Above average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Altercare Post-acute Rehab Center during CMS and state inspections, most recent first.
A resident with multiple conditions, including type II DM and acute kidney failure, had orders for scheduled Humulin insulin and routine blood glucose checks with parameters for physician notification. On a morning when the resident was lethargic, breathing heavily, slow to respond, and later became unresponsive, staff did not administer the ordered insulin despite a blood glucose of 240 and held other morning medications based on nursing judgment. A CMA reported being told by an LPN to hold insulin if the resident did not eat, and the DON confirmed medications, including insulin, were held while staff awaited a physician callback. The MD stated he was not informed that medications were held and did not recall giving such orders, and facility policies requiring documentation and prescriber notification when vital medications are withheld and immediate consultation for significant condition changes were not followed.
A resident with type II DM and multiple comorbidities had orders for scheduled Humulin insulin and routine blood glucose checks, with instructions to notify the physician for extreme glucose values. On a morning when the resident was lethargic, breathing heavily, and slow to respond, nursing staff reported the change in condition but, after being told to continue monitoring, the LPN instructed a CMA to hold the resident’s insulin if breakfast was not eaten. The CMA held the morning medications, including insulin, without documented physician orders to do so, and the physician was not effectively notified that a vital medication was withheld. The resident’s condition deteriorated to unresponsiveness with hypotension and tachypnea before EMS was called, and EMS and hospital records documented severe hyperglycemia and subsequent diagnoses of DKA, septic shock, altered mental status, and hypotension, demonstrating a failure to follow physician orders and facility policy for medication administration and timely emergency transfer.
Surveyors found the facility exceeded the acceptable medication error rate when an LPN administered multiple ophthalmic medications to a resident with complex medical conditions and moderate cognitive impairment. The LPN instilled Atropine and Prednisolone, which were ordered for only one eye, into both eyes, and also gave Brimonidine and Brinzolamide in both eyes without clarifying an incomplete order for Brinzolamide. The LPN did not observe the required time intervals between different eye drops as specified by manufacturer instructions and facility policy, contributing to four medication errors during a single medication pass.
A resident with diabetes and multiple comorbidities had physician orders for scheduled NPH and Aspart insulin. On a morning when the resident was noted to be lethargic with labored breathing and slow response to stimuli, an LPN instructed a medication aide to hold the resident’s insulin if breakfast was not eaten, and the insulin was not administered. The medical record lacked any physician order to hold insulin, lacked documentation of the decision and rationale to withhold the medication, and did not include the actual vital sign values, only that they were within normal limits. The DON confirmed these omissions, which were inconsistent with facility policy requiring documentation of assessments, notifications, interventions, and responses when there is a change in condition.
Failure to Notify Physician and Improperly Holding Ordered Medications After Resident Status Change
Penalty
Summary
The deficiency involves the facility’s failure to timely notify the physician of a significant change in condition and failure to notify the physician when ordered medications, including insulin, were independently held. A resident with diagnoses including hypervolemia, orthostatic hypotension, hypertension, dehydration, acute kidney failure, type II diabetes, anxiety, and depression was admitted on 12/11/25 and had physician orders for Humulin insulin twice daily and blood glucose checks before meals and at bedtime, with instructions to notify the physician for blood glucose levels over 400 or under 70. On the morning of 12/18/25, the resident’s blood glucose was 240 at 7:30 A.M., but the ordered Humulin at 8:00 A.M. was not administered. Nurse documentation indicated the resident was lethargic, breathing heavily, and slow to respond, and that the physician was called and the nurse was waiting for a response, but there was no documentation of any physician order to hold medications, including insulin. Later that morning, the resident became unresponsive, with a blood pressure of 70/30, blood glucose of 182, and respirations of 30 per minute, and EMS was called after another attempt to contact the physician without a return call. The Medical Director stated he was not informed that medications were held and did not recall giving any order to hold the resident’s medications, including insulin, and clarified he would only hold fast-acting insulin, not long-acting insulin. A CMA reported being instructed by an LPN to hold insulin if the resident did not eat breakfast, and stated the resident was not awake that morning. The LPN confirmed instructing the CMA to hold insulin if the resident did not eat, based on nursing judgment, and reported sending a message to the physician without receiving a response. The DON stated the nurse called the physician and waited for a call back, and that the CMA held morning medications, including insulin, per nursing judgment. Facility policies required explanatory notes when regularly scheduled medications are withheld and prescriber notification when vital medications are withheld, and required immediate consultation with the physician and notification of the resident representative for significant changes or deterioration in health, which did not occur as required in this case.
Failure to Administer Ordered Insulin and Delay in Emergency Transfer After Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to administer insulin as ordered and to ensure timely transfer to the emergency room for a resident with multiple comorbidities, including type II diabetes, acute kidney failure, dehydration, hypervolemia, orthostatic hypotension, hypertension, anxiety, and depression. The resident had physician orders for Humulin, an intermediate-acting insulin, to be given subcutaneously at 8:00 A.M. and 4:30 P.M., with blood glucose checks before meals and at bedtime, and instructions to notify the physician for blood glucose levels over 400 or under 70. On the morning in question, the resident’s blood glucose was 240 at 7:30 A.M. and 182 at 11:30 A.M., but Humulin was not administered between 7:00 A.M. and 11:00 A.M. as ordered. There was no documentation that the physician ordered the insulin or other medications to be held, and the Medical Director later stated he was not informed that medications were held and would only hold fast-acting insulin, not long-acting insulin. Nursing documentation and interviews showed that the resident was reported as lethargic, breathing heavily, and slow to respond to voice commands beginning on the night shift, with this significant change in condition continuing into the morning. The day-shift LPN received report that the resident was not doing well and was not eating, observed the resident as lethargic and slow to respond, and wanted to send the resident to the emergency room but was told by the night nurse and the DON to continue monitoring. The LPN instructed the CMA to hold insulin if the resident did not eat breakfast, and the CMA held the morning medications, including insulin, based on this instruction and nursing judgment. The physician was called and a message sent, but there was no documented response before the resident became unresponsive late in the morning, at which time EMS was called. EMS documented the resident as unresponsive and hyperglycemic with a blood glucose too high to register on the glucometer (over 600), and hospital records later showed a glucose of 951 with diagnoses including diabetic ketoacidosis, septic shock, altered mental status, and hypotension. Facility policy required explanatory notes when scheduled medications were withheld and prescriber notification when vital medications were withheld, refused, or not available, but this was not followed for the held insulin dose.
Medication Error Rate Exceeded Due to Improper Ophthalmic Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying 4 errors in 34 opportunities, resulting in an 11.76% error rate. The deficiency involved one resident who was admitted with diagnoses including respiratory failure, malnutrition, embolism of the right upper extremity and bilateral lower extremities, anemia, and hypotension, and who had moderate cognitive impairment and required substantial assistance with activities of daily living. The resident’s March physician orders included multiple ophthalmic medications: Brinzolamide 1% eye drops ordered as one drop twice a day without specifying which eye(s); Brimonidine 0.2% eye drops ordered as one drop in each eye twice a day; Atropine 1% eye drops ordered as one drop in the right eye; and Prednisolone Acetate 1% eye drops ordered for the right eye once daily. During observed medication administration, an LPN prepared the resident’s morning eye medications and then administered Atropine, Prednisolone, Brimonidine, and Brinzolamide in both eyes in rapid succession, without waiting the required interval between different eye drops. The LPN confirmed she did not wait five minutes between administering the eye drops, despite facility policy and manufacturer instructions requiring a waiting period between multiple ophthalmic products. She also acknowledged administering Atropine, Prednisolone, and Brinzolamide in both eyes because the resident requested drops in both eyes, even though the orders for Atropine and Prednisolone specified the right eye only and the Brinzolamide order lacked clarification regarding which eye(s) to treat. The Brinzolamide order was not clarified with the physician, contrary to facility policy requiring clarification of incomplete or questionable medication orders. Manufacturer instructions for all four medications specified waiting at least five minutes between drops (and ten minutes for Brinzolamide when used with another eye medication), which was not followed.
Failure to Document Insulin Hold and Vital Signs for Diabetic Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for a resident with multiple diagnoses, including type II diabetes mellitus with hyperglycemia, cognitive communication deficit, orthostatic hypotension, dehydration, depression, generalized anxiety disorder, and acute kidney failure. The resident required assistance with bathing, personal hygiene, and mobility, and was documented as alert and oriented to person and place. Physician orders in the medical record directed that the resident receive Humulin N NPH insulin 8 units subcutaneously twice daily at 8:00 A.M. and 4:30 P.M., and insulin Aspart 5 units subcutaneously twice daily within specified morning and afternoon time windows. On the morning in question, a nurse’s progress note documented that the resident was lethargic, breathing heavily, slow to arouse, and slowly responding to stimuli, with vital signs described only as within normal limits, and that the physician and the resident’s daughter were notified. Record review showed that the resident did not receive ordered insulin that day, and there was no physician order to hold insulin in the medical record. A medication aide reported being instructed by an LPN to hold the resident’s insulin if the resident did not eat breakfast, and the aide did not administer insulin when the resident did not eat. The LPN confirmed instructing the aide to hold insulin based on nursing judgment and acknowledged that her progress note should have contained information about the decision to hold insulin, the rationale, and the actual vital sign values rather than only stating they were within normal limits. The DON verified that the medical record contained no documentation of the decision to withhold insulin, no rationale for that decision, no recorded vital sign values for that time, and no physician order to withhold insulin, despite facility policy requiring documentation of assessments, notifications, interventions, and responses when there is a change in a resident’s condition or status.
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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 Kent
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tamarack Ridge Health And Rehabilitation | 2 mi | ★★★★★ | 2 | 0 |
| The Colony Healthcare Center | 5 mi | ★★★★★ | 17 | 0 |
| Majestic Care Of Kent | 5 mi | ★★★★★ | 30 | 0 |
| Heather Knoll Retirement Village | 5.4 mi | ★★★★★ | 2 | 0 |
| The Pinnacle Rehabilitation And Nursing Center | 5.7 mi | ★★★★★ | 8 | 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.