Average — CMS composite of the measures below.
The next survey window likely opens around January 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 Alderwood Manor during CMS and state inspections, most recent first.
Hand hygiene was not completed when indicated during medication administration by an RN and an LPN, including after contact with unclean items and between residents. EBP was not implemented for two residents with indwelling medical devices, including a dialysis catheter and a feeding tube, with no signage or PPE tote observed outside their rooms. The facility also lacked documentation showing routine Water Management Plan measures were completed to reduce Legionella risk.
A resident with dementia, repeat falls, and moderate cognitive impairment sustained numerous falls, including multiple falls on the same day. After several unwitnessed falls, VS and neuro checks were not completed per the facility flow sheet, alert/progress notes were not done each shift for 72 hours, and when the resident fell again during monitoring, the checks were not restarted at 15-minute intervals. The DON confirmed staff did not follow the facility process for post-fall monitoring.
A facility failed to ensure dialysis residents received medications as ordered when they were away for treatments, and fluid restrictions were not accurately documented or monitored for two residents. Records showed multiple missed or undocumented doses of meds such as phosphate binders, beta blockers, and pain meds, along with incomplete dialysis communication forms and fluid intake totals far below ordered limits. Staff interviews confirmed inconsistent tracking of fluids and incomplete dialysis documentation.
Expired vaccines were found in a medication refrigerator, and both medication rooms had temperatures outside the recommended range with inconsistent temperature monitoring. An LPN, an RN, and the DON acknowledged that proper storage temperatures were important because medications and vaccines could lose effectiveness when not kept within range.
The facility failed to maintain a clean kitchen, and dietary staff did not perform hand hygiene when indicated during meal prep and glove changes. Two nourishment refrigerators also had missing temperature log entries and contained unlabeled, expired, or improperly stored food items, including food with no name or date and food that appeared spoiled or contaminated.
Failure to Document COVID-19 Vaccine Education and Offer: The facility failed to document COVID-19 vaccine education and offer for 4 staff members and 1 resident. Employee files for several staff members contained no evidence they were educated on the risks vs benefits or offered the vaccine, and a resident's record also lacked documentation of vaccine education or offer. The IP and Administrator acknowledged documentation of vaccine education and consent or declination should be recorded.
Urinary catheters were not maintained in a dignified manner for two residents. One resident with cancer, respiratory failure, obstructive uropathy, and severe cognitive impairment had a urine collection bag repeatedly visible from the doorway without a privacy bag. Another resident with BPH and obstructive uropathy had a catheter bag repeatedly left uncovered, visible from the doorway, touching the floor in the dining room, and dragging on the ground; the resident stated a preference for the catheter to be covered when possible.
Missing Personal Property Documentation: A cognitively intact resident with cancer reported that a bag of clothes went missing and was not found, replaced, or reimbursed. Record review found no personal effects inventory form in the chart or unit binder for the resident, despite facility policy requiring admission inventory documentation and updates for added items; the grievance log also showed multiple complaints about missing items.
Baseline care plans were not developed and implemented with needed admission instructions for two residents. One resident was admitted with respiratory failure, obstructive uropathy, an indwelling Foley, and O2 orders, but the baseline plan did not note respiratory risk, the Foley, or any interventions. Another resident had muscle weakness, difficulty walking, a recent history of falls and fractures, and orthostatic hypotension, but the baseline plan did not identify fall risk or include fall prevention interventions; the resident later sustained a fall.
Respiratory equipment was not kept sanitary for two residents who required oxygen therapy, and one also used CPAP. One resident's oxygen concentrator filter was repeatedly observed covered in thick dust debris despite an order for weekly cleaning. The other resident's oxygen tubing and CPAP care were not documented as completed on scheduled dates, and the CPAP mask and machine were observed dirty with dust, debris, and a greasy film. Staff gave conflicting statements about when and by whom the equipment was cleaned.
A resident with COPD had an order for Arnuity Ellipta, and the pharmacist later recommended adding instructions to rinse the mouth with water after use to prevent thrush. When the order was reviewed later, the recommendation had not been implemented, and the DON acknowledged that some pharmacy recommendations had been missed.
Medication administration errors exceeded the allowed rate, with 3 of 25 meds given incorrectly. One resident received a multivitamin with minerals instead of ordered Preservision AREDS, another resident’s lansoprazole DR disintegrating tablet was crushed before administration, and a third resident’s weekly alendronate dose was omitted when it could not be located. The DON stated the medications were different, that the lansoprazole should not be crushed, and that staff were expected to administer meds as ordered.
A resident with a history of diabetes, peripheral vascular disease, and recent finger amputation did not receive consistent monitoring or documentation of their surgical wound. Although wound care was marked as completed on the TAR, there was little to no documentation in nurse notes about the wound's condition or changes. The resident developed a blister and infection, which was not adequately tracked, resulting in hospitalization and further amputation. Staff interviews revealed inconsistent wound monitoring practices and unclear responsibilities.
