Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
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 Agility Health And Rehabilitation during CMS and state inspections, most recent first.
A resident with DM, weakness, and right-sided hemiplegia after a stroke had a 20% body weight loss and appeared gaunt and thin. Meal intake was under 50% on many days, but there was no documentation that meal replacement was offered, the Kardex lacked that intervention, and the IDT care conference did not result in any documented weight-loss strategies or feeding tube plan.
Care plans were inaccurate for multiple residents because current needs were omitted and resolved or discontinued issues remained listed. A resident with a pressure injury had no pressure injury care plan, another resident’s healed venous wound remained on the plan, one resident’s AC therapy and thrush were not updated, a resident on AC medication had no related focus area, and a resident with impaired vision had no vision-related care plan entries.
Bathroom emergency call light pull cords in several resident rooms were observed hanging above the handrail and not readily accessible from the floor. The Maintenance Director stated they were unaware of any regulation related to bathroom pull cords, and the Administrator stated the expectation was that resident bathroom pull cords should be accessible if a resident was on the floor.
A facility failed to initiate a grievance for concerns raised during a resident council meeting. Residents reported that concerns were not consistently resolved, including getting residents out of bed for meals and activities and shortages of washcloths and towels. Review of grievance logs showed no matching grievances, and the Activities Director stated a grievance should have been initiated.
Unclean and Poorly Maintained Resident Rooms: Two residents were affected by environmental issues in their rooms. One resident’s windowpane had a crack extending the length of the window for months, and staff gave conflicting statements about awareness of the damage. Another resident reported housekeeping was not sweeping or mopping, and trash and a liquid spill remained on the floor between the beds across multiple observations. Resident council notes also documented repeated housekeeping concerns about room cleanliness.
Failure to initiate a grievance after a resident reported that staff turned off the call light without providing assistance. The resident, who had pneumonia, CKD, and DM, said they needed help to use the restroom, but a staff member turned off the call light and did not return for 15 to 20 minutes. The concern was reported to an LPN, and the Administrator stated no grievance or investigation was initiated.
Failure to ensure appropriate use of an antipsychotic medication for a resident with dementia and depression. The resident was prescribed Risperidone for dementia with behaviors, but the record had no target-behavior monitoring order and no documentation of admission review for the psychotropic. An LPN, the Social Services Director, and the DON stated the diagnosis was not appropriate for Risperidone and that the resident should have had related behaviors monitored.
Failure to report allegations of abuse and verbal mistreatment involved two residents. One resident with cancer, PVD, and Alzheimer’s disease was reported by a family member to have been rough-handled by two male CNAs during care, left in a wheelchair overnight, and not fed breakfast, but the allegation was not documented or logged. Another resident with stroke and recent abdominal surgery reported that staff talked about them like they were not there and called them fat; the concern was not clearly recognized as a current facility allegation and was not reported or investigated as expected.
Inaccurate MDS coding affected two residents. One resident had significant weight loss documented in the EHR, but the quarterly MDS did not reflect the loss as required. Another resident with lung cancer and metastatic disease had an admission MDS that omitted active cancer diagnoses from section I. The MDS/LPN acknowledged the missing diagnosis, and the DON stated MDS assessments were expected to be coded accurately.
A resident with a stage 4 pressure injury and sepsis had ongoing loose stools, but the MAR showed no documented PRN loperamide use and the record showed no provider notification despite repeated large loose stools. The same resident was also receiving daily anticoagulant injections and was observed with dark red urine in an indwelling catheter, yet there was no documented bleeding/bruising monitoring, no progress note about the blood in the urine, and no alert charting.
Failure to maintain ROM services for two residents. One resident with ankylosis of the knee, diabetes, and generalized weakness was discharged from PT with a recommendation for a restorative ROM program, but no restorative intervention was added to the care plan and the resident reported not being offered the program. Another resident with diabetes, weakness, and right-sided hemiplegia had an order for a right elbow extension splint, but the restorative program and splinting were discontinued after refusals even though documentation showed the resident was later agreeable when re-approached by staff.
Two residents were involved in accident-hazard deficiencies. One resident with cancer, PVD, and Alzheimer’s disease was observed in a wheelchair with feet extending past short footrests, with the lower legs resting against the hard footrests despite a care plan entry for padding. Another resident with dementia and a hx of falls had an unwitnessed fall, but ordered orthostatic BP monitoring was not completed accurately and staff reported no post-fall PT referral was received.
An LPN administered nine oral medications to a resident 1 hour and 36 minutes late, despite provider orders specifying an 8:00 AM administration time. Surveyors found nine errors in 31 medication administration opportunities, and the DON stated the expected medication window was 1 hour before and 1 hour after the ordered time.
The facility failed to thoroughly investigate incidents involving two residents, including a fall with major injury and an unexpected death due to choking, by not interviewing all relevant staff, omitting key timeframes, and not reporting significant injuries as required. Another resident with severe vision impairment experienced an unwitnessed fall, and the investigation did not address prolonged periods without staff contact or include all necessary witness statements.
The facility failed to ensure safe and appropriate respiratory care for several residents with COPD and other respiratory conditions by not consistently following physician orders for oxygen administration, not documenting actual oxygen flow rates, and delaying the provision of prescribed respiratory equipment. Staff also inconsistently changed and documented respiratory equipment, and there was confusion regarding the correct procedures for respiratory care.
A resident with respiratory needs repeatedly refused oxygen therapy, BiPAP/CPAP, and other care, but the facility did not involve social services or update the care plan to address these refusals. Nursing staff documented the refusals and informed the resident's representative, but social services was unaware and did not explore the reasons or participate in care planning.
The facility did not follow up on concerns raised by residents during multiple council meetings about staff using cell phones, chatting at the nurse's station, and delayed responses to call lights. These issues were documented in meeting minutes but were not entered into the grievance log or otherwise addressed, as confirmed by both the Activities Supervisor and the Administrator.
Licensed nurses failed to consistently follow provider orders for holding blood pressure medication based on parameters and did not document non-pharmacological interventions prior to administering PRN pain medications for several residents. Facility policy required such actions and documentation, but medication records and staff interviews confirmed these steps were not taken.
Staff failed to date multiple food items and did not consistently monitor or record meal and beverage temperatures before service. The dietary manager confirmed that beverage temperatures were not taken and food temperatures were checked out of view, which did not meet regulatory expectations.
