Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Grandview Healthcare Center during CMS and state inspections, most recent first.
Food storage, hand hygiene, and dishwashing practices were deficient. Staff stored multiple dry goods, refrigerated items, and frozen foods in undated or improperly sealed containers, with several items past use-by dates or not used in first-in, first-out order. Staff also failed to wash hands appropriately after touching trash, dirty items, raw meat, and clean dishware, and handwashing was often too brief with faucet shutoff using bare hands. The kitchen had visible debris, grease, and personal items stored in food areas, while wet dishes were stacked or towel-dried instead of air-dried. The dishwasher temperatures were below the posted requirement, and the kitchen lacked a sanitizer test kit and current dish machine log.
Failure to maintain an Antibiotic Stewardship Program. Facility policy required tracking antibiotic use, conducting a 72-hour time out, reviewing the MAR, and mapping infection locations, but the program record from May 2025 through January 2026 did not show documentation that antibiotics and infections were being tracked. The ADON said he/she had been working the floor and did not have time to keep up with the program, the DON was unsure if it had been done, and the administrator was not aware it had not been completed.
Surveyors found that staff failed to review and revise care plans when residents’ needs changed. Several residents experienced significant weight loss with physician orders for special diets, supplements, and increased weight monitoring, but these changes were not added to their care plans, and CNAs reported they were unaware of the weight loss. Other residents used bed rails or assist bars observed in daily care, yet their care plans contained no directions for this equipment. A resident with Alzheimer’s disease had the diagnosis documented in the MDS but not in the care plan, and no cognitive interventions were listed. The MDS nurse, who was inexperienced with MDS and care planning, was identified as responsible for updates, while the DON and Administrator stated they expected individualized care plans to reflect weight changes, nutritional interventions, cognitive status, assistive devices, and required assistance levels.
The facility did not consistently complete physician-ordered weights, weekly skin assessments, or required post-fall documentation for multiple residents with serious conditions such as severe cognitive impairment, dementia, diabetes, malnutrition, CKD, wounds, and high fall risk. Records showed repeated missed weight entries, missed weekly skin checks, and several falls without Event Reports or required neuro checks, including unwitnessed falls and falls with minor injury.
Staff failed to safely propel several residents in wheelchairs when they moved residents without properly using foot pedals, and observations showed residents’ feet dragging on the floor or dropping down during transport. The residents involved had cognitive impairment or required assistance for wheelchair locomotion. The facility also left medication and treatment carts unlocked and unattended at the nurses’ station, with medications or ointment left on top of the carts while residents were nearby.
Facility staff failed to obtain informed consent and complete bed rail assessments for six sampled residents with bed grab bars or assist bars in place. Records for these residents lacked signed consent, and some lacked current assessments after earlier documentation without consent. Observations repeatedly showed the bars upright on the beds, while staff interviews showed confusion about who was responsible for obtaining the consents and the DON and administrator stated the consent should be completed quarterly.
Improperly stored and labeled medications were found in a medication cart and two medication rooms, including expired Vitamin E, Mylanta, and Aspirin, an open undated TB solution vial, and multiple open undated insulin pens. Two opened bottles of Lorazepam were also kept in unlabeled cups for two residents. Staff stated that opened medications should be dated and expired items removed, but the observed medications remained in storage without proper labeling or disposal.
Staff failed to perform proper hand hygiene during resident care, failed to use or post EBP signage for residents with catheters and dialysis needs, and allowed a urinary drainage bag to touch the floor. Observations showed an NA and CNAs entering resident rooms and providing care without washing hands at key points, without gowns during EBP-required care, and without EBP signs posted for residents who required them. A resident's catheter bag was also observed on or touching the floor on multiple occasions.
Failure to Complete Bed Rail Entrapment Assessments: Facility staff did not complete entrapment measurements for six residents who had bed rails or assist bars in use. Several residents were cognitively intact, while others were cognitively impaired or severely cognitively impaired and dependent for bed mobility. Records lacked entrapment documentation, and staff including an LPN, maintenance staff, the DON, and the Administrator were unsure who was responsible for the measurements or how often they should be updated.