The facility failed to ensure proper hand hygiene and hair coverings during food service, risking foodborne illness. A Dietary Aide had visible facial hair without a beard covering, and a Cook wore a bandana that did not contain their hair. The Cook also engaged in improper hand hygiene, such as wiping their head with gloved hands and washing hands inadequately. The facility's policy required head and beard coverings and thorough handwashing, which were not followed.
The facility failed to obtain accurate and timely consents for psychotropic medications for several residents. A resident received sertraline with an incorrect consent, another was given lorazepam without prior consent, and a third had medications consented by a cognitively impaired representative. Additionally, a resident received Trazodone before signing the consent. These oversights were acknowledged by facility staff.
The facility failed to provide adequate ADL assistance for four residents, leading to deficiencies in cleanliness and grooming. A resident reported receiving fewer baths than care planned, while another with severe cognitive impairment received only weekly showers instead of twice-weekly. Observations noted unshaven facial hair and unkempt hair. Another resident had unclean nails and protruding nasal hair, and a fourth resident reported fewer showers than planned. Staff interviews highlighted inconsistencies in care delivery.
The facility failed to properly assess and implement interventions for residents at risk of elopement, as several residents were not included in the Elopement Book, leading to staff unawareness. Additionally, a resident with a history of falls did not receive updated care plan interventions after multiple falls, and two residents were observed smoking unsupervised despite a non-smoking policy, with care plans lacking clear instructions for supervision and storage of smoking materials.
The facility failed to properly store and dispose of medications and medical supplies, with expired medications found in carts, anti-anxiety meds not secured behind two locks, and incomplete narcotic logs. Unsecured lab supplies were found in The Bistro, and temperature logs for storage rooms were incomplete, risking medication effectiveness. Staff acknowledged these issues.
A resident's preferences for waking and bedtime hours were not accommodated or documented in their care plan, despite the facility's policy requiring person-centered planning. The resident expressed a desire to be woken up early to remove bi-pap equipment and preferred an early bedtime, but these preferences were not reflected in the care plan, leading to a risk of diminished quality of life.
A resident with dementia and depression reported missing jewelry, highlighting the facility's failure to provide secure storage for valuables. The facility's policy did not address securing personal belongings, and not all rooms had locked drawers. Staff interviews revealed inconsistencies in offering lock boxes to residents, and the grievance logs lacked documentation of the resident's concerns.
A facility failed to report and investigate abuse allegations as per its policies, involving a resident with verbal and behavioral symptoms. Despite multiple incidents of verbal aggression, the facility did not document investigations or implement protective measures, placing residents at risk for repeated abuse.
A facility failed to notify the State Long-Term Care Ombudsman of a resident's hospital transfer, as required. The resident, who was cognitively intact and had anxiety and opioid dependence, was sent to the hospital after exhibiting severe symptoms. Staff interviews revealed that the necessary transfer notification form was not completed or sent, resulting in a deficiency.
A resident was transferred to the hospital without receiving a required bed-hold notice, which informs them of their right to pay to hold their room/bed during hospitalization. Despite being cognitively intact and having conditions like anxiety and opioid dependence, the resident's record lacked this documentation. Interviews with the DON and Medical Records staff confirmed the oversight.
A facility failed to incorporate PASARR Level 2 recommendations for a resident with bipolar disorder, neglecting to implement environmental and communication strategies to support mental health needs. The care plan lacked documentation of these recommendations, and an observation showed missing items like a visible clock and schedule.
The facility failed to complete required PASARR Level 1 screenings for two residents, risking inappropriate placement and unmet mental health needs. One resident's PASARR was outdated and did not reflect current diagnoses, while another's PASARR did not indicate the need for a Level II evaluation despite documented mental health conditions. The oversight was acknowledged by the facility's administration.
A resident with dementia and paralysis exhibited possible seizure activity, but the facility failed to notify the provider. The incident was not documented in the communication binder, and no vital signs were recorded in the EMR. Staff interviews revealed uncertainty about whether the provider was informed, and the notification sheet was missing. The provider was scheduled to evaluate the resident ten days later.
A resident with a history of paralysis and a fractured femur developed an unstageable pressure ulcer on their left heel due to the facility's failure to monitor and document skin assessments. The resident was resistant to care, and refusals were not documented, leading to a delay in identifying the ulcer. Hospital records indicated pre-existing wounds, but the facility was unaware, contributing to the deficiency.
A facility failed to implement and monitor orthotic devices for a resident with a progressive neurological condition, leading to the use of rolled washcloths instead. The resident experienced discomfort with the prescribed splints, and staff used washcloths to prevent nails from digging into palms. The care plan required orthotics for six hours daily, but there was no documentation of application, monitoring, or management of refusals. The DON acknowledged the lack of monitoring and documentation.
A resident with a history of stroke and moderate cognitive impairment did not receive necessary care to maintain bowel and bladder functions. Despite assessments indicating the need for a timed voiding program, the facility failed to implement such a program, resulting in frequent incontinence. The resident expressed a preference for using the bathroom but was hindered by delayed staff response and lack of structured toileting support. The care plan lacked interventions, and therapy referrals did not address incontinence issues.
