Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Washington Senior Living during CMS and state inspections, most recent first.
A facility failed to remove a CNA from resident contact after an abuse allegation was raised. An Activity Aide reported that a resident appeared fearful after a shower, said she was scared and thought someone was trying to kill her, and had bruising on her wrist/hand. The Activity Director notified the Administrator, who confirmed he knew the concern involved possible abuse, but the CNA continued working that afternoon/evening and was not suspended or removed from residents.
Failure to investigate possible abuse and a bruise of unknown origin: an activity aide reported that a resident said she was scared and thought someone was trying to kill her after a shower, and also noticed wrist bruising. The activity director notified the administrator because she believed it was a suspicion of abuse, but the administrator did not treat it as an abuse investigation, citing the resident’s usual fear after showers and wheelchair use. The resident’s care plan did not address shower-related fear or hand bruising risk, and the DON later documented a moderate dark purple wrist bruise with yellowish tints after the resident could not explain what happened.
Failure to report suspected abuse: An Activity Aide observed a resident after a shower, heard the resident say she was scared and thought someone was trying to kill her, and noted bruising on the wrist. The Activity Director said the resident appeared afraid of the CNA and notified the Administrator due to suspected abuse, but the Administrator confirmed the State Agency was not notified when the bruise was found or 5 days later.
The facility did not educate residents or staff on the grievance process, failed to provide grievance forms, and lacked a clear method for submitting grievances. Multiple residents reported missing personal items but were unaware of how to file a grievance, and staff did not advise them to do so. The Social Services Director and Activities Director were not trained on grievance procedures, and there was no public location for grievance forms or a grievance box.
A resident with severe cognitive impairment and multiple chronic conditions developed unexplained discoloration, swelling, and pain in a lower extremity. The LPN on duty notified hospice and the ADON but did not promptly inform the resident's POA, resulting in the POA learning of the injury from hospice instead of the facility. This delay in notification was contrary to facility policy requiring immediate communication of significant changes in condition to the resident's representative.
Staff engaged in verbal and physical altercations in resident areas, with multiple residents and staff reporting discomfort and unprofessional conduct. The incident, which occurred in a hallway where residents reside, involved two CNAs with prior disciplinary issues and resulted in a failure to provide a respectful and dignified environment for all residents.
Two residents were involved in an altercation where one kicked the other multiple times, resulting in pain and no follow-up assessment or investigation by the facility. Staff failed to communicate the incident to key personnel, and no protective measures or behavioral interventions were implemented, despite ongoing concerns about aggressive behavior. This lack of action and documentation affected all residents in the facility.
Two residents were involved in an altercation where one kicked the other multiple times, resulting in pain and no subsequent assessment or follow-up by nursing staff. The facility did not notify the residents' physicians or representatives, nor did they document the incident or initiate an immediate investigation, contrary to facility policy.
A resident with a history of aggressive behavior physically abused another resident in the dining room after becoming agitated, resulting in the victim experiencing pain in her knees. Despite facility policy requiring immediate protection and follow-up, staff did not assess or follow up with the injured resident after the incident.
Two residents were involved in an altercation where one kicked the other, causing pain to the recipient who had pre-existing knee issues. Although a CNA witnessed and reported the incident to the administrator, there was no immediate investigation or timely report to the State Agency as required by facility policy. The administrator only interviewed one resident and delayed reporting the incident, resulting in a deficiency related to abuse reporting and investigation protocols.
Staff failed to immediately report a resident's allegations of misappropriation of funds and sexual abuse to the administrator and State Agency as required. CNAs did not report the resident's claim of missing money, and the DON delayed reporting the sexual abuse allegation for over 12 hours. The resident was sent to the ED for evaluation, and documentation showed no timely reporting of either incident.
A resident reported to a CNA that a staff member took her money to buy food and did not return with the money or food. The CNA did not report the allegation, and the Administrator confirmed that no investigation was conducted. Review of records showed no evidence that the allegation of misappropriation of funds was investigated.
A CNA performed a mechanical lift transfer of a resident with significant mobility impairments without the required second staff member, resulting in the lift tipping over and the resident needing to be lowered to the floor with assistance from an LPN. Facility policy mandated two-person assistance for all mechanical lift transfers, but this was not followed during the incident.
A resident alleged that an agency CNA ripped off his brief and left him naked in bed. The DON reported the allegation to the administrator, who treated it as a customer service issue and did not notify the State Agency or conduct an abuse investigation, contrary to facility policy.
A resident with incontinence and a stage three pressure ulcer reported that a CNA became upset, forcefully removed the resident's brief, and left the resident naked in bed. The incident was reported to the DON and then to the Administrator, who treated it as a customer service issue rather than a potential abuse allegation, failing to initiate the required abuse investigation as outlined in facility policy.
A facility failed to investigate an abuse allegation involving a resident with Alzheimer's disease, who reported inappropriate touching by a male caregiver. The facility did not suspend or interview the only male CNA employed, despite policy requirements to remove alleged perpetrators from resident contact pending investigation. The administrator admitted to forgetting about the male CNA's employment, and the CNA continued working after the allegation was reported.
The facility failed to maintain daily sanitation during outbreaks of respiratory and gastrointestinal viruses, affecting all 76 residents. Insufficient housekeeping staff led to unclean rooms and inadequate sanitizing, despite the facility's protocols requiring daily cleaning, especially during outbreaks. Residents reported having to clean their own spaces, and the DON acknowledged the ongoing issue with cleanliness.
A cognitively impaired, high fall risk resident was neglected by an LPN who failed to document multiple falls or provide necessary care. The resident was left on a cold floor without a mattress or blankets, despite being care planned to have a mattress beside the bed. The facility's policies on abuse prevention and fall protocol were not followed, resulting in the resident experiencing neglect.
The facility failed to maintain a routine cleaning schedule for the kitchen, with no cleaning check-off sheets for staff. Observations revealed food boxes on the freezer floor, no sanitization logs for the dishwasher, and no temperature logs for the freezer, cooler, or refrigerator. Bread lacked expiration dates, and the kitchen steamer/oven and floors were unclean. The Dietary Manager acknowledged these issues, which could affect all 73 residents, except one who is NPO.
The facility failed to implement procedures to reduce Legionella risk in its water system, affecting 73 residents. The Maintenance Director lacked documentation and knowledge of Legionella procedures, only checking water temperatures weekly. The Infection Preventionist did not manage a Legionella water plan. The facility's policy requires a water management program, risk assessments, and documentation maintenance.
The facility failed to document COVID-19 vaccinations, screening, offering, or education for staff, potentially affecting all 73 residents. The Infection Preventionist was unable to provide documentation or confirm staff vaccination status, admitting to not having screened, educated, or offered the vaccine to staff.
The facility failed to conduct thorough fall investigations for three residents, resulting in incomplete documentation and lack of interventions to prevent future falls. The DON acknowledged missing details due to inadequate charting by agency nurses, who were difficult to contact post-shift. Residents with various medical conditions experienced multiple falls, with investigations lacking root cause analysis and necessary preventive measures.
The facility failed to make survey results from the past five years accessible to residents, as required by regulations. During a resident council meeting, several residents were unaware of their right to review these results. An investigation found no survey results available, and staff were unable to locate the survey binder. This deficiency affects all 73 residents in the facility.
The facility failed to document or provide written notification to residents or their representatives about the reasons for emergent hospital transfers or discharges, as required by their policy. This oversight affects all 73 residents, as it disrupts continuity of care and violates residents' rights. The administrator admitted to the lack of documentation, citing recent changes and an inability to find the necessary paperwork.
The facility did not provide Bed Hold Policy notifications to residents or their representatives during hospital transfers, as required by their policy. The administrator acknowledged the oversight, citing recent changes and missing paperwork, potentially affecting all 73 residents.
The facility failed to post complete nurse staffing information daily, omitting total nursing hours worked and not retaining 18 months of postings. The administrator confirmed the absence of total hours on the form, and the HR Director was unaware of the requirement to include this information. This deficiency potentially affects all 73 residents in the facility.
A facility failed to protect residents from abuse, resulting in two incidents. One resident with a history of aggression injured another by slamming a door on her hand, causing severe injuries. Another incident involved inappropriate touching between residents, but the investigation found insufficient evidence of abuse. The facility's policies on abuse prevention were not effectively implemented.
The facility failed to ensure CNAs completed required in-service training, including dementia management and abuse prevention. The DON could not provide proof of training completion for the past six months, and recent sessions lacked attendance records for all CNAs. This oversight potentially affects all 61 residents, especially those with cognitive impairments.
A resident with dementia, known to wander, was repeatedly injured by another aggressive resident in an LTC facility. Despite the facility's Abuse Prevention Program, no increased supervision or care plan updates were implemented after the first incident, leading to a second injury. Staff acknowledged the challenges in monitoring the resident but failed to take necessary protective measures.
A facility failed to report a resident-to-resident abuse incident where one resident entered another's room, resulting in verbal aggression and physical harm when the door was slammed on the intruding resident's hand. Despite the facility's policy requiring immediate reporting of such incidents, this event was not documented or reported to the State Agency, as confirmed by the corporate administrator.
The facility failed to investigate a potential abuse incident between two residents, where one resident was injured after the other slammed a door on their hand. Despite the facility's policy requiring an investigation, no action was taken by the staff or administration, with the incident being dismissed as typical aggressive behavior by one of the residents.
A facility failed to provide a resident with a copy of the bed hold policy upon their transfer to the hospital. The facility's policies indicate that bed hold and readmission rights should be maintained, but the resident's clinical record lacked documentation of written notice of the bed hold policy. The DON confirmed the omission.
The facility failed to serve food at a palatable temperature, affecting all 68 residents. Food temperatures were not consistently taken or documented, and meals were often served cold, as reported by residents and staff. On the day of the survey, cheese pizza was served at inadequate temperatures without reheating, and unheated carts were used for room trays. The administrator acknowledged the failure to adhere to temperature-taking policies.
Failure to Remove Accused CNA From Resident Contact
Penalty
Summary
The facility failed to remove a staff member from resident contact after an allegation of abuse was raised. The facility’s Abuse Prevention Program stated that employees accused of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property are to be removed from resident contact immediately and not permitted to return until the investigation is reviewed by the administrator and the allegation is determined to be unsubstantiated. On 4/27/2026, an Activity Aide observed a resident sitting in the hallway after receiving a shower from a CNA and heard the resident say she was scared and thought someone was trying to kill her. The Activity Aide also noted bruising on the resident’s wrist and reported concerns to the Activity Director, who notified the Administrator because she believed the report reflected a suspicion of abuse. The Administrator later confirmed he was aware the Activity Aide was alleging the resident was overly scared of the CNA and had concerns about a bruise to the resident’s hand, but the CNA continued to work that afternoon and evening while the Administrator was investigating and was never suspended or removed from contact with residents.
Failure to Investigate Possible Abuse and Bruise of Unknown Origin
Penalty
Summary
The facility failed to recognize an incident as an allegation of abuse and failed to thoroughly investigate a bruise of unknown origin for one resident. The facility’s Abuse Prevention Program stated that suspicious bruises or other abnormalities of unknown origin must be reported, documented, and assessed, and that an appointed investigator must gather facts, interview relevant individuals, and determine whether the injury should be classified as an injury of unknown source. In this case, an activity aide reported that after a shower a resident said she was scared and thought someone was trying to kill her, and the aide also noticed bruising on the resident’s wrist and brought the concern to the activity director, who notified the administrator because she felt the concern was a suspicion of abuse. The administrator stated he did not treat the incident as an abuse investigation because the resident was often fearful and upset after showers due to her cognition and because she propelled her own wheelchair, suggesting she may have injured herself. However, the resident’s care plan did not include information that she was always fearful with showers and did not address any risk for bruising to her hands. The resident’s wrist bruise was not documented before the DON noted it the next day as a moderate-sized dark purple bruise with yellowish tints and no open areas, and the resident was unable to verbalize what happened. The DON confirmed she first learned of the bruise on that date and had not previously assessed or documented bruising on the resident.
Failure to Report Suspected Abuse
Penalty
Summary
The facility failed to report an allegation of abuse to the State Reporting Agency and the resident’s family for one resident. The facility’s Abuse Prevention Program stated that staff are responsible for reporting suspicious bruises, lacerations, or other abnormalities of unknown origin, completing a full assessment, and that the administrator or designee must notify the State Survey Agency immediately by telephone or fax when an allegation of abuse, neglect, exploitation, mistreatment, or misappropriation of property is made. On 4/27/2026, an Activity Aide saw the resident sitting in the hallway after a shower from a CNA and heard the resident say she was scared and thought someone was trying to kill her. The Activity Aide also noted bruising on the resident’s wrist and reported her concern to the Activity Director, who stated the resident seemed afraid of the CNA and immediately notified the Administrator because she felt the concern represented a suspicion of abuse. The Administrator later confirmed that he did not notify the State Agency when the bruise was discovered or 5 days later.
Failure to Educate Residents and Staff on Grievance Process and Provide Accessible Grievance Submission
Penalty
Summary
The facility failed to educate residents on what constitutes a grievance, did not provide grievance forms, and lacked a clear and accessible method for residents to submit grievances. Multiple residents reported missing personal clothing items but were unaware of what a grievance was or how to file one. Staff members, including laundry aides, the Housekeeping/Laundry Supervisor, the Social Services Director, and the Activities Director, also demonstrated a lack of knowledge regarding the grievance process and did not advise residents to file grievances. The facility's grievance policy was not effectively communicated or implemented, and there was no visible location for residents to obtain or submit grievance forms. Resident Council meeting minutes and interviews with residents and staff confirmed that residents frequently experienced missing personal items and voiced their concerns to staff, but these concerns were not addressed through a formal grievance process. The Social Services Director, who was supposed to oversee grievances, had not been trained on the process and did not have access to grievance forms. The Administrator confirmed that there was no public location for grievance forms or a grievance box, and staff were instructed to direct all concerns to the Administrator rather than following a formal grievance procedure.
Failure to Promptly Notify Family of Resident Injury
Penalty
Summary
The facility failed to promptly notify a resident's family or legal representative of a significant change in the resident's condition, as required by facility policy. The incident involved a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease, diabetes with chronic kidney disease, and generalized anxiety disorder. Staff discovered discoloration, swelling, and pain in the resident's left lower extremity, with no record of a fall. The nurse on duty reported the injury to hospice and the Assistant Director of Nursing but did not notify the resident's Power of Attorney (POA) until several hours later. The facility's policy specifies that the resident's legal representative should be promptly informed of such changes, and documentation should be made in the nurse's notes. The delay in notification was confirmed through interviews and record review. The POA expressed dissatisfaction upon learning of the injury from hospice rather than directly from the facility. The nurse involved stated she was accustomed to a different protocol from another state, where hospice would notify the POA, but was informed by the Director of Nursing that this was not the correct procedure at this facility. The failure to promptly notify the resident's representative of the injury constituted a deficiency in following the facility's established policy for communication regarding changes in resident condition.
Failure to Maintain Resident Dignity Due to Staff Altercation
Penalty
Summary
The facility failed to maintain an environment free from inappropriate staff behavior, specifically failing to provide respect and dignity for residents. Documentation and interviews revealed that certified nursing assistants (CNAs) engaged in verbal arguments in resident areas, with multiple residents and staff reporting that such incidents were observed and created discomfort. Resident council meeting minutes and concern forms documented ongoing issues with staff approach and professionalism, and residents reported feeling uncomfortable due to staff arguing and unprofessional conduct. On a specific occasion, two CNAs were involved in a physical altercation in a hallway where residents reside. Video evidence and staff interviews confirmed that one CNA approached another in an assigned area, leading to a verbal argument that escalated when one CNA pushed the other. The altercation was witnessed by residents and staff, and both CNAs had prior disciplinary records for attendance and conduct issues. The incident occurred in a public area of the facility, directly impacting the environment experienced by residents. The facility's own policies and job descriptions require staff to treat residents and each other with respect and dignity, and to maintain a safe, homelike environment. Despite these requirements, the documented staff conflict and lack of effective intervention prior to the altercation resulted in a failure to uphold residents' rights to a dignified existence and a respectful environment. The deficiency had the potential to affect all residents in the facility.
Failure to Investigate and Protect Residents After Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation into an alleged abuse incident involving two residents. According to the facility's own Abuse Prevention Program Policy, all reports and allegations of abuse must be promptly and aggressively investigated, with immediate protection for the residents involved. However, after an altercation in the dining room where one resident kicked another multiple times in the knees, the administrator only interviewed the resident who reported being kicked and did not initiate a full investigation or provide an investigation report. No assessment or follow-up was conducted to check for injuries or offer pain management to the resident who was kicked. Multiple staff interviews revealed that the incident was not communicated to key personnel, including the DON, and was not discussed in staff meetings. The CNA who witnessed the altercation reported it to the administrator, but no further action was taken to separate the residents or evaluate the aggressor for behavioral interventions. Other staff and residents described ongoing behavioral issues with the resident who committed the kicking, including frequent yelling and aggressive behavior, but these concerns were not addressed or documented in care planning or meetings. The facility's failure to follow its abuse investigation policy and to protect residents from further potential abuse affected not only the two residents directly involved but also had the potential to impact all 79 residents in the facility. The lack of documentation, communication, and follow-up after the incident demonstrates a breakdown in the facility's systems for identifying, investigating, and responding to abuse allegations as required by policy.
Failure to Notify Physicians and Representatives After Resident-to-Resident Abuse
Penalty
Summary
The facility failed to notify the physicians and representatives of two residents involved in an abuse incident, as required by policy and regulation. An altercation occurred in the dining room where one resident, who was alert, oriented, and serving as Resident Council President, was kicked multiple times in the knees by another resident using a wheelchair. The affected resident reported pain in the knees for several days following the incident and stated that no nursing staff assessed or followed up regarding the injury. There was no documentation in either resident's medical records, care plans, or nursing notes regarding the incident or any notifications to their physicians or representatives. Interviews with facility staff, including the Administrator and DON, revealed that no investigation was initiated immediately after the incident, and the event was not reported to the local State Agency until several days later. The Administrator acknowledged not investigating or reporting the incident initially, and the DON was unaware of the event, indicating a lack of communication and follow-up. The facility's policies require prompt investigation and notification in cases of abuse, but these procedures were not followed in this instance.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A resident with a history of dementia, aggressive behavior, and other psychiatric and mobility issues (R2) physically abused another resident (R1) in the dining room. R2, whose care plan noted a risk for psychosocial problems, physical aggression, and behavioral outbursts, became agitated when attempting to maneuver his wheelchair through a crowded area. After R1 suggested an alternative route, R2 began yelling and kicked R1 several times in the knees, causing pain due to R1's pre-existing knee problems. Staff were alerted by the commotion and separated the residents, but the incident was not followed up with an assessment of R1's injuries or further communication with R1 regarding the event. The facility's Abuse Prevention Program Policy requires immediate protection of residents involved in abuse, prompt investigation, and ongoing monitoring of residents with increased vulnerability. Despite these policies, R1 reported that no one followed up to check on her or her injuries after the incident, and there was no documentation of an assessment or intervention for R1 post-incident. The event was reported to the state agency, but the lack of immediate and appropriate response to R1's needs following the altercation constituted a failure to protect the resident from abuse as required by facility policy.
Failure to Timely Report and Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of abuse to the local State Agency for two of four residents reviewed for abuse. According to the facility's Abuse Prevention Program Policy, all allegations or suspicions of abuse must be immediately reported to the administrator and the State Agency, and a thorough investigation must be conducted and documented. In this incident, one resident reported being kicked several times on the knees by another resident during an altercation in the dining room, which caused pain due to pre-existing knee problems. The altercation was witnessed by a CNA, who separated the residents and reported the incident to the administrator. Despite being informed of the incident, the administrator did not conduct a full investigation or report the event to the State Agency as required by policy. Only the resident who reported being kicked was interviewed, and no further follow-up or assessment of injuries was performed. The initial report to the State Agency was delayed, occurring several days after the incident rather than immediately as mandated. This failure to promptly report and investigate the abuse allegation resulted in noncompliance with both facility policy and regulatory requirements.
Failure to Immediately Report Allegations of Abuse and Misappropriation
Penalty
Summary
The facility failed to immediately report allegations of misappropriation of funds and sexual abuse involving a resident to the State Agency and the facility administrator, as required by policy. Certified Nursing Assistants (CNAs) were informed by a resident that a staff member had taken money to purchase food but did not return with the food or the money. Both CNAs did not report this allegation to the administrator or a nurse. Additionally, the resident later reported to an LPN that the administrator had engaged in inappropriate sexual behavior. The LPN immediately notified the administrator and the Director of Nursing (DON) of the allegation. Despite the facility's policy requiring immediate reporting of such allegations, the DON did not report the sexual abuse allegation to the State Agency until over 12 hours after being informed. There was also no evidence that the misappropriation of funds allegation was reported to the administrator or the State Agency. The resident was sent to the emergency department for evaluation following the sexual abuse allegation. Documentation review confirmed the lack of timely reporting for both incidents.
Failure to Investigate Alleged Misappropriation of Resident Funds
Penalty
Summary
The facility failed to investigate an allegation of abuse involving one resident who reported to a CNA that a staff member took her money to purchase food but did not return with either the money or the food. The resident was unable to identify or describe the staff member involved. The CNA did not report the allegation to a nurse or the Administrator. Upon interview, the Administrator confirmed that no investigation had been conducted regarding the resident's allegation of misappropriation of funds. Review of the facility's Abuse Prevention Program policy and the resident's electronic medical record showed no documentation or evidence that the allegation was investigated.
Failure to Ensure Two-Person Assist During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) performed a mechanical lift transfer of a resident without the required assistance of a second staff member, contrary to facility policy. The resident, who had diagnoses including Multiple Sclerosis, muscle wasting and atrophy, encephalopathy, and neuromuscular dysfunction of the bladder, was dependent for transfers and required a two-person assist for mechanical lift use. During the transfer, the CNA attempted to maneuver the resident into a high back reclining wheelchair alone, resulting in a change in the resident's center of gravity and causing the mechanical lift to tip over. The CNA called for help, and an LPN responded to assist in safely lowering the resident to the floor. The resident was cognitively intact but had significant functional impairments, including limited use of one upper extremity and both lower extremities, and was at risk for falls due to deconditioning and Multiple Sclerosis. The facility's policies clearly stated that two staff members were required for all mechanical lift transfers. Interviews and documentation confirmed that the transfer was performed by a single CNA, in violation of these policies, which directly led to the incident where the resident and CNA became pinned against a dresser and required assistance to resolve the situation.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report a potential allegation of abuse to the State Agency for one resident. According to the facility's Abuse Prevention Training Program, employees are required to report any allegation of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property immediately to the administrator, who must then report it to the State Agency after the resident has been assessed and the alleged perpetrator removed. Documentation shows that a resident reported feeling that some staff rushed through care and had a poor attitude, specifically identifying an agency CNA. The grievance form did not contain further information, and the staff member was removed from the schedule. The DON stated she was notified that the resident alleged an agency CNA ripped his brief off and left him naked in bed, and she reported this to the administrator. The administrator acknowledged being made aware of the allegation but treated it as a customer service issue rather than a potential abuse case, and did not notify the State Agency or conduct an abuse investigation. The administrator confirmed that this incident was not included in the facility's abuse investigations for the past three months.
Failure to Investigate Potential Abuse Allegation
Penalty
Summary
The facility failed to identify and investigate a potential allegation of abuse involving a resident with incontinence, ADL self-care deficiency, and a stage three pressure ulcer. The resident reported that a CNA became upset after being asked to change his brief, ripped the brief off, and left him naked in bed without replacing it. The resident stated he informed another CNA about the incident, who then reported it to the DON. The DON relayed the information to the Administrator, who did not treat the incident as a potential abuse allegation but instead handled it as a customer service issue and completed a grievance form. The facility's abuse prevention protocol requires that all alleged occurrences of abuse be investigated promptly, including interviewing all involved parties and reviewing relevant records. However, the Administrator did not initiate an abuse investigation or document whether the grievance was confirmed. The incident was not included in the facility's list of reported abuse allegations, and there was no evidence that the required investigative steps were followed as outlined in the facility's policy.
Failure to Investigate and Protect Resident in Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an alleged abuse incident involving a resident with Alzheimer's disease, who reported being inappropriately touched by a male caregiver. The facility's policy requires the removal of any alleged perpetrators from resident contact pending an investigation, but this was not followed. The resident, who is not cognitively intact and requires maximum assistance with bathing, described the alleged perpetrator as a blonde male caregiver of average height. However, the facility does not employ any male CNAs fitting this description, and the male nurse present at the facility did not match the description and did not provide direct care to the resident. Despite the facility's policy, the male CNA, who was the only male CNA employed and did not match the description given by the resident, was not suspended or interviewed during the investigation. The administrator admitted to forgetting about the male CNA's employment and confirmed that the CNA continued to work after the allegation was reported. The failure to remove the male CNA from resident contact and to conduct a thorough investigation constitutes a deficiency in the facility's handling of the abuse allegation.
Inadequate Housekeeping During Viral Outbreaks
Penalty
Summary
The facility failed to maintain daily sanitation of the facility and resident rooms during outbreaks of respiratory and gastrointestinal viruses, affecting all 76 residents. Between late January and early February, 23 residents exhibited symptoms of nausea, vomiting, and diarrhea, with two diagnosed with Norovirus. Additionally, nine residents showed respiratory symptoms, with six testing positive for Influenza A and five for RSV. The housekeeping staff was insufficient, with only one housekeeper present during the day and another in the evening, making it impossible to perform enhanced sanitizing during the outbreak. The Housekeeping Manager, V8, was occupied with room changes and unable to complete regular cleaning tasks. Residents reported that their rooms were not cleaned daily, with some having to clean their own spaces due to the lack of housekeeping services. The Director of Nursing, V2, acknowledged the ongoing issue with housekeeping and the lack of cleanliness, emphasizing the importance of sanitizing high-touch surfaces during the outbreak. The facility's Infection Prevention and Control Manual and housekeeping procedures outlined the need for daily cleaning and sanitizing, especially during outbreaks, but these protocols were not followed due to staffing shortages.
Neglect of High Fall Risk Resident
Penalty
Summary
The facility failed to prevent neglect of a cognitively impaired, high fall risk resident, resulting in the resident lying on a cold, hard floor for an undetermined amount of time. The resident, who was admitted with multiple diagnoses including dementia, agitation, and orthostatic hypotension, was found cold and shivering with chattering teeth in the early hours of the morning. The care plan for the resident included keeping the bed in a low position with a mattress on the floor, but this intervention was not followed. The Licensed Practical Nurse (LPN) on duty, identified as V5, was aware of the resident's falls throughout the night but failed to document the incidents or notify the Director of Nursing, the doctor, or the family. The LPN did not conduct necessary assessments or follow the facility's fall protocol, which includes immediate assessment, neurological checks, and risk management fall assessments. The resident was left on the floor without a mattress or blankets, despite the hallway being cooler than usual due to heating issues in the facility. The facility's policies on abuse prevention and fall clinical protocol were not adhered to, as the LPN allowed the resident to remain on the floor without adequate care or documentation. The Director of Nursing confirmed that the resident's care plan did not include instructions to allow the resident to lay on the floor, and the LPN's actions were deemed neglectful. The facility's failure to provide necessary care and services to the resident resulted in neglect, as defined by their own policies.
Deficiencies in Kitchen Sanitation and Food Storage
Penalty
Summary
The facility failed to maintain a routine cleaning schedule for the kitchen, which included the absence of cleaning check-off sheets for staff. During a kitchen tour, it was observed that multiple boxes of food were stacked on the floor in the freezer, and there were no sanitization logs available for the dishwasher. Additionally, there were no temperature logs for the freezer, cooler, or refrigerator. Eight loaves of bread were found on storage racks without any delivery or expiration dates. The kitchen steamer/oven had a build-up of a black sticky substance, and the kitchen floors were dirty with brown streaks and debris. The Dietary Manager, who has been in the position since July 2024, acknowledged the lack of a cleaning schedule and check-off sheets for staff. She admitted that the freezer food delivered the previous night had not been put away and was unsure of the location of the dishwasher sanitization logs and temperature logs for the cooler or freezer. The facility's food storage policy from 2020 requires food to be stored off the floor, labeled with expiration dates, and kept at appropriate temperatures, but these standards were not met. All 73 residents, except one who is NPO, receive food from the dining room, indicating that these deficiencies could potentially affect all residents in the facility.
Failure to Implement Legionella Risk Reduction Procedures
Penalty
Summary
The facility failed to implement a procedure to reduce the risk of Legionella in its water system, potentially affecting all 73 residents. During a survey, the Maintenance Director was unable to provide documentation or information on Legionella procedures, water system management, or risk assessment. The Maintenance Director admitted to not flushing pipes for Legionella or having a water management plan, only checking water temperatures weekly since February 2024. The Infection Preventionist also stated that they do not manage a Legionella Disease water plan and noted no residents had contracted Legionella. The facility's undated Water Management Program policy outlines the need for procedures to reduce Legionella risk, requiring the Maintenance Director to maintain documentation of the water system and conduct risk assessments, with the Infection Preventionist maintaining related documentation.
Failure to Document COVID-19 Vaccination Efforts
Penalty
Summary
The facility failed to maintain documentation of COVID-19 vaccinations, screening, offering, or education for staff, which has the potential to affect all 73 residents living in the facility. The facility's COVID-19 Vaccine policy, effective January 4, 2021, requires the Infection Control Coordinator to maintain surveillance data on COVID-19 vaccine coverage and make it available to staff as part of educational efforts. However, during a survey conducted from December 18 to December 20, 2024, the Infection Preventionist (IP) was unable to provide any documentation regarding staff COVID-19 vaccinations, screening, offering, or education. The IP admitted to not knowing which staff members were fully vaccinated and stated that they had not screened, educated, or offered the COVID-19 vaccination to staff.
Inadequate Fall Investigations and Documentation
Penalty
Summary
The facility failed to conduct thorough fall investigations for three residents, R15, R48, and R49, as observed during a survey. The Director of Nursing (DON) acknowledged that the details of falls were often missing from the computer system due to inadequate documentation by agency nurses, who comprised about 85% of the nursing staff. The Administrator confirmed that these agency nurses were not diligent in charting and were difficult to contact after their shifts, which contributed to the lack of comprehensive fall investigations. Resident R15 experienced multiple falls, including unwitnessed falls from her chair and bed. The investigations for these incidents lacked root cause analysis, progress notes, and interviews with the resident or staff. Additionally, there were no documented interventions to prevent further falls. R15, who has a history of cerebral infarction and other medical conditions, stated that she does not attempt to get up by herself and requires assistance. Resident R48, diagnosed with vascular dementia and other cognitive impairments, had several witnessed and unwitnessed falls. The investigations for these falls were incomplete, missing root cause analysis, witness statements, and interventions to prevent future incidents. Similarly, Resident R49, who has difficulty walking and other health issues, experienced unwitnessed falls with investigations lacking in fall interventions and staff education on safe transfers. The facility's fall policy requires thorough documentation and analysis of falls, which was not adhered to in these cases.
Survey Results Not Accessible to Residents
Penalty
Summary
The facility failed to ensure that survey results from the past five years were readily accessible to residents, as required by the State Long-Term Care Ombudsman Program and the facility's own policies. During a resident council meeting, several residents expressed that they were unaware of their right to review the facility's survey results and did not know where these results were located within the facility. This indicates a lack of communication and transparency regarding the availability of important regulatory documents. Further investigation revealed that no survey results were available in the facility for residents to review. The administrator and receptionist were unable to locate the survey binder, despite searching in multiple areas, including the front lobby and resident television area. This deficiency affects all 73 residents currently residing in the facility, as documented in the facility's Long-Term Care Facility Application for Medicare and Medicaid CMS 671 Form.
Failure to Notify Residents of Hospital Transfers
Penalty
Summary
The facility failed to document in the residents' Electronic Medical Records or provide written notification to the residents or their representatives regarding the reason for emergent hospital transfers or discharges. This deficiency was identified during an interview and record review, where it was revealed that the facility did not adhere to its own Transfer and Discharge Policy. The policy mandates that residents and their representatives receive appropriate notice of an impending transfer or discharge, including the reason for the transfer, the effective date, and the location to which the resident will be transferred. However, the facility's administrator admitted that no such documentation or notifications were provided. The deficiency has the potential to affect all 73 residents residing in the facility, as the lack of documentation and notification could disrupt continuity of care and violate residents' rights. The facility's administrator acknowledged the issue, citing recent changes at the facility and an inability to locate the necessary paperwork or written notifications. This oversight indicates a systemic failure to comply with established policies designed to ensure residents and their representatives are informed and prepared for transfers or discharges.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide a copy of the Bed Hold Policy notification to residents or their representatives during emergent hospital transfers or discharges. This deficiency was identified through interviews and record reviews, revealing that the facility's Bed Hold Policy, which should be given at admission and upon each transfer, was not provided. The policy states that residents will be readmitted to the first available bed in a semi-private room after hospitalization. Additionally, the facility's Transfer and Discharge Policy and Notice of a Transfer or Discharge Policy require informing residents of their bed hold rights during temporary transfers. However, the administrator admitted that no such notifications were given, citing recent changes and missing paperwork. This oversight potentially affects all 73 residents residing in the facility.
Failure to Post Complete Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the nurse staffing information was posted daily with the required details, including the total nursing hours worked. This deficiency was observed on multiple occasions, where the nurse staffing posting at the receptionist desk did not include the total hours for CNAs, LPNs, or RNs. The administrator confirmed that the form used for nurse staffing did not document the total hours worked by the nursing staff. Additionally, the facility was unable to provide 18 months of nurse staffing postings as required, with only four months available and several specific dates missing. The HR Director, who was responsible for completing the nurse staffing posting after the former administrator left, admitted to not knowing the specific information that needed to be included on the form, including the requirement to total the hours. The postings were not updated to reflect the actual number of nursing staff or the hours worked. This oversight has the potential to affect all 73 residents residing in the facility, as accurate staffing information is crucial for ensuring adequate care and compliance with regulatory requirements.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, resulting in two significant incidents involving residents with cognitive impairments. In the first incident, a resident with a history of aggression and cognitive communication deficit physically abused another resident by slamming a door on her hand, causing severe injuries that required hospitalization and surgical intervention. This resident had a documented history of aggressive behaviors, including physical and verbal aggression, yet the facility did not implement effective measures to prevent further incidents or protect other residents. In the second incident, a resident with moderate cognitive impairment was reported to have inappropriately touched another resident with advanced dementia in the dining room. The staff member who witnessed the incident reported it to the nurse, and the residents were separated. However, the investigation concluded with insufficient evidence to substantiate abuse due to the lack of intent and physical or mental distress, despite the staff member's account of the inappropriate contact. Both incidents highlight the facility's failure to adequately monitor and manage residents with known behavioral issues, resulting in harm and potential harm to other residents. The facility's policies on abuse prevention and resident rights were not effectively implemented, leading to these deficiencies.
Deficiency in CNA In-Service Training Compliance
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) completed the required in-service training, which is essential for maintaining their competence. The facility's assessment mandates that CNAs receive at least 12 hours of training annually, including dementia management and abuse prevention. However, the Director of Nursing (DON) was unable to provide proof of completed trainings for the past six months, indicating a lapse in compliance with these requirements. The facility's job description for CNAs also emphasizes the importance of attending in-service training programs, yet the DON admitted that the electronic training records were not up to date. The deficiency was further highlighted by the fact that recent in-service sessions did not have attendance records for all 32 CNAs employed at the facility. This lack of documentation suggests that not all CNAs participated in the mandatory training sessions held on specific dates. The facility currently houses 61 residents, all of whom could potentially be affected by this oversight in training, particularly those with cognitive impairments who require specialized care.
Failure to Protect Resident from Repeated Abuse
Penalty
Summary
The facility failed to implement its Abuse Prevention Program effectively, resulting in repeated physical abuse of a resident. The program's policy, dated 10/2022, mandates the protection of residents from abuse and requires immediate evaluation and separation of residents involved in incidents. However, the facility did not take adequate steps to prevent further abuse after an initial incident where a resident's hands were caught in a door by another resident, leading to injuries. The resident who was injured, identified as R4, has dementia and is known to wander into other residents' rooms. Despite this behavior, the facility did not increase supervision or update care plans to protect R4 after the first incident. Staff members, including CNAs and nurses, acknowledged the difficulty in keeping R4 safe due to her wandering tendencies but did not implement any new interventions to prevent further incidents. The resident who caused the injury, identified as R3, has a history of aggressive behavior and was considered a threat to others. Despite this, no measures were taken to separate R3 from R4 or to provide increased supervision. The facility's inaction led to a second incident where R4's hand was again caught in a door by R3, resulting in fractures. The Director of Nursing confirmed that no interventions were put in place to protect R4 after the first incident, highlighting a significant lapse in the facility's abuse prevention efforts.
Failure to Report Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to report an allegation of resident-to-resident verbal and physical abuse involving two residents. According to the facility's Abuse Prevention Program policy, employees are required to report any incident, allegation, or suspicion of potential abuse immediately to the administrator or a designated individual. However, an incident occurred where one resident entered another resident's room, leading to verbal aggression and physical harm when the door was slammed on the intruding resident's hand, causing immediate bleeding. This incident was not documented in the facility's list of State Agency Reportables, indicating a failure to report the event as required. The incident involved a resident who frequently exhibited restlessness and agitation, with a history of attempting to harm staff and other residents. The resident showed no remorse for injuring others, as noted in a progress note by the facility's nurse practitioner. Despite the severity of the incident, which included physical injury and potential abuse, the corporate administrator confirmed that the incident should have been reported but was not. This oversight highlights a significant deficiency in the facility's adherence to its abuse prevention and reporting policies.
Failure to Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to investigate a potential allegation of resident-to-resident verbal and physical abuse involving two residents. The incident occurred when one resident entered another resident's room, leading to the second resident becoming agitated and verbally abusive. During the altercation, the second resident slammed the door, causing injury to the first resident's hand. Despite the immediate physical harm observed, the facility did not conduct an investigation into the incident as required by their Abuse Prevention Program policy. The report highlights that the facility's staff, including the Registered Nurse and the Director of Nursing, did not take appropriate action following the incident. The Corporate Administrator confirmed that no investigation was conducted, and the Director of Nursing admitted to not investigating the incident, attributing the behavior to the aggressive tendencies of the resident involved. The lack of investigation was further compounded by the previous administrator's decision not to address the incident, despite it being reported.
Failure to Provide Bed Hold Policy to Resident
Penalty
Summary
The facility failed to provide a copy of the bed hold policy to a resident who was transferred to the hospital. The facility's undated Bed Hold Policy states that if a resident pays to hold their bed, the facility guarantees the availability of a bed upon their return, although it does not assure the same room and bed. The Transfer and Discharge Policy, dated March 2014, specifies that relocation rights, including bed hold and readmission rights, will be maintained in all transfers. However, the clinical record of a resident who was transferred to the hospital did not contain documentation of written notice of the facility's bed hold policy. The Director of Nursing confirmed that the bed hold policy was not provided to the resident.
Facility Fails to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to serve food at a palatable and appetizing temperature, affecting all 68 residents. The facility's policy requires food temperatures to be taken and documented before serving, with corrective actions for foods not at the correct temperature. However, the facility's logs showed that food temperatures were not taken for 29 meals, and a second temperature was not taken before serving for 44 meals. Residents and staff reported that food was often served cold, and the facility's food committee and resident council minutes documented complaints about long wait times and cold food. On the day of the survey, a cook was observed serving cheese pizza from a flat baking sheet without using a steam table or heating element. The pizza was not reheated to the required temperature before being served, with one slice measuring 108 degrees F. Another resident's pizza was served at 78 degrees F without reheating. Staff interviews confirmed that meals were often served cold, with unheated carts used for room trays and food not placed in steam table pans. Residents expressed dissatisfaction with the cold food, describing it as tasteless and hard. Staff members, including CNAs and an RN, corroborated these complaints, noting that residents frequently complained about cold meals. The facility administrator acknowledged that dietary staff were not consistently taking food temperatures as required by policy, and the pizza should have been reheated to 140 degrees F before serving.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Washington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Loft Rehab Of East Peoria, The | 5.1 mi | ★★★★★ | 0 | 0 |
| Accolade Hc Of East Peoria | 5.5 mi | — | 0 | 0 |
| Apostolic Christian Home Of Eureka | 5.5 mi | ★★★★★ | 0 | 0 |
| Fondulac Rehabilitation And Health Care Center | 6.3 mi | ★★★★★ | 4 | 1 |
| Snyder Village | 6.9 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.