A resident prescribed olanzapine for delirium with agitation did not have an accurately completed informed consent form, as the form incorrectly listed a diagnosis of psychotic disorder, which was not present in the medical record. Both an LPN Supervisor and the DON confirmed the documentation was inaccurate and did not meet expectations.
A resident with heart failure and diabetes did not have an advance directive (AD) documented in the EHR, despite care plan notes indicating an AD was in place and that education was provided. The resident believed the facility had the AD paperwork, but both the Social Services Director and Administrator confirmed that no AD was on file and that required documentation and review did not occur as expected.
The facility did not properly identify or report allegations of abuse involving two residents. In one instance, a resident involved in a verbal altercation had no documented report to the state agency, despite claims it was reported. In another case, a resident's grievance about inappropriate staff behavior during care was not investigated or reported as potential abuse, and only customer service training was provided to the staff member.
A resident with multiple health conditions was involved in an altercation when another resident operating an electric scooter bumped their chair, causing distress. The facility did not conduct or document a thorough investigation of the incident, nor did it implement or record any interventions for the resident operating the scooter, contrary to facility policy. The DON indicated the lapse was due to a new staff member's lack of training.
Two residents were not consistently monitored according to their care plans, resulting in lapses in elopement precautions for a resident with dementia and in fall prevention measures for another resident with a history of multiple falls. Required documentation of 15-minute night checks was missing for one resident, and fall prevention signage and supervision were not maintained for the other. Staff interviews confirmed that care plan interventions were not consistently followed.
A resident with an indwelling urinary catheter was not properly monitored by nursing staff, despite care plans and orders requiring regular assessment for complications. Over several days, the resident's catheter drainage bag showed abnormal findings, and the resident experienced discomfort and urinary retention, but these issues were not documented or addressed until a provider intervened and replaced the non-functioning catheter, resulting in symptom relief.
A resident with chronic respiratory failure and COPD received oxygen at a higher flow rate than ordered, with staff administering 4.5 LPM instead of the prescribed 3 LPM via nasal cannula. Staff interviews confirmed the oxygen setting was changed without a provider's order, contrary to facility policy and the resident's care plan.
A resident with chronic kidney disease and diabetes, who was able to express needs, had broken and missing bottom teeth and reported waiting for dental care. Although an oral exam recommended a dental hygiene cleaning, there was no documentation of follow-up or that the resident was seen by a dental hygienist.
Two residents did not receive timely dental services as required. One resident with significant dental needs was not seen by the dental hygienist as recommended, and their name was omitted from follow-up lists. Another resident with dental prosthetic issues missed two dental consults and had not been seen by a dentist, with staff confirming these missed appointments did not meet expectations.
Multiple residents reported that food was served cold, tasted bad, or was unpalatable. Observations showed staff did not take food temperatures before service, and a test tray revealed overcooked and flavorless items. Resident Council records and surveys reflected ongoing concerns about food quality, and staff confirmed that temperature checks were not performed as expected.
The facility did not post the actual hours worked for nursing staff on a daily basis, instead displaying 0.00 hours for each discipline and shift over several days. Staff confirmed that while actual hours were tracked internally, they were not made available as required, and the administrator was unaware of the lapse.
The facility failed to accurately assess two residents, leading to potential risks in their care. One resident's MDS inaccurately indicated no PASRR level two and no dental issues, despite previous documentation and consultations. Another resident's MDS inaccurately showed adequate vision, despite having cataracts and blurred vision.
The facility failed to maintain sanitary conditions in resident refrigerators, with observations revealing outdated and improperly labeled food items. Both the Dietary Supervisor and the Administrator acknowledged the deficiency, noting that resident food should be labeled and discarded after three days.
The facility failed to provide and accurately complete required forms regarding potential liability for payment related to Medicare services ending for a resident. The resident's forms lacked proper documentation and signatures, diminishing their ability to make informed financial and care decisions.
The facility failed to ensure a PASRR assessment was accurately completed for a resident with depression and adjustment disorder with anxiety. The initial PASRR assessment did not document these diagnoses, and no subsequent PASRR was completed. Staff confirmed the deficiency and the need for another assessment.
The facility failed to meet professional standards of practice for two residents. One resident did not have proper measurements of their PICC line recorded before IV antibiotic administration, and another resident experienced a 30-day delay in obtaining a urology referral despite a provider's order and ongoing symptoms.
The facility failed to obtain provider orders, complete assessments, and update the care plan for a resident using a transfer pole and bed mobility bar, placing the resident at risk of improper use.
The facility failed to ensure enteral nutrition was administered according to provider orders for a resident with a feeding tube, leading to a significant weight loss. The care plan was not followed, and discrepancies in documentation and communication were identified.
The facility failed to provide timely dental assistance to two residents. One resident reported a missing denture in October 2023 and required a tooth extraction and new denture by January 2024, which had not been done by May 2024. Another resident with only four teeth had a care plan initiated in December 2023 for a dental referral, which had not been acted upon by May 2024. Staff confirmed that these services should have been provided promptly.
Failure to Address Significant Weight Loss and Poor Intake
Penalty
Summary
The facility failed to timely assess, investigate, and implement interventions for significant weight loss for Resident 112, who was admitted with diagnoses including uncontrolled diabetes, weakness, and right-sided hemiplegia and hemiparesis due to a stroke. The resident was able to make needs known. On 06/04/2026, the resident appeared gaunt and thin. The electronic health record showed weights of 184 pounds on 03/14/2026, 150 pounds on 04/11/2026, and 146 pounds on 04/19/2026, reflecting a 20 percent loss in total body weight. The care plan directed staff to monitor meal intake and offer a meal replacement if the resident ate less than 50 percent. Nutritional intake documentation showed the resident had less than 50 percent intake for one or more meals on 26 of 31 days in March 2026, 15 of 30 days in April 2026, and for 28 days from 05/14/2026 to 06/09/2026. The record contained no documentation that meal replacement was offered during March, April, May, or June 2026, and the Kardex did not include an intervention to offer meal replacement. A dietary note on 04/21/2026 stated the resident was triggering for significant weight loss and that a feeding tube would be discussed at the 04/29/2026 care conference, but the care conference documented no concerns, changes, or questions, and no feeding tube or other weight loss strategies were implemented. A nutritional assessment on 05/07/2026 noted unintentional weight loss, swallowing difficulty, self-feeding difficulty, and mild-moderate wasting in the temples and orbitals, with the resident appearing to have looser-fitting clothes and being thin.
Care plans missing current needs and unresolved conditions
Penalty
Summary
Care plans were not accurate for 5 of 22 sampled residents because needed care was not included and some resolved or discontinued conditions were not removed. The deficiency involved Residents 7, 5, 27, 4, and 98, and was identified through interview and record review. The report cited WAC 388-97-1020(1)(2)(a)(b). Resident 7 was admitted with stroke and right-sided weakness and had a pressure injury to the bottom. The resident stated their bottom was very sore and was observed lying flat on their back with heels on the mattress. The EHR showed no actual pressure injury care plan, even though a weekly skin assessment documented a stage two pressure ulcer to the bottom. Staff stated the resident should have had a pressure injury care plan but did not. Resident 5 had a focused skin integrity care plan that identified a chronic venous leg ulcer/wound on the right lower leg, but later EHR review showed no documentation of a current venous wound and the MDS showed zero venous ulcers/wounds. Resident 27 had a care plan that still listed anticoagulant therapy and thrush, but the EHR showed no current anticoagulant therapy or thrush infection, and staff stated both conditions should have been updated or resolved in the care plan. Resident 4 received an anticoagulant medication, but the plan of care had no focus area for anticoagulant use. Resident 98 had impaired vision noted on the MDS and stated they could not see well and needed to see the eye doctor, but the care plan had no problem, goal, or intervention related to visual deficit or glasses use.
Bathroom Emergency Call Light Pull Cords Not Accessible
Penalty
Summary
The facility failed to ensure bathroom emergency call light pull cords were accessible to residents from the floor in resident rooms 106, 107, 121, and 311 on 2 of 4 sampled halls (100 and 300) reviewed for call light systems. Observations showed the pull cords in those bathrooms hung above the handrail on the wall and were not readily accessible to a resident if the resident were on the floor after a medical emergency or fall. During interview, the Maintenance Director stated they were unaware of any regulation related to bathroom call light pull cords, and the Administrator stated the expectation was that resident bathroom pull cords should be accessible to call for help if the resident was on the floor.
Failure to Initiate Grievance for Resident Council Concerns
Penalty
Summary
The facility failed to initiate a grievance for resident care concerns voiced during a resident council meeting. During an interview on 06/08/2026, resident council members stated the facility did not consistently provide resolutions to concerns discussed at council meetings. Review of the May 2026 resident council minutes showed concerns about getting residents out of bed for meals and activities and a shortage of washcloths and towels. Review of grievance logs from 02/2026 through 06/2026 showed no grievances corresponding to the concerns raised at the resident council meeting. Staff R, Activities Director, stated they did not initiate a grievance related to the residents' concerns but should have, and Staff A, Administrator, stated it did not meet expectations that specific concerns brought up in resident council had not been addressed and followed up on.
Unclean and Poorly Maintained Resident Rooms
Penalty
Summary
The facility failed to maintain a clean, sanitary, and well-maintained resident environment for two sampled residents. Resident 112’s room was observed on two occasions to have a single crack in the right windowpane extending the length of the window. During interview, the Maintenance Director stated the window had been broken for six months, that they did not have authority to purchase a replacement window, and that facility administration was aware of the crack. The Administrator later stated they were unaware the window was cracked and said the maintenance department conducted several monthly resident room audits, during which the window should have been noted and repaired. The Administrator also stated the cracked resident window did not reflect a homelike environment. Resident 67, who was admitted with diabetes and was able to make needs known, stated during observation and interview that housekeeping did not sweep and mop and had just finished cleaning the room but left the floors dirty. Trash and a liquid spill were observed on the floor between the beds, and the same trash and spill were still present the next day. Resident council notes from March 2026 documented a request for housekeeping to ensure beds, nightstands, and surrounding areas were cleaned thoroughly, and April 2026 notes documented concerns that housekeeping was not removing trash from under the bed for three days. The Housekeeping staff member stated rooms should be swept and mopped every day, and the Administrator stated it was the expectation that resident rooms be swept and mopped daily and as needed.
Failure to Initiate Grievance for Resident Concern About Call Light Response
Penalty
Summary
The facility failed to initiate a grievance after Resident 138 raised a concern about staff customer service. Resident 138 was admitted with pneumonia, chronic kidney disease, and diabetes, and was able to make needs known. During observation and interview, Resident 138 was sitting in a wheelchair just inside the room door with an upset expression and stated they had turned on the call light because they needed help to use the restroom. Resident 138 stated a staff member entered the room, turned off the call light, and said they would return to assist, but the resident waited 15 to 20 minutes for the staff member to come back and was upset about having to wait. The concern was reported to an LPN, and during interview the Administrator stated that if a resident reported staff had turned off the call light without providing care, a grievance should be completed. The Administrator also stated that turning off the call light without providing care increased the likelihood of neglect if the staff member forgot to return. The Administrator stated no grievance or investigation was initiated in response to Resident 138's concern, and this did not meet expectations.
Failure to Monitor and Justify Antipsychotic Use
Penalty
Summary
The facility failed to ensure the use of an antipsychotic medication was appropriate for one sampled resident, Resident 50, by not providing adequate monitoring or an appropriate indication for its use. Resident 50 was admitted with diagnoses of dementia with behaviors and depression, and the record also showed PASRR findings of depression, anxiety, and later severe depression. The provider ordered Risperidone daily at bedtime for dementia with behaviors starting 03/31/2026, but the electronic health record contained no order to monitor target behaviors related to the antipsychotic medication. The record also showed no documentation that Resident 50 was reviewed on admission for the use of an antipsychotic medication. During interviews, an LPN stated the diagnosis of dementia with behaviors was not an appropriate diagnosis for an antipsychotic medication and that target behaviors should have been monitored but were not. The Social Services Director stated the resident should have been reviewed in the monthly psychotropic meeting on admission, that dementia with behaviors was not an appropriate diagnosis for Risperidone, and that related behaviors should have been monitored. The DON stated the resident should have been reviewed in the monthly psychotropic meeting, had target behaviors monitored, and had an appropriate diagnosis for the antipsychotic.
Failure to Report Allegations of Abuse and Verbal Mistreatment
Penalty
Summary
The facility failed to ensure that allegations of potential abuse, neglect, or verbal abuse were identified and reported to the Administrator and/or the State Survey Agency for 2 of 7 sampled residents. The report cites WAC 388-97-0640(5)(a) and the facility’s Purple Book guidance stating that alleged violations involving mistreatment, neglect, or abuse must be reported immediately to the Administrator and to other officials in accordance with State law, including the State survey and certification agency. Resident 27 was re-admitted with diagnoses including cancer, peripheral vascular disease, and Alzheimer’s disease, and was sometimes able to make needs known. A family member reported that Resident 27 said two male nursing aides awakened them in the middle of the night or early morning and handled them roughly during care, and that the resident had been left in a wheelchair all night and had not eaten breakfast. The family member said they reported this to nursing staff, but there was no documentation of an abuse allegation in the EHR and no incident logged for the resident. Staff E stated they did not report it because they thought the nurse would follow up. Resident 7 was admitted with stroke with right side weakness and recent abdominal surgery and was able to make needs known. Resident 7 stated staff talked about them like they were not there and called them fat, and later clarified that the incident happened at the facility. Staff L, the speech therapist, stated the resident mentioned a concern but that the resident’s husband said it happened at the last facility, so it was not understood as a current facility issue. The Administrator and DNS stated it was their expectation that the concern be reported and investigated, and that this did not meet their expectations.
Inaccurate MDS Coding for Weight Loss and Active Diagnoses
Penalty
Summary
The facility failed to ensure the minimum data set (MDS) accurately reflected the status of 2 of 22 sampled residents reviewed for assessment accuracy. For Resident 112, the electronic health record showed admission with diagnoses including diabetes, weakness, and hemiplegia/hemiparesis affecting the right side. The resident was able to make needs known. The record also showed weights of 184 pounds on 03/14/2026, 150 pounds on 04/11/2026, and 146 pounds on 04/19/2026, but the 05/06/2026 quarterly MDS marked the item for loss of 5 percent or more in the last month or loss of 10 percent or more in the last 6 months as NO or UNKNOWN. For Resident 21, the electronic health record showed admission with diagnoses including malignant neoplasm of the lung and secondary malignant neoplasm of the brain and adrenal gland. The admission MDS showed the resident was able to communicate needs, but the cancer diagnoses were not coded in section I for active diagnoses. During interviews, the MDS/LPN stated the cancer diagnosis was missing from the MDS and should have been coded, and the DON stated the expectation was that MDS assessments were coded accurately and that active diagnoses should be on the MDS.
Failure to Monitor Loose Stools and Bleeding During Anticoagulant Therapy
Penalty
Summary
The facility failed to provide treatment and care according to orders, resident preferences, and goals for Resident 81, who was admitted with a stage 4 pressure injury to the bottom and sepsis and was able to make needs known. For bowel management, the resident reported loose stools for a couple of weeks and later stated they had been having diarrhea with abdominal discomfort for 3 days, so loperamide was started as needed. The bowel monitor documented repeated loose stools over several days, including two loose stools on 06/04/2026, three large loose stools on 06/05/2026, and two large loose stools on 06/06/2026 through 06/08/2026. The resident stated staff had not given any medication for the loose stools, the June 2026 MAR showed no documented doses of loperamide, and the record showed no documentation that the provider was notified of the three large loose stools. Staff interviews indicated that frequent loose stools should have been reported to the provider, PRN medication given, and the resident placed on alert charting, but this did not occur. For anticoagulant therapy, Resident 81 was receiving daily anticoagulant injections starting 05/21/2026. During observation, the resident was lying in bed with an indwelling urinary catheter and dark red urine was noted in the tube and bag; the resident stated, "It's never been like that. It's scary." The EHR showed no monitoring for bleeding and bruising related to anticoagulant therapy, and the progress notes contained no documentation about the blood in the urine or alert charting. Staff interviews confirmed the resident had blood in the catheter for a couple of days and that monitoring for bleeding should have been in place, but it was not.
Failure to Maintain ROM Services for Two Residents
Penalty
Summary
The facility failed to ensure residents with limited ROM received the necessary services to maintain their level of functioning for 2 of 4 sampled residents reviewed for limited ROM. Resident 24 was admitted with diagnoses including ankylosis of the left knee, diabetes, and generalized muscle weakness. The resident stated they had been told they would start an exercise program after discharge from PT but had not been offered participation in a restorative program. The PT discharge summary recommended a restorative ROM program for both lower extremities, but the care plan initiated on 12/25/2025 did not include any restorative program intervention. The DOR stated the facility failed to initiate and implement a restorative program for Resident 24 after PT discharge. Resident 112 was admitted with diagnoses including diabetes, weakness, and hemiplegia and hemiparesis affecting the right side. Observations showed an elbow splint on a corner table in the resident’s room, and the EHR included an order to apply a right elbow extension splint in the morning for up to six hours per day, as tolerated, three to six times per week. A progress note stated the restorative program and splinting were discontinued per recommendations related to resident refusal, and the care plan, tasks, and restorative aide were updated. The restorative flow sheet showed three refusals of splint assistance between 05/14/2026 and 06/04/2026, with documentation that the resident was re-approached by alternate staff and then agreeable to wear the splint. The restorative aide stated they had no experience with the resident refusing splint assistance, and the DOR stated that three refusals in 30 days was uncommon and did not meet expectations for discontinuing the restorative program.
Unsafe Wheelchair Fit and Incomplete Post-Fall Monitoring
Penalty
Summary
The facility failed to provide an environment free from accident hazards for two residents. Resident 27 was readmitted with diagnoses including cancer, peripheral vascular disease, and Alzheimer's disease and was sometimes able to make needs known. On multiple observations, Resident 27 was seated in a slightly tilted back wheelchair with feet extending beyond the footrests, and the back of the lower legs rested against the hard footrests above the ankle/heel area. A pillow was observed either on the floor or behind the legs rather than padding the footrests. The focused care plan for skin integrity included padding to wheelchair footrests, and staff interviews confirmed the footrests were too short and needed adjustment or replacement, but staff had not notified therapy or otherwise addressed the wheelchair fit. Resident 50 was admitted with diagnoses including dementia, history of falls, and UTI and was sometimes able to make needs known. The care plan identified the resident as at risk for falls. After an unwitnessed fall in the 300 hallway, the incident investigation added interventions to monitor orthostatic blood pressures and refer to physical therapy. However, the record showed an orthostatic blood pressure order on 05/20/2026 was not completed, and subsequent orthostatic blood pressures recorded the same blood pressure and pulse for all three positions on 05/22/2026, 05/23/2026, and 05/24/2026. Staff later stated they had not received a post-fall therapy referral, and the DNS stated the resident should have had orthostatic blood pressures taken accurately to rule out orthostatic hypotension.
Medication Administration Timing Error Exceeded Allowed Error Rate
Penalty
Summary
The facility failed to ensure a medication error rate of less than five percent. During observation, interview, and record review, surveyors found that Staff J, an LPN, prepared and administered nine oral medications to Resident 96 at 9:36 AM even though the provider’s orders for June 2026 specified that the medications were to be given at 8:00 AM. The medications were administered one hour and 36 minutes late, and this accounted for nine errors in 31 opportunities during medication administration for 1 of 6 sampled residents reviewed for medication administration. During interview, Staff J stated nurses had up to two hours to administer medications after the ordered time, while the DON stated the medication administration time was one hour before and one hour after the specific time of the order and that the nurse’s practice did not meet expectations.
Failure to Conduct Thorough Investigations into Abuse, Neglect, and Significant Injury
Penalty
Summary
The facility failed to implement its abuse prohibition policy for two residents by not conducting thorough investigations into incidents of abuse, neglect, and significant injury. For one resident, after a fall resulting in a broken arm and hip, the facility's investigation did not include statements from all relevant staff, such as those who delivered and picked up the resident's lunch, the nursing assistant assigned to the resident, or the student who found the resident. The investigation also failed to address the period between the last staff contact and the discovery of the fall, and did not consider whether the resident received lunch or if pain medication was effective. Additionally, the resident was not receiving oxygen at the physician-ordered rate at the time of the fall, and the incident was not reported in the abuse reporting logs as required for substantial injury related to a fall. In the case of the same resident's unexpected death, the facility did not thoroughly investigate the possibility of choking, despite multiple indications that choking may have been involved. Staff interviews and documentation revealed inconsistencies regarding the location of the meal tray and the events leading up to the resident being found unresponsive. The police report and statements from the resident's representative indicated that the resident had a history of choking and that food was found in the airway during the autopsy. The facility's investigation did not include all relevant witness statements or consider the choking hazard, even though the death certificate listed choking on a food bolus as the cause of death. For another resident with severely impaired vision and a history of falls, the facility's investigation into an unwitnessed fall was incomplete. The resident, who required extensive assistance and one-on-one staff support for meals, was found on the floor after not being seen by staff for over two hours. The investigation did not address why the resident was left unattended for such a period or include statements from all staff involved in the resident's care. The facility's actions did not align with its own policies for investigating abuse, neglect, and significant injuries, as required by regulation.
Failure to Provide Safe and Appropriate Respiratory Care per Physician Orders
Penalty
Summary
The facility failed to provide respiratory care and services in accordance with physician orders and accepted professional standards for four out of five residents reviewed for respiratory services. For one resident with chronic hypoxic respiratory failure and COPD, there were multiple inconsistencies in oxygen administration, including titrating oxygen below the ordered rate, not documenting the actual flow rate delivered, and delays in providing prescribed respiratory equipment such as CPAP and BiPAP machines. Documentation showed that staff did not consistently follow or document the specific oxygen flow rates as ordered, and there were periods when the resident did not have access to required respiratory equipment, resulting in repeated hospitalizations for respiratory complications. Another resident with COPD was observed receiving oxygen at a rate that was not documented in the medical record, and staff failed to record the oxygen flow rate or corresponding oxygen saturation as required by physician orders. Orders for changing nasal cannulas and oxygen tubing were inconsistently documented, and staff interviews confirmed that documentation practices did not align with facility policy or physician directives. Additionally, there was confusion among staff regarding the necessity and frequency of changing respiratory equipment, with some orders being redundant or unclear. For two other residents with COPD, observations revealed improper use of humidification with oxygen therapy, lack of documentation regarding whether oxygen saturation was measured with or without supplemental oxygen, and discrepancies between observed oxygen flow rates and those ordered by the provider. Staff interviews further revealed a lack of clarity and consistency in following and documenting respiratory care orders, including the administration of oxygen at the correct flow rates and the timely replacement of respiratory equipment such as humidifier bottles and tubing.
Failure to Provide Social Services for Resident Refusing Respiratory Care
Penalty
Summary
The facility failed to provide medically-related social services for a resident who was reviewed for respiratory services. Despite multiple documented instances of the resident refusing essential care, such as oxygen therapy, BiPAP/CPAP use, fluid restrictions, and showers, there was no evidence that the facility's social services department was involved to address these refusals. Nursing notes and care manager documentation repeatedly described the resident as noncompliant with prescribed treatments and care recommendations, and the resident's representative was informed of these refusals. However, the social services director confirmed they were unaware of the resident's ongoing refusals and had not been notified by nursing staff. Additionally, the care plan did not include any interventions to address the resident's refusal behaviors, and there was no documentation of social services exploring the reasons for the refusals or participating in care conferences regarding these issues. The resident's representative had requested to be notified of refusals so they could intervene, but reported not receiving further communication from the facility. The lack of social services involvement and absence of a behavior-focused care plan contributed to the deficiency, as the resident continued to refuse necessary care up until their passing.
Failure to Address Resident Council Concerns Regarding Staff Responsiveness
Penalty
Summary
The facility failed to follow up on concerns raised by residents during three consecutive resident council meetings, as documented in the minutes from November and December 2024, and January 2025. Residents expressed issues regarding staff on the evening and night shifts, specifically noting that staff were chatting at the nurse's station, using cell phones, and not responding promptly to call lights, resulting in long wait times. Despite these concerns being documented in the council meeting minutes, there was no corresponding documentation in the grievance log, and no grievances were initiated related to these issues. The Activities Supervisor confirmed that grievances were not initiated for concerns raised in resident council meetings and indicated that residents should seek assistance from social services if they wished to file a grievance. The Administrator acknowledged that it was not their expectation for such concerns to go unaddressed.
Failure to Follow Medication Orders and Document Non-Pharmacological Interventions
Penalty
Summary
The facility failed to ensure that provider orders for medication administration were consistently followed and that non-pharmacological interventions (NPI) were initiated prior to administering as needed (PRN) pain medications. For one resident with multiple diagnoses including heart, lung, and kidney disease, and hypertension, the provider's order specified that midodrine should be held if the systolic blood pressure was greater than 120. However, review of the medication administration records over several months showed that licensed nurses administered midodrine multiple times when the resident's systolic blood pressure exceeded the specified parameter. Both a Licensed Practical Nurse and the Director of Nursing Services confirmed that the expectation was to hold the medication as ordered, but this was not done. Additionally, three other residents with various diagnoses, including depression, diabetes, bipolar disorder, osteomyelitis, pressure ulcer, heart failure, fractures, and acute kidney failure, were administered PRN pain medications such as acetaminophen and oxycodone without documentation that NPIs were offered or provided beforehand. Medication administration records for these residents showed repeated instances where pain medications were given without any record of NPIs being attempted or documented, as required by facility policy. Interviews with nursing staff and the Director of Nursing Services confirmed that NPIs should have been offered and documented prior to administering PRN pain medications, but this was not consistently done. The facility's own policy required licensed nurses to be familiar with medications, especially those with boxed warnings, and to monitor and document appropriate parameters and interventions. The lack of adherence to these policies and provider orders resulted in residents receiving medications without proper justification or prior use of alternative interventions, as evidenced by the documentation and staff interviews.
Failure to Date Food Items and Monitor Meal Temperatures
Penalty
Summary
The facility failed to ensure that food items were properly dated and that meals and beverages were served at appropriate temperatures, as required by professional standards. During an initial kitchen tour, multiple flavored syrups and large containers of seasonings, including parsley, paprika, taco seasoning, ground pepper, thyme, and ginger, were observed to be undated. On a subsequent observation of the tray line, a cook placed all entrees and side items for the lunch meal on the steam table, but there were no observations of temperatures being taken prior to service. Review of the lunch meal temperature log showed temperatures for all items, including cold beverages, but it was later confirmed by the dietary manager that beverage temperatures were not taken and that food temperatures were taken out of view. Both the dietary manager and the administrator acknowledged that these actions did not meet facility expectations or regulatory requirements.
Inaccurate Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that informed consent for the use of a psychotropic medication was accurately completed prior to administration for one resident. The resident, who had diagnoses of depression and bipolar disorder, was prescribed olanzapine for delirium with agitation. However, the informed consent form indicated the medication was prescribed for a psychotic disorder, a diagnosis not present in the resident's medical record. Interviews with facility staff confirmed that the informed consent form was not accurately filled out, as the resident did not have a diagnosis of psychotic disorder. Both the LPN Supervisor and the Director of Nursing Services acknowledged that the documentation did not meet expectations, as the consent form did not reflect the resident's actual diagnoses or the correct indication for the medication.
Failure to Obtain and Document Advance Directive for Resident
Penalty
Summary
The facility failed to obtain and document an advance directive (AD) for one resident, despite multiple indications in the resident's records that an AD was either in place or should have been reviewed. The electronic health record (EHR) for the resident, who was admitted with diagnoses including heart failure and diabetes, did not show an AD on file. The resident believed that an AD had been completed and that the facility had the paperwork. Care plan documentation referenced an AD and indicated that education was provided and that staff would review healthcare directives with the resident at least quarterly. However, upon review, the admission record did not show an AD, and the Social Services Director confirmed that no AD was in place at the time. The Social Services Director also acknowledged that a discussion about the AD should have been documented upon the resident's readmission, but this did not occur. The Administrator stated that ADs were to be reviewed upon admission and quarterly, and documented in the EHR, but was unable to locate the AD for this resident, confirming that documentation did not meet expectations.
Failure to Identify and Report Allegations of Abuse
Penalty
Summary
The facility failed to identify and report allegations of abuse for two residents. For one resident with a history of fracture, diabetes, insomnia, and chronic pain, a verbal altercation with a roommate was documented in the incident log. Although the incident report indicated it was reported to the state hotline, there was no documentation to confirm this, and the Director of Nursing Services could not provide evidence that the report was made to the state agency. In another case, a grievance was filed by a resident who reported that a staff member acted inappropriately during care, including grinning, singing, and winking while the resident was undressed. The facility's investigation was limited to providing customer service training to the staff member and did not include interviews with other residents or a formal investigation to rule out abuse. The Director of Nursing Services acknowledged that no investigation was conducted for this allegation, and the Administrator was not present during the time of the grievance.
Failure to Investigate Resident Altercation and Rule Out Abuse
Penalty
Summary
The facility failed to thoroughly investigate an incident involving an altercation between two residents, one of whom had a history of a right humerus fracture, type 2 diabetes, insomnia, and chronic pain syndrome, and was able to communicate needs. The incident occurred when one resident, using an electric scooter, bumped another resident's chair, causing it to spin. Following the event, staff observed the affected resident with their head down and moved them to another area to relax. The incident report indicated that the plan was to remove the electric scooter from the resident who caused the incident. However, a review of records showed that no investigation was conducted or documented regarding the altercation, and no interventions were recorded for the resident operating the scooter after the occurrence. The facility's policy required identification and interviews of all involved parties and thorough documentation to determine if abuse had occurred. During an interview, the DON stated that investigations are typically conducted for such incidents but was unsure why it did not happen in this case, attributing the lapse to a new staff member who needed more training.
Failure to Consistently Monitor and Implement Accident Prevention Interventions
Penalty
Summary
The facility failed to consistently monitor and address risk factors to minimize accident hazards for two residents. One resident, with diagnoses including dementia, substance abuse, and severe cognitive impairment (BIMS score of 5/15), was identified as high risk for elopement. Despite a care plan requiring one-on-one supervision during day and evening shifts and 15-minute checks at night, there was no documentation of the required 15-minute checks during the night shift. The resident exhibited ongoing exit-seeking behaviors, including being found in the parking lot attempting to leave the facility, and staff documented continued attempts to leave and poor safety awareness. Another resident, with a history of depression, diabetes, and bipolar disorder, was identified as a fall risk and had experienced multiple falls. The care plan included interventions such as a 'CALL DON'T FALL' sign and keeping the bed in the lowest position when unattended. Observations revealed that the sign was not posted in the resident's room during multiple visits, and the resident was found alone on a bed in the highest position while being partially dressed. The CNA assisting the resident was unfamiliar with the resident's fall risk status and left the resident unattended, contrary to the care plan interventions. Interviews with staff confirmed lapses in following care plan interventions for both residents. The Director of Nursing Services acknowledged that the required monitoring and documentation for the resident at risk of elopement were not completed as expected. Similarly, staff confirmed that the fall prevention interventions for the other resident were not consistently implemented, and the absence of the required signage and supervision did not meet facility expectations.
Failure to Monitor and Document Indwelling Catheter Function
Penalty
Summary
A deficiency occurred when the facility failed to properly monitor and document the use and function of an indwelling urinary catheter for a resident with multiple diagnoses, including neurogenic bladder and a history of urinary tract infection. The resident's care plan and physician orders required licensed nurses to check catheter functionality and monitor for complications every shift, including observing for signs of infection, catheter occlusion, and changes in urine output or appearance. Despite these requirements, observations over several days revealed the resident's catheter drainage bag contained sediment, dark cloudy urine, and later, a scant amount of dark blood-tinged urine. The resident also exhibited increased anxiety, a distended abdomen, and an increased respiratory rate, but there was no documentation of these findings or any action taken to address the catheter's function during this period. The resident reported feeling the urge to urinate and abdominal discomfort, which had persisted since the previous evening. Staff interviews confirmed that the LPN was unaware of the abnormal urine output and had not notified the provider until prompted. Upon assessment by the provider, a bladder scan revealed significant urine retention, leading to the immediate replacement of the non-functioning catheter, which resulted in prompt relief of the resident's symptoms. The lack of timely assessment, documentation, and intervention regarding the resident's catheter and urinary output constituted a failure to provide appropriate catheter care as required by facility policy and professional standards.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to provide respiratory care in accordance with professional standards for one resident who required continuous oxygen therapy. The resident, who had a history of heart and kidney disease, neurogenic bladder, urinary tract infection, and chronic respiratory failure with COPD, had a provider's order for oxygen at 3 liters per minute (LPM) via nasal cannula every shift. The resident's care plan also specified continuous oxygen therapy at the ordered rate, with licensed nurses responsible for administering oxygen as ordered. Despite these orders, observations on multiple occasions showed the resident receiving oxygen at a flow rate of 4.5 LPM, which exceeded the provider's order. During interviews, an LPN acknowledged that the oxygen flow rate had been increased without a provider's order and stated they would return it to the prescribed 3 LPM. The DON confirmed that the expectation was for staff to follow the provider's order and not change the oxygen setting without authorization. This failure to adhere to the ordered oxygen flow rate constituted a deficiency in providing safe and appropriate respiratory care.
Failure to Provide Dental Services Following Recommendation
Penalty
Summary
The facility failed to provide dental services for one resident who was admitted with chronic kidney disease and diabetes and was able to communicate their needs. Observation revealed that the resident had broken and missing bottom teeth and reported waiting to see the dental hygienist. A prior oral exam had recommended a dental hygiene cleaning, but review of the electronic health record showed no documentation of follow-up on this recommendation. During an interview, the Social Services Director confirmed that there was no documentation indicating the resident had been seen by the dental hygienist, despite the recommendation.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide prompt dental services for two residents. One resident, who had a history of heart failure, anxiety disorder, and depression, was identified as having obvious or likely cavities, broken natural teeth, inflamed or bleeding gums, or loose natural teeth during a significant change in condition assessment. The care plan included a referral to a dentist or dental hygienist, and a dental prophylaxis report recommended a six-month follow-up for maintenance. However, there was no documentation that this maintenance was conducted as recommended, and the resident's name was not included on the dental exam list for subsequent visits. Staff interviews confirmed that the resident was not seen by the dental hygienist as scheduled, and communication with the dental scheduler was delayed. Another resident, admitted with a fracture, type two diabetes, insomnia, and chronic pain syndrome, reported not having an upper denture and an ill-fitting lower denture. This resident had not seen the dentist and was unaware of any plans for a dental visit. Dental consult records showed that the resident was not seen on two separate occasions due to not being present in the room. Staff acknowledged that missing these appointments did not meet expectations.
Failure to Serve Palatable Food at Safe Temperatures
Penalty
Summary
The facility failed to ensure that food was served at proper temperatures and with palatable taste, as evidenced by multiple resident interviews and direct observations. Residents reported that food was served cold, tasted bad, and was described as horrible. Observations showed that staff did not take food temperatures prior to service, and a test tray revealed overcooked and unpalatable food items. Review of Resident Council Minutes and questionnaires indicated ongoing dietary concerns and poor ratings for food quality. Staff interviews confirmed that the lack of temperature checks did not meet facility expectations.
Failure to Post Actual Nurse Staffing Hours Daily
Penalty
Summary
The facility failed to post the actual hours worked for nursing staff each day over a five-day survey period. Observations on multiple days showed that the posted nurse staffing information listed 0.00 actual hours worked for each discipline on each shift. Interviews with the staff schedule coordinator and the human resources specialist confirmed that while actual hours worked were tracked in the computer system, they were not posted as required. The administrator was unaware that the postings were not being updated with actual hours worked, despite the expectation that this information be updated at the beginning of each shift. This failure prevented residents, family members, and visitors from accessing accurate information about the number of available nursing staff in the facility during the survey period.
Inaccurate Resident Assessments
Penalty
Summary
The facility failed to accurately assess two residents, leading to potential risks in their care. Resident 2's annual minimum data set (MDS) inaccurately indicated no pre-admission screening and resident review (PASRR) level two and no dental issues. However, the resident had a PASRR level two completed previously and had reported losing their denture months earlier. Despite a denture consultation recommending new dentures, the MDS was not updated to reflect these dental issues. Staff interviews confirmed the oversight in coding the PASRR and dental issues accurately. Resident 68's quarterly MDS inaccurately showed adequate vision without corrective lenses, despite the resident having cataracts and blurred vision. The resident's care plan noted impaired vision due to cataracts, but this was not reflected in the MDS. Staff interviews revealed that the resident's vision issues were not mentioned during the assessment, leading to incorrect coding. The Director of Nursing Services acknowledged the inaccuracies in the PASRR section for Resident 2 and the need for re-assessment of Resident 68's vision issues.
Failure to Maintain Sanitary Conditions in Resident Refrigerators
Penalty
Summary
The facility failed to maintain resident refrigerators in sanitary conditions, as observed on 05/07/2024. The resident refrigerator's freezer contained a severely freezer burnt hotdog in a plastic container without a date label and a box of yogurt sticks with a best by date of November 2023. The refrigerator section had a brown paper bag dated 04/26/2024 with artichoke dip and antipasto salad with sell-through dates of 04/29/2024, an original cardboard pizza box with a date of 04/26/2024 with dried, curled slices of pizza, a small cake without name or date, a plastic bag with a hamburger wrapped in paper with no name or date, and a bag with cut fruit with a sell-through date of 04/22/2024. During interviews, both the Dietary Supervisor and the Administrator acknowledged that the resident refrigerator did not meet the expected sanitary food storage standards, with the Administrator noting that resident food should be marked with a name and date label and discarded after three days.
Failure to Provide and Complete Required Medicare Coverage Forms
Penalty
Summary
The facility failed to provide and accurately complete the required forms regarding potential liability for payment related to Medicare services ending for Resident 14. Resident 14, who was admitted with diagnoses including pneumonia and weakness, was their own responsible party and did not have a durable power of attorney. The electronic health record did not show documentation that Resident 14 was provided the Notice of Medicare Non-Coverage (NOMNC) or the Skilled Nursing Facility (SNF) Advanced Beneficiary Notice (ABN). The NOMNC form indicated that coverage would end on 03/07/2024, but lacked the resident's or representative's signature. Similarly, the SNF ABN form was undated and unsigned, with only a handwritten note indicating a phone call, but no further documentation or signatures were present. During interviews, Staff C, the Business Office Manager, acknowledged that they should have documented additional information and attempts to obtain signatures on the forms. The Administrator, Staff A, also reviewed the forms and confirmed that they did not meet expectations. The lack of proper documentation and signatures on these forms diminished Resident 14's ability to make informed financial and care decisions related to their continued stay.
Incomplete PASRR Assessment for Resident
Penalty
Summary
The facility failed to ensure a Pre-Admission Screening and Resident Review (PASRR) assessment was accurately completed upon or prior to admission for one resident reviewed for unnecessary medications. Resident 76 was admitted with diagnoses of depression and adjustment disorder with anxiety. The quarterly minimum data set (MDS) indicated that the resident was able to make their needs known. However, the PASRR assessment completed by the hospital prior to admission did not document these serious mental illness indicators and showed no Level II evaluation was indicated. The facility's electronic health record also lacked documentation of another PASRR assessment. Interviews with the Senior Regional Social Services Director and the Director of Nursing Services confirmed that the PASRR was missing critical diagnoses and did not meet expectations, necessitating another PASRR assessment.
Failure to Meet Professional Standards of Practice
Penalty
Summary
The facility failed to ensure services provided met professional standards of practice for two residents. Resident 214, admitted with osteomyelitis and requiring long-term IV antibiotic treatment via a PICC line, did not have proper measurements of the PICC line catheter length recorded prior to administering the IV antibiotics. The medication administration record and care plan lacked directives for licensed nurses to measure the PICC line, and staff interviews confirmed that measurements were not taken or recorded as required. Resident 39, admitted with multiple diagnoses including heart disease, diabetes, and a UTI, had a provider order for a referral to a urologist due to a mass on the left kidney. Despite complaints of dysuria, there was no documentation of the urology consultation being obtained. Staff interviews revealed that the referral was not sent until 30 days after the order was made, indicating a significant delay in following the provider's order for a specialist consultation.
Failure to Ensure Proper Use of Safety Devices
Penalty
Summary
The facility failed to ensure that proper procedures were followed for the use of safety devices, specifically a transfer pole and a bed mobility bar, for Resident 11. Resident 11, who has hemiplegia affecting the left side of the body, was observed using these devices without any provider orders, safety device assessments, or consents documented in their electronic health record (EHR). Multiple observations over several days showed the transfer pole and bed mobility bar in use, but there were no markings to indicate the correct placement of the bed in relation to these devices to ensure safe transfers. Interviews with Resident 11 and staff members confirmed the lack of proper documentation and procedures. Resident 11 stated that they used the transfer pole with staff assistance and the bed mobility bar for repositioning. Staff members, including a Registered Nurse/Manager and the Director of Nursing Services, acknowledged that there should have been provider orders, assessments/consents, and care plan updates for the use of these safety devices. The absence of these critical steps placed Resident 11 at risk of improper use of the transfer pole and bed mobility bar.
Failure to Administer Enteral Nutrition per Provider Orders
Penalty
Summary
The facility failed to ensure enteral nutrition was administered in accordance with provider's orders and professional standards of practice for a resident with a feeding tube. Resident 15, who had diagnoses including stroke, hemiplegia, and dysphagia, was admitted to the facility and required tube feeding. The care plan for Resident 15 included monitoring caloric intake and following provider orders for tube feeding. However, the facility did not have a system in place to reconcile the amount of enteral formula the resident received with the amount they were ordered to receive. This led to discrepancies in the documentation of the total volume of enteral feed infused, as evidenced by multiple instances where the medication administration records (MAR) showed an 'X' instead of the actual amount infused. Consequently, Resident 15 experienced a significant weight loss of 9.8 pounds over a short period, which was not promptly addressed or communicated to the provider or registered dietician as required by the facility's protocols. Interviews with staff revealed that the weight loss was not placed into the weight loss binder to inform the registered dietician, and the resident was not re-weighed or the provider notified in a timely manner. The Assistant Director of Nursing Services (ADNS) and the Director of Nursing Services (DON) acknowledged that the enteral feed totals should have been monitored and documented per provider orders, and any significant weight loss should have been re-weighed and reported. The registered dietician also noted the absence of a designated area in the electronic health record (EHR) MAR for documenting the total volume of enteral feed infused. This lack of proper documentation and communication led to the resident's nutritional needs not being adequately met, as evidenced by the significant weight loss.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide timely dental assistance to two residents, leading to deficiencies in their care. Resident 2 reported a missing denture in October 2023, and a progress note from 10/10/2023 confirmed this. A denture consultation on 01/24/2024 recommended an x-ray, tooth extraction, and a new lower partial denture, but these actions had not been taken by the time of the interview on 05/09/2024. Resident 53, who had only four teeth, had a care plan initiated on 12/25/2023 that included a referral to a dentist/hygienist. However, by 05/09/2024, this referral had not been acted upon. Staff interviews confirmed that these dental services should have been provided promptly.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,021 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near University Place
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Birch Creek Post Acute & Rehabilitation | 1.4 mi | ★★★★★ | 35 | 0 |
| Orchard Park Health Care & Rehab Center | 1.5 mi | ★★★★★ | 45 | 0 |
| Park Rose Care Center | 3.1 mi | ★★★★★ | 0 | 0 |
| Alaska Gardens Health And Rehabilitation | 3.3 mi | ★★★★★ | 20 | 1 |
| Avamere Transitional Care Of Puget Sound | 3.4 mi | ★★★★★ | 56 | 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.