Staff failed to follow abuse and misappropriation protocols when a cognitively intact resident experienced multiple fraudulent charges on their credit card over an extended period, allegedly involving a housekeeper who was later observed by law enforcement using the resident’s card at a gas station. Although facility policy required prompt reporting to the state agency and a thorough investigation of alleged exploitation, there was no documentation that an investigation into this misappropriation was completed, and the current administrator was unaware of the incident until surveyors inquired.
Staff failed to provide adequate daily hygiene and clothing changes for three cognitively impaired residents who required assistance with ADLs. One resident had a care plan directing staff to monitor and remove facial hair as needed, yet was repeatedly observed with long facial hair. Another resident, assessed as needing extensive assistance with hygiene, dressing, and bathing and care planned for two-person assistance and clean clothing daily, was observed wearing the same sweatshirt over multiple days with long facial hair. A third resident, care planned to receive supervision and assistance for all ADLs and clean clothing daily, was also observed in the same sweatsuit over several days with long facial hair. An LPN, the DON, and the Administrator stated that aides are responsible for changing clothes and shaving, charge nurses must ensure cares are completed, and residents’ clothes should be changed daily, but they were unaware these cares had not been provided or documented as refused.
Staff failed to consistently monitor and document bowel movements for two residents at risk for constipation, resulting in prolonged periods without documentation or intervention. One resident was hospitalized with fecal impaction, and staff interviews revealed a lack of awareness and adherence to facility policy regarding bowel movement monitoring and administration of as-needed laxatives.
The facility failed to transmit MDS data for ten residents within the required timeframe. The MDS Coordinator completed the assessments, but the DON, responsible for submission, missed deadlines due to vacations and lack of a backup. The administrator was unaware of submission frequency, contributing to the deficiency.
A resident, who is cognitively intact and uses a motorized wheelchair, was restricted from independently visiting a nearby park, a preferred activity that helps manage their depression and anxiety. Despite being assessed as a safe smoker and having no documented safety issues related to this activity, the facility staff cited safety concerns due to incidents of the resident hitting objects with their wheelchair. The decision was made without proper documentation or communication among staff, leading to a failure in respecting the resident's right to self-determination.
Facility staff failed to maintain and label oxygen equipment properly, leading to a deficiency in infection control. Observations showed that oxygen tubing for several residents was not dated, and concentrator filters were unclean. Interviews with staff revealed a lack of adherence to the facility's policy for regular equipment maintenance and labeling, contributing to the risk of infection spread.
Facility staff failed to connect a resident's nasal cannula to the oxygen concentrator and did not turn it on, despite the resident's severe cognitive impairment and medical conditions requiring oxygen therapy. The resident's care plan lacked directions for oxygen therapy, and staff did not notify the physician of the resident's low oxygen saturation.
Food Storage, Hand Hygiene, and Dishwashing Deficiencies
Penalty
Summary
Food was not stored in a manner that prevented contamination or ensured first-in, first-out use. During observation, multiple dry goods were found in undated bulk containers or opened packages, including quick oats with a hole in the container, fish breading with a delivery sticker dated 02/14/23 that prevented the lid from sealing, flour, sugar, instant mashed potatoes, cereals, graham crumbs, vinegar with a use-by date of 5/18/22, and several opened baking mixes and cereals in the dry goods pantry. In the walk-in refrigerator, opened and undated containers of parmesan cheese, mozzarella cheese, and sweet pickle relish were observed, along with salsa and other items. In the walk-in freezer, multiple opened and undated bags and boxes of corn, tater tots, french fries, hashbrowns, biscuits, chicken tenders, pork egg rolls, and breadsticks were observed. The dietary manager stated food should be dated when it enters the facility and when opened, and that items past their best-by or use-by dates should be discarded, but said there was no good reason the items were not dated or stored as required. Hand hygiene was not performed consistently or using approved technique. Staff were observed entering the kitchen and handling trash, food service pans, trays, dishes, raw hamburger, and other items without washing hands when indicated. When handwashing did occur, staff scrubbed for only two to seven seconds and turned off the faucet with a bare hand instead of using a towel. The dietary manager also entered the kitchen and retrieved clean items without performing hand hygiene. During interview, the dietary manager stated staff should wash hands when entering the kitchen, after touching trash or dirty items, and after handling raw meat, and should scrub for at least 20 seconds and turn off the faucet with a towel. Kitchen sanitation and dishwashing practices were also deficient. Observations showed dried food debris, liquid stains, hardened grease, paper trash, dirt, and food debris on kitchen equipment and floors, and personal items were stored on top of the chest freezer in the kitchen. The dietary manager stated staff personal items were being stored on the freezer and that there was no routine cleaning schedule for staff to follow. In the dishwashing area, dishes were removed wet from the mechanical dishwasher, stacked while still wet, and dried with a cloth towel instead of air-dried. The dishwasher wash and rinse temperatures measured 100 dF and 108 dF, the kitchen did not have a visible sanitizer test kit, and the Dish Machine Temperature Log was dated August 2025. The dietary manager stated the facility had switched chemical companies, had not posted a new log, and did not have a sanitizer test kit. The administrator stated staff should check water temperature and sanitizer concentration each time dishes are washed and that dishes should air-dry before being put away.
Failure to Maintain Antibiotic Stewardship Program
Penalty
Summary
Facility staff failed to maintain an Antibiotic Stewardship Program to monitor appropriate antibiotic use and effectiveness. The facility’s policy titled, Antibiotic Stewardship Champion Program, required an Antibiotic Stewardship Champion to review antibiotic use during morning meetings, list the resident’s name, antibiotic, start date, and location/type of infection on a white board for follow-up, conduct a 72-hour time out to review the clinical record for the correct antibiotic, length of therapy, lab or culture results, and adverse reactions, review the MAR throughout antibiotic use, and track the location of infections monthly on a facility map. Review of the Antibiotic Stewardship program from May 2025 through January 2026 did not contain documentation that staff tracked antibiotics and infections in the facility. During interview, the ADON said he/she had been working the floor a lot and had not had time to keep up with the program, and stated there was no other trained staff member to help. The DON said he/she was unsure whether the program had been getting done because he/she had only worked at the facility since December 2025. The administrator said he/she was not aware the program had not been getting done and was not sure who was responsible for completing it, but would ensure the ADON was responsible moving forward.
Failure to Update Care Plans for Weight Loss, Cognitive Status, and Bed Rail Use
Penalty
Summary
The deficiency involves the facility’s failure to review and revise comprehensive care plans when residents’ needs changed, as required by facility policy and federal regulations. The policy states that individualized care plans must be based on thorough assessments, including the MDS, and must be updated with significant changes in condition, at least quarterly, and when changes occur that impact care. Surveyors found that for multiple residents, care plans did not reflect significant weight loss, new or ongoing nutritional interventions, use of bed rails or assist bars, or cognitive diagnoses, despite these being documented elsewhere in the record and observed in practice. For one resident with severe cognitive impairment, stroke, dementia with agitation, anxiety, depression, violent behavior, and stage III chronic kidney disease, the MDS and physician orders showed a soft and bite-sized diet, nutritional supplements (Boost Breeze and Super Cereal), and weekly weights due to weight loss from 155.4 lbs to 140.4 lbs. However, the care plan dated 12/03/25 was not updated to include the recent weight loss, the ordered supplements, or the increased frequency of weights. A CNA reported not knowing the resident had weight loss and stated that if aware, they would have tried to encourage more intake. The MDS Coordinator confirmed that weight loss and related interventions, including supplements and assistance level with eating, should be on the care plan. Another resident with anoxic brain damage, diabetes, stroke, dementia, schizophrenia, gastroparesis, depression, and anxiety experienced a weight decrease from 179.2 lbs to 151.6 lbs over five months. Physician orders included a Level Six soft and bite-sized diet, yogurt twice daily, weekly weights, and a high-calorie supplement. Despite this, the care plan dated 12/15/25 did not document the significant weight loss, the use of nutritional supplements, or the change in weight-monitoring frequency. The CNA who assisted with feeding did not know about the weight loss, and the DON described needing to encourage this resident to eat, while the MDS Coordinator again stated that weight loss and interventions should be reflected in the care plan. A resident assessed as cognitively intact was repeatedly observed in bed with a right grab bar/bed rail in the upright position on multiple days, yet the care plan dated 10/03/25 contained no direction for the use of bed rails. The MDS Coordinator stated that if a resident used bedrails, this should be listed on the care plan. Another resident with severe cognitive impairment, delusions, daily behavioral symptoms, and dependence on staff for eating had a documented weight drop from 129.8 lbs to 103.6 lbs over five months, with physician orders for a regular diet, house supplement, and weekly weights. The care plan dated 12/22/25 did not include the significant weight loss, the nutritional supplement, or the change in weight frequency. The CNA did not know the resident had weight loss and described variable assistance with eating, while the MDS Coordinator reiterated that weight loss and related interventions should be care planned. A further resident with severe cognitive impairment and a diagnosis of Alzheimer’s disease had an admission MDS reflecting this condition, but the care plan dated 11/12/25 did not document the Alzheimer’s diagnosis or include any interventions related to cognitive impairment. The MDS Coordinator stated that the diagnosis should be on the care plan so staff know how to care for the resident. Another resident, cognitively impaired and requiring substantial/maximal assistance for bed mobility and transfers, was repeatedly observed with a left assist bar in the upright position on the bed, yet the care plan dated 10/23/25 did not document direction for use of the assist bar. A CNA stated that bed rails should be listed on care plans and that dementia or Alzheimer’s diagnoses should be included so staff know how to care for residents. Interviews with leadership confirmed expectations that care plans be individualized and updated with changes. The MDS Coordinator reported having worked at the facility for only a couple of months, with no prior experience in MDS or care planning, and acknowledged that care plans should be updated with every change of condition, quarterly, and annually. The DON and Administrator both stated that the MDS nurse is responsible for updating care plans and that they expect care plans to direct resident care and include bed rails, weight loss and interventions, frequency of weight checks, nutritional supplements, cognitive status, and the amount of assistance needed. The Administrator also noted that the facility holds a morning meeting to discuss incidents or changes and expects care plans to be updated when needed based on those discussions.
Missing ordered weights, skin assessments, and fall documentation
Penalty
Summary
The facility failed to ensure that physician-ordered weights, weekly skin assessments, and post-fall documentation were completed and recorded as required for multiple residents. Several residents with significant medical histories, including severe cognitive impairment, dementia, stroke, diabetes, malnutrition, chronic kidney disease, schizophrenia, and fall risk, had missing weight entries despite orders for weekly or monthly weights. For example, one resident with severe cognitive impairment, stroke, dementia with agitation, anxiety, depression, and stage three chronic kidney disease had a physician order to be weighed weekly until stable, but weights were not documented on multiple ordered dates. Another resident with severe cognitive impairment and malnutrition or risk for malnutrition also had missed weekly or monthly weight documentation, and a resident with severe cognitive impairment and a diagnosis of malnutrition or risk for malnutrition had missing monthly weight documentation. The facility also did not complete ordered weekly skin assessments for residents identified as at risk for skin breakdown or with wounds. One resident with schizophrenia, bipolar disorder, malnutrition, venous insufficiency, and diabetes had a physician order for weekly skin assessments, but several weekly assessments were not documented. Another resident with heart failure, cellulitis, lymphedema, chronic kidney disease, venous insufficiency, and wounds also had multiple missed weekly skin assessments. A third resident with spina bifida, incomplete paraplegia, and end stage renal disease had ordered weekly skin assessments that were not documented on several scheduled dates. In addition, the facility did not complete required Event Reports and neurological checks after falls. One resident had an unwitnessed fall without injury and the record did not contain a completed Event Report; another unwitnessed fall also lacked an Event Report and 11 of the 14 required neurological checks. A different resident had an unwitnessed fall and neurological checks were not documented after the event. Another resident had an unwitnessed fall with minor injury and multiple additional unwitnessed falls without injury, but the medical record did not contain Event Reports for those falls and one fall lacked 13 of the 14 required neurological checks. A resident with two or more falls since admission also had witnessed and unwitnessed falls documented in progress notes without completed Event Reports.
Unsafe wheelchair propulsion and unsecured medication carts
Penalty
Summary
The facility failed to ensure residents were safely propelled in wheelchairs when staff moved four sampled residents without properly using foot pedals. Resident #2 had severe cognitive impairment and required supervision or touch assist for wheelchair locomotion. On multiple observations, the Activity Director, Social Service Designee, an LPN, and a CNA propelled the resident without foot pedals, and the resident’s feet dragged the ground. During interview, the CNA stated staff should not propel residents without foot pedals and acknowledged uncertainty about why the resident’s feet were not checked. The LPN later stated staff should ensure foot pedals are on the wheelchair before propelling a resident. Resident #15 had severe cognitive impairment and was dependent on staff for wheelchair locomotion. An observation showed a CNA propelling the resident from the nurses’ station to the dining room in a wheelchair that did not have foot pedals, and the resident’s feet dragged the floor. Resident #37 was cognitively intact but required substantial to maximal assistance for wheelchair locomotion and was dependent on staff for wheeling 150 feet. An observation showed a nurse aide propelling the resident from the hallway to the dining room in a wheelchair without foot pedals, and the resident’s right heel dragged the floor. Resident #52 had cognitive impairment and required partial to moderate assistance for wheelchair locomotion and substantial to maximal assistance for wheeling 150 feet. An observation showed an LPN propelling the resident in a wheelchair with the feet in the foot pedals, but the resident’s foot dropped to the floor and stopped the wheelchair. Interviews with the nurse aide, CNA, Activity Director, MDS coordinator, another CNA, the DON, and the administrator all reflected that staff expected foot pedals to be used when propelling residents and that residents could be injured if they were not used. The facility also failed to store medications safely and effectively. The medication storage policy required medications to be kept in locked cabinets, locked medicine rooms, or locked mobile medication carts, and stated unattended carts must remain locked. Observations showed the 100/200/300 hall medication cart and treatment cart left unlocked and unattended at the nurses’ station, with residents nearby. One resident who wandered frequently in a merry walker was observed near the unlocked carts on several occasions, and on one observation a cup of pink ointment and on another a tube of triamcinolone acetonide cream were left on top of an unattended treatment cart. An LPN stated medication and treatment carts should never be left unlocked and unattended and that medications or treatments should not be left on top of the cart unattended.
Failure to Obtain Bed Rail Consent and Assessments
Penalty
Summary
Facility staff failed to obtain informed consent and complete bed rail assessments for six sampled residents who had grab bars or assist bars on their beds. The facility policy titled Bed Rails required education of the resident or legal representative on the benefits and risks of bed rail use, review of those risks and benefits after the bed rail observation, signed consent by the resident or representative and the nurse, and upload of the signed consent into the medical record. The survey found that the medical records for Residents #3, #7, #8, #27, #38, and #50 did not contain a signed consent for bed rail use, and several records also lacked a current bed rail assessment after an earlier assessment had been documented without consent. Resident #3 was assessed by MDS as cognitively intact and not using restraints, and the care plan listed bilateral grab bars to assist with repositioning and transfers. The record showed a bed rail assessment dated 05/05/25 without signed consent, and no later assessment or consent was found. Observations on multiple dates showed the resident in bed with both grab bars in the upright position. Resident #7 was also assessed as cognitively intact and not using restraints; the care plan did not direct use of grab bars, and the record contained no informed consent or bed rail assessment. Observations showed the resident in bed with the right grab bar upright on several occasions. Resident #8 was assessed as cognitively intact and not using restraints, with a care plan for bilateral grab bars to assist with mobility, but the record had no informed consent or bed rail assessment. Resident #27 was cognitively impaired and required substantial to maximal assistance for bed mobility; the care plan did not direct use of the U-bar, and the record had no informed consent or bed rail assessment. Resident #38 was severely cognitively impaired and dependent for bed mobility; the record showed a bed rail assessment on 06/30/25 without signed consent and no later assessment or consent. Resident #50 was cognitively intact and required supervision or touch assistance for bed mobility; the care plan listed bilateral grab bars, but the record showed a bed rail assessment on 05/13/25 without signed consent and no later assessment or consent. Staff interviews showed uncertainty about who was responsible for obtaining bed rail consents, while the DON and administrator stated the consent should be completed quarterly and the administrator said the facility would be out of compliance if no consent had been completed since October 2025.
Improperly Stored and Labeled Medications
Penalty
Summary
Drugs and biologicals were not maintained in accordance with accepted storage and labeling practices in one medication cart and two medication rooms. Surveyors observed a supply room with one bottle of Vitamin E 180 mg that had an expiration date of 09/25, an opened vial of TB solution that was open and undated, and two opened bottles of Lorazepam 2 mg/ml for two residents that were placed in cups not labeled by the pharmacy. In the 100/300 hall medication cart, surveyors found multiple expired or improperly dated medications, including Mylanta, Aspirin 325 mg, and several insulin pens that were open and undated, including Lispro, Lantus, Tresiba, and Aspart insulin pens. The facility’s policies stated that multiple-dose vials must be dated and initialed when opened and that no discontinued or outdated biologicals may be retained for use. During interviews, RN F, LPN C, the DON, and the Administrator all stated that staff who open medications are responsible for dating them, that insulin pens and TB solution should be dated when opened, and that staff should check expiration dates before administration and never give expired medication. They also stated that expired medications should be removed and destroyed when found. Despite these expectations, the observed medications remained in storage without proper dating, labeling, or removal, and the facility staff failed to discard the discontinued or expired items found during the survey.
Hand Hygiene, EBP, and Catheter Bag Placement Failures
Penalty
Summary
Staff failed to use appropriate hand hygiene and enhanced barrier precautions during resident care, and failed to maintain sanitary conditions for a urinary drainage bag. The facility policy on handwashing did not include direction for staff on when to wash hands while performing resident care, and the enhanced barrier precautions policy did not include direction for signage. The facility also had a catheter policy directing staff to keep the drainage bag and tubing off the floor at all times to prevent contamination and damage. For one resident with severe cognitive impairment and a urinary catheter, a nurse assistant entered the room, did not wash hands before applying gloves, assisted the resident to bed, wiped the resident's face, removed gloves, gave the resident a drink, and left the room without washing hands. For another resident with severe cognitive impairment and an indwelling urinary catheter, staff documented the resident returned from the hospital with a catheter in place, but observations on multiple days showed the room did not have enhanced barrier precaution signage. During catheter care, two CNAs did not wash hands before glove use, did not perform hand hygiene between glove changes, and did not wear gowns during care. For a third resident who was cognitively intact and received dialysis three times a week, the care plan identified infection risk related to a dialysis shunt, but the room did not have enhanced barrier precaution signage during multiple observations. An LPN stated he/she had not received EBP training and did not know what EBP was used for, and the DON and administrator stated staff were responsible for placing the signs. For another resident with an indwelling urinary catheter, observations on multiple days showed the catheter bag on the floor or touching the floor. Staff stated the bag should never touch the floor because it can cause contamination and infection, and the DON and administrator confirmed the bag should always have a barrier between it and the floor.
Failure to Complete Bed Rail Entrapment Assessments
Penalty
Summary
Facility staff failed to complete entrapment assessments for six residents who used bed rails or assist bars on their beds. The facility policy titled Bed Rails stated that staff should follow manufacturer recommendations and specifications for bed rails, mattresses, and bed frames, and conduct regular inspections of bedframes, mattresses, and bed rails to identify possible entrapment. Review of the medical records for the six residents showed no entrapment measurements documented for any of them. Resident #3 was cognitively intact and had bilateral grab bars documented in the care plan for repositioning and transfers. Resident #7 was cognitively intact, had no care plan direction or physician orders for grab bars, and was observed multiple times with the right grab bar in the upright position. Resident #8 was cognitively intact, had bilateral grab bars in the care plan for mobility, and was repeatedly observed in bed with bilateral grab bars in the upright position. Resident #27 was cognitively impaired and required substantial to maximal assistance for bed mobility, and was observed with a left assist bar in the upright position. Resident #38 was severely cognitively impaired, dependent for bed mobility, had bilateral grab bars in the care plan for turning and repositioning, and was observed with a right-side grab bar in the upright position. Resident #50 was cognitively intact, required supervision or touch assistance for bed mobility, had bilateral grab bars in the care plan for self-repositioning and transfers, and was observed with assist bars in the upright position on both sides of the bed. During interviews, an LPN, maintenance staff, the DON, and the Administrator all stated they did not know who was responsible for completing the entrapment measurements. The LPN said the measurements should be completed when grab bars are initially placed on the bed, but did not know how often they should be updated. The DON and Administrator stated the measurements should be updated quarterly, and the Administrator said if the measurements had not been completed since October 2025, the facility would be out of compliance.
Failure to Investigate Alleged Misappropriation of Resident Funds
Penalty
Summary
Facility staff failed to initiate and complete a thorough investigation into an allegation of misappropriation of a resident’s funds. The facility’s Abuse Prohibition Protocol Manual directed staff to thoroughly investigate alleged violations of abuse, neglect, exploitation, or mistreatment, to prevent further incidents while an investigation was in process, and to take appropriate corrective action based on findings. The policy also required the Administrator or designee to report allegations to the state survey agency within two hours. A cognitively intact resident, as documented on a Significant Change MDS dated 04/23/25, had multiple fraudulent charges made on their credit card over an extended period. A detective reported that a housekeeper employed by the facility was caught using the resident’s credit card at a gas pump and then using their own personal card inside the gas station. The facility’s prior abuse and neglect investigation records did not contain documentation that an investigation into this misappropriation allegation had been completed. The former Administrator stated that the facility was not made aware of any incidents involving the resident’s credit card until after the resident had been discharged and that an investigation was started, but they did not know what happened to it or whether it was finished. The former Administrator also reported that when they spoke with the housekeeper, the housekeeper denied making the fraudulent charges. The current Administrator, who began employment after the incident period, reported having no knowledge of the incident or any facility-reported incident until the survey team began the annual survey and stated that a detailed investigation and timely report to the state agency would have been expected if a misappropriation report had been made. The facility had a practice of discouraging residents from keeping valuables in their rooms and maintained a lock box in the business office for residents’ valuables, but there was no documented investigation into whether other residents were affected or into the specific misappropriation allegation involving this resident.
Failure to Provide Daily Hygiene and Clothing Changes for Dependent Residents
Penalty
Summary
Facility staff failed to provide adequate assistance with activities of daily living (ADLs), specifically personal hygiene, grooming, and clothing changes, for three cognitively impaired residents. For one resident, the Quarterly MDS dated 12/02/25 documented severe cognitive impairment, no behaviors or care refusals, and independence with ADLs, with a care plan directive for staff to monitor and remove facial hair as needed. Despite this, repeated observations from 01/11/26 through 01/14/26 showed the resident consistently had long facial hair, indicating that staff did not follow the care plan related to grooming. A second resident’s admission MDS showed severe cognitive impairment, no behaviors or refusals, and a need for extensive assistance with hygiene, dressing, and bathing, with a care plan dated 12/02/25 directing staff to provide assistance from two staff for all ADLs and to provide clean, appropriate clothing daily. Observations over four consecutive days showed this resident wearing the same grey sweatshirt and having long facial hair. A third resident’s Quarterly MDS documented severe cognitive impairment, no behaviors or refusals, independence with dressing, and moderate assistance needed for hygiene and bathing, with a care plan dated 09/26/25 requiring supervision and assistance for all ADLs and clean clothing daily. Observations over multiple days showed this resident wearing the same green sweatsuit and having long facial hair. In interviews, an LPN, the DON, and the Administrator each stated that aides are responsible for assisting residents with changing clothes and shaving, that charge nurses are responsible for ensuring these cares are completed, and that they were not aware these residents’ clothes were not changed and their faces not shaved, despite expectations for daily clothing changes and shaving as needed, particularly with showers and with documentation of any refusals.
Failure to Monitor and Document Bowel Movements Leads to Fecal Impaction
Penalty
Summary
Facility staff failed to monitor and document bowel movements for two residents, both of whom were assessed as being at risk for constipation and dehydration. The facility's policy required staff to determine daily if residents had a bowel movement, document this information, and notify the charge nurse if a resident had not had a bowel movement in three days. For one resident with impaired cognition and a history of opiate use, staff did not document any bowel movements for over a week, nor did they administer prescribed as-needed laxatives. This resident was ultimately sent to the hospital and diagnosed with fecal impaction. For the second resident, who also had a diagnosis of constipation and was prescribed multiple medications with constipating side effects, staff failed to document bowel movements for several extended periods, including gaps of seven, eight, and eleven days. There was no documentation that as-needed laxatives were administered during these times. Interviews with staff revealed a lack of awareness regarding the residents' bowel movement status and inconsistent monitoring and documentation practices. Staff interviews confirmed that CNAs were responsible for documenting bowel movements each shift and notifying licensed staff if a resident had not had a bowel movement in three days. However, both CNAs and licensed staff were unaware of the prolonged periods without bowel movements for the affected residents, and there was no evidence that appropriate interventions were implemented as required by facility policy and physician orders.
Failure to Transmit MDS Data Timely
Penalty
Summary
The facility failed to transmit the required Minimum Data Sets (MDS) for ten residents within the mandated timeframe. According to the Centers for Medicare and Medicaid Services (CMS) guidelines, all MDS assessments must be transmitted electronically within 14 days of completion. However, the facility did not meet this requirement for ten residents, including those with quarterly, annual, and Significant Change of Status assessments. The facility's census was 48, and the deficiency was identified through interviews and record reviews. Interviews with facility staff revealed that the MDS Coordinator was responsible for completing the MDS, while the Director of Nursing (DON) was responsible for submitting the data. The DON admitted to submitting the data every other week but failed to do so due to taking vacations in June and forgetting to submit upon return. The administrator was unaware of the submission frequency and confirmed that there was no backup person to handle submissions in the DON's absence. This lack of a backup plan contributed to the failure to transmit the MDS data as required.
Failure to Support Resident's Right to Self-Determination
Penalty
Summary
Facility staff failed to respect and promote the rights of a resident to make choices about significant aspects of their life, specifically the choice to independently go outside the facility. The resident, who is cognitively intact and uses a motorized wheelchair, expressed a preference to visit a nearby park independently, which was previously allowed. However, the facility staff recently prohibited this activity, citing safety concerns, despite the resident's ability to operate the wheelchair independently and use a cell phone for assistance if needed. The resident's family member also supported the resident's choice, noting its importance for managing depression and anxiety. The facility's decision was based on an assessment that deemed the resident an unsafe smoker and noted incidents of the resident hitting objects with their wheelchair. Despite these concerns, the resident's medical record did not document any specific safety issues related to the preferred activity of going to the park. Interviews with various staff members, including the Assistant Director of Nursing, MDS coordinator, and Director of Nursing, revealed a consensus on the safety concerns, leading to the restriction of the resident's unsupervised trips. However, there was a lack of communication among staff, as some were unaware of the restriction, highlighting a gap in the implementation of the resident's rights policy.
Deficiency in Oxygen Equipment Maintenance and Infection Control
Penalty
Summary
The facility staff failed to properly manage and maintain oxygen equipment for four residents, leading to a deficiency in infection prevention and control. Observations revealed that oxygen tubing for these residents was not labeled with dates, indicating that it had not been changed as per the facility's policy. Additionally, the oxygen concentrator filters were found to be covered with a white residue, suggesting they were not cleaned regularly. The facility's policy, dated March 2015, requires regular checks and cleaning of oxygen equipment, including changing humidifiers and tubing according to cleaning guidelines. Interviews with staff, including an LPN and the Director of Nursing (DON), confirmed that oxygen tubing should be changed monthly and labeled with the date of change. However, it was noted that there was no preventative maintenance plan for cleaning oxygen filters. The DON acknowledged the responsibility to ensure tubing changes, while the administrator was uncertain about the frequency of changes, indicating a lack of clarity and adherence to the facility's policy. This lack of compliance with established procedures contributed to the risk of infection spread among residents using oxygen therapy.
Failure to Properly Administer Oxygen Therapy
Penalty
Summary
Facility staff failed to connect a resident's nasal cannula tubing to the oxygen concentrator and did not turn the concentrator on. The resident, who had severe cognitive impairment, was dependent on staff for various activities and had medical conditions including atrial fibrillation, heart failure, and dementia. The resident's care plan did not include directions for oxygen therapy, despite a physician's order for two to five liters of oxygen per minute as needed. On the day of the incident, the resident was found with an oxygen saturation of 55%, and there was no documentation that the physician was notified of this change in condition. Interviews revealed that the CNA working with the resident believed the nasal cannula was connected and the concentrator was on, but later it was found disconnected and off. The LPN confirmed that the resident was too lethargic to have removed the cannula independently. The Director of Nursing and the facility administrator both expected staff to follow physician orders and ensure proper oxygen administration, but this was not done in this case.
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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) |
|---|---|---|---|---|
| Sunset Health Care Center | 8 mi | ★★★★★ | 0 | 0 |
| Union Nursing | 10.1 mi | ★★★★★ | 15 | 0 |
| New Haven Care Center | 10.8 mi | ★★★★★ | 0 | 0 |
| St Clair Nursing Center | 14.7 mi | ★★★★★ | 1 | 0 |
| Pacific Care Center | 16.5 mi | ★★★★★ | 21 | 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.