The facility failed to maintain clean respiratory equipment for two residents, risking respiratory complications. A resident with heart failure and sleep apnea had an unclean CPAP mask, while another with chronic respiratory failure had a dusty oxygen concentrator filter. The DON confirmed the importance of regular cleaning to prevent breathing issues.
The facility failed to provide consistent dialysis care for two residents. One resident was not consistently evaluated post-dialysis, missing nine evaluations in two months, while another did not receive morning medications on dialysis days, with no blood sugar checks performed. Staff acknowledged the importance of these evaluations and medication administration, but the facility's practices did not align with its policies.
The facility failed to provide trauma-informed care for two residents with histories of trauma. For one resident, the facility did not identify potential triggers or develop a comprehensive care plan, leading to an incident with a male staff member that was not promptly addressed. The other resident, with a history of mental illness, exhibited disruptive behaviors, but the facility did not document specific triggers or involve family in the evaluation process. The care plans lacked guidance for staff to prevent re-traumatization.
Two residents received medications without proper monitoring of vital signs, contrary to prescribed parameters. One resident was given metoprolol despite a low pulse, and another received Carvedilol without documented blood pressure or heart rate checks. The facility's MAR lacked sections for vital sign documentation, leading to these oversights.
The facility failed to develop a complete water management plan to mitigate Legionnaire's Disease risks and did not ensure proper handling of soiled linens. Additionally, a resident with chronic respiratory failure was exposed to infection risks when their nasal cannula was placed back in use after being on the floor without cleaning or replacement.
The facility failed to maintain clean wheelchairs for two residents, one with a history of stroke and hemiplegia and another with heart failure and diabetes. Observations over several days revealed unclean conditions, including food debris and substances on the wheelchairs. The DON confirmed that wheelchairs should be cleaned weekly, and failure to do so was a dignity issue.
A resident with a history of stroke required substantial assistance for transfers, as per their care plan. However, a staff member attempted to transfer the resident alone, resulting in the resident being assisted to the floor and sustaining a fractured arm and clavicle. The staff member did not review the resident's Kardex, which specified the need for two staff members for transfers.
Residents in the facility reported ongoing issues with the dietary services, including not receiving meals according to their preferences and being served items they disliked or were allergic to. Despite attending food committee meetings and filing grievances, residents felt their concerns were not resolved, leading to dissatisfaction and some resorting to buying their own food. Staff interviews revealed communication issues and a lack of effective resolution to the dietary complaints.
The facility failed to thoroughly investigate allegations of abuse and neglect for four residents, including grievances about rough treatment, inadequate staffing, and delayed responses to call lights. Despite residents' complaints, there was no documentation of comprehensive investigations, placing residents at risk for further abuse and neglect.
Hand Hygiene, EBP, and Water Management Failures
Penalty
Summary
Hand hygiene was not completed when indicated during medication administration for two staff members. One RN prepared and administered medications to a resident with a g-tube, assisted with changing the resident’s shirt, handled the resident’s incontinence pad, and then continued the medication task while wearing the same gloves without removing them or performing hand hygiene after contact with unclean items. The RN later stated hand hygiene should have been completed before and after the medication pass and acknowledged that gloves should have been removed and hand hygiene performed after touching the unclean shirt and incontinence pad. A second staff member, an LPN, prepared and administered medications for another resident and did not perform hand hygiene during the observed medication preparation and administration process. The LPN handled medication supplies in the medication room, retrieved liquid medications, documented in the narcotic count book, administered the medications to the resident, left the room, briefly entered the medication room, and then began preparing medications for another resident without performing hand hygiene. The LPN stated hand hygiene should be performed in between residents or after touching unclean surfaces, and the DON acknowledged that hand hygiene was not completed when indicated. Enhanced barrier precautions were not implemented when indicated for two residents with indwelling medical devices. One resident had a tunneled dialysis catheter to the right chest and care plan instructions to follow EBP, but repeated observations showed no EBP signage and no PPE tote outside the room. A resident care manager acknowledged that EBP was indicated for the dialysis access line but had not been implemented. Another resident received nutrition through a feeding tube and had care plan instructions to follow EBP, yet repeated observations showed no EBP signage and no PPE tote outside the room. The resident stated staff wore gloves but did not wear gowns when managing the feeding tube, and an RN stated residents with an indwelling medical device such as a catheter or feeding tube required EBP. The facility also failed to ensure its Water Management Plan included documented routine measures to minimize the risk of Legionella. The plan identified areas that could encourage growth and spread of waterborne bacteria, including vacant rooms, eye wash stations, ice machines, standing water coolers, an unused whirlpool bathtub, and several basement locations with an unused shower, toilet, and sink. The plan listed measures such as wiping down the water dispenser daily, running water in unused sinks weekly, flushing unused toilets weekly, and cleaning ice machines monthly. During interview and record review, the administrator stated the facility had no documentation showing routine measures to minimize the risk of Legionella were completed and acknowledged that if it was not documented, it was not done.
Failure to Monitor Resident After Repeated Falls
Penalty
Summary
The facility failed to consistently monitor a resident for latent injuries after numerous falls. Resident 10 had diagnoses including dementