard water deposits inside. Staff interviews confirmed that daily cleaning and sanitation routines had not been followed, reportedly due to short staffing. Additionally, food was not maintained at safe temperatures during service. When a test tray was plated and delivered, the milk was at 43°F, chicken cordon blue bites at 120°F, and green beans at 114°F, all below the required hot holding temperature of 135°F or above, except for the mashed potatoes and gravy at 145°F. The dining room steam table temperature log for the same meal showed much higher temperatures, indicating a discrepancy between recorded and actual food temperatures at the time of service. The RDN confirmed that the observed food temperatures did not meet food safety standards.
Failure to Administer Bowel Care Medications as Ordered
Penalty
Summary
The facility failed to follow professional standards of practice for bowel and bladder care for one resident with multiple diagnoses, including congestive heart failure, diabetes, and constipation. The resident had poor decision-making abilities and required cues and supervision. Physician orders specified a bowel care protocol involving Milk of Magnesia (MOM) after two days without a bowel movement, followed by a Dulcolax suppository if MOM was ineffective, and then a Fleets enema if needed, with physician notification if there was still no result. Despite these orders, the resident did not have a bowel movement for nine consecutive days, as documented in the bowel movement records. During this period, the medication administration record showed that no bowel care medications were administered. The Director of Nursing confirmed that the resident should have received MOM after two days without a bowel movement and that the physician should have been notified prior to a recent visit.
Failure to Hold Insulin per Physician Order
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors related to insulin administration. Record review showed that a resident with diabetes and hypertension was prescribed seven units of insulin Aspart subcutaneously before meals, with instructions to hold the dose if blood glucose was less than 140 mg/dl. Despite this order, documentation revealed that the resident was administered the insulin on multiple occasions when her blood glucose was below the specified threshold. The Director of Nursing confirmed that, according to the documentation, insulin was given when it should have been held.
Failure to Address Resident Concerns
Penalty
Summary
The facility failed to address resident concerns as documented in Resident Council Meeting minutes and confirmed through interviews with residents and staff. During a Resident Group interview attended by eight residents, concerns were raised about staffing issues and long call light response times, which were described as ongoing problems. The Resident Council minutes from May to October 2024 consistently documented various issues, including staffing continuity, inadequate training, inappropriate staff behavior, and unmet care needs such as unmade beds and unanswered call lights. However, there was no documentation of actions taken to resolve these concerns. The Activities Director, who has been in her role since August 2024, stated that residents' concerns were discussed during staff meetings and communicated to department heads, but she did not document the resolutions. The Administrator confirmed the absence of call light audits for the period in question. This lack of documentation and follow-up on resident concerns indicates a failure to ensure that issues raised by residents were addressed, potentially leading to ongoing frustration and unmet care needs.
Failure to Address Resident Grievance on Call Light Response
Penalty
Summary
The facility failed to ensure resident grievances were investigated and resolutions were documented, which placed all residents at risk of having unmet needs and poor quality of life. A review of the facility's grievances from May 2024 to October 2024 revealed an unresolved grievance involving a resident with multiple diagnoses, including sepsis, urinary tract infection, and quadriplegia. The grievance report, dated July 10, 2024, documented that the resident activated his call light, but a staff member entered the room, turned off the call light, and left without providing assistance. The report lacked documentation of any investigation or actions taken by the facility to address the resident's concerns. On November 8, 2024, the Administrator confirmed that the grievance related to the call light response was not addressed.
Glucometer Calibration Deficiency
Penalty
Summary
The facility failed to ensure the proper calibration of glucometers, which is essential for maintaining the accuracy of blood glucose readings. This deficiency was identified across three halls: Oak Hall, Maple Hall, and the Transitional Care Unit (TCU). The EvenCare Blood Glucose Monitoring System guidelines require control solution testing under specific conditions, including using the meter for the first time, using a new package of test strips, and at least once per week. However, the review of the facility's glucometer calibration logbooks revealed that calibration was not consistently performed for Oak Hall and Maple Hall from October to November 7, 2024. Additionally, the logbook for the TCU glucometer calibration was missing. Interviews with staff, including an RN and the CNO, confirmed the lack of consistent calibration and the absence of a facility policy for glucometer calibration.
Failure to Provide Necessary Medical Information During Resident Transfers
Penalty
Summary
The facility failed to ensure that necessary medical information was provided to the receiving hospital during the transfer of three residents, which is a requirement as per the State Operations Manual, Appendix PP. This deficiency was identified through record reviews and staff interviews. The records for three residents, who were transferred to the hospital on various dates, did not include documentation that medical information was provided to the hospital to ensure a safe and effective transition of care. Specifically, the records lacked documentation of the basis for the transfer, contact information of the responsible practitioner, resident representative information, advance directive information, special instructions for ongoing care, comprehensive care plans, and other necessary information. The Chief Nursing Officer (CNO) confirmed that the facility did not have a hospital transfer policy and acknowledged that the necessary documentation was not provided during the transfers of the residents. The CNO also confirmed that the facility had not been providing hospital paperwork when residents were transferred. This lack of documentation and communication had the potential to cause harm if residents were not treated in a timely manner due to the absence of critical information.
Failure to Notify Ombudsman of Resident Hospital Transfers
Penalty
Summary
The facility failed to provide transfer notices to the ombudsman for three residents who were transferred to the hospital. This deficiency was identified during a review of records and staff interviews. Resident #3, who had Alzheimer's disease and dementia, was transferred to the hospital on two occasions, but the facility did not notify the ombudsman of these transfers. Similarly, Resident #45, with diagnoses including respiratory failure, chronic obstructive pulmonary disease, and stroke, was transferred twice to the hospital without ombudsman notification. Additionally, Resident #51, who had right hemiplegia and hemiparesis following a stroke, was transferred to the emergency room due to critical lab results, but the ombudsman was not informed of this transfer. The Chief Nursing Officer (CNO) and Chief Executive Officer (CEO) confirmed that the facility had not been providing the required notifications to the ombudsman for hospital transfers, which is a violation of the residents' rights to be informed and to have a safe and effective transition of care.
Failure to Provide Bed-Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to provide bed-hold notices to residents or their representatives upon transfer to the hospital, as required. This deficiency was identified for three residents during a review of records and staff interviews. Resident #3, who was admitted with Alzheimer's disease and dementia, was transferred to the hospital on two occasions, but there was no documentation of a bed-hold notice being provided. Similarly, Resident #45, with diagnoses including respiratory failure, COPD, and stroke, was transferred twice without receiving a bed-hold notice. The Chief Nursing Officer (CNO) confirmed that the facility had not been providing the necessary bed-hold paperwork to residents or their representatives during hospital transfers. Resident #51, admitted with right hemiplegia and hemiparesis following a stroke, was transferred to the emergency room due to critical lab results indicating elevated blood sugar and low blood pressure. Despite the urgency of the situation, there was no documentation of a bed-hold notice being provided to her or her representative. The CNO was unable to find any record of a bed-hold notice for Resident #51, further confirming the facility's failure to comply with the requirement to inform residents or their representatives of their right to return to their former bed or room within a specified time frame.
Failure to Complete PASARR Level II Evaluation for Resident with Major Mental Illness
Penalty
Summary
The facility failed to refer a resident for further evaluation when diagnosed with a major mental illness, which is a requirement under the Pre-Admission Screening and Resident Review (PASARR) program. This deficiency was identified for a resident who was admitted with multiple diagnoses, including Parkinson's disease, bipolar disorder, major depressive disorder, anxiety disorder, and unspecified psychosis. Despite these diagnoses, the resident's pre-admission PASARR level I screening did not identify the major mental illnesses, and a PASARR level II evaluation was not completed as required. The resident's care plan indicated the use of various medications for mental health conditions, yet the necessary PASARR level II evaluation was overlooked. A subsequent facility PASARR level I screening later identified the resident's mental health conditions, but the documentation was not forwarded to the Bureau of Long Term Care. The Social Services Manager acknowledged that the resident should have had a PASARR level II completed, indicating that the preadmission screening and follow-up paperwork were filled out incorrectly.
Failure to Update Resident Care Plan for Kidney Monitoring
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised and updated, which was identified during a review of care plans for 18 residents. Specifically, the care plan for a resident with multiple diagnoses, including Parkinson's disease, kidney disease, and bipolar disorder, was not updated to reflect accurate monitoring for renal failure. The care plan, initiated in March 2024, included directives for staff to monitor for signs and symptoms of hypo/hypervolemia and other kidney-related issues. However, a review of the resident's treatment administrative record from 2023 through 2024 did not show evidence of such monitoring as ordered in the care plan. Further investigation revealed that there were no physician's orders on file directing staff to monitor kidney function, which the MDS Coordinator acknowledged might have been an error. The care plan interventions for kidney monitoring were selected before a doctor's order was placed, based on the admitting diagnoses. The Director of Nursing confirmed that the resident's record did not include the necessary monitoring related to the kidney interventions as directed by the care plan, and the care plan had not been updated after MDS quarterly or annual assessments.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to administer medication according to professional standards of practice for two residents, leading to medication errors. Resident #57, who had chronic kidney disease and a history of falling, received hydrocodone after the order for the medication had been discontinued. The error occurred because the nurse did not check the electronic medication administration record (EMAR) before administering the drug. The nurse realized the mistake only after attempting to document the administration in the EMAR, which showed the order had been discontinued. The Chief Nursing Officer (CNO) confirmed the error and noted that discontinued medications should be removed from the medication cart. Resident #55, with a diagnosis of a non-pressure chronic ulcer, was supposed to receive Augmentin for a venous stasis ulcer but was instead given Amoxicillin. The error was due to a transcription mistake when the nurse entered the medication order into the facility's computer system. The system did not recognize Augmentin, which appeared as Amoxicillin-Potassium Clavulanate, leading the nurse to select Amoxicillin. The CNO stated that the nurse should have sought clarification from another nurse or the Resident Care Manager (RCM) when the order was unclear.
Medication Error in Insulin Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of insulin. The resident, who was admitted with multiple diagnoses including diabetes, was prescribed 10 units of insulin Lispro to be administered as needed between meals when their blood sugar level exceeded 360 mg/dl. However, the Medication Administration Record (MAR) for October and November 2024 documented that the resident received 10 units of insulin Lispro on several occasions when their blood sugar was below the prescribed threshold of 360 mg/dl. These instances occurred on specific dates and times, with blood sugar levels recorded as low as 237 mg/dl. The Chief Nursing Officer (CNO) confirmed upon review that the insulin was administered incorrectly according to the physician's order, which could potentially lead to hypoglycemia for the resident.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 12 citations issued within 25 miles in the last 12 months — 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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lewiston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cascadia Of Lewiston | 0 mi | ★★★★★ | 5 | 0 |
| Lewiston Transitional Care Of Cascadia | 0.9 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Lewiston | 1.3 mi | ★★★★★ | 0 | 0 |
| Orchard View Post Acute | 1.4 mi | ★★★★★ | 0 | 0 |
| Idaho State Veterans Home - Lewiston | 1.4 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Royal Plaza Health And Rehabilitation Of Cascadia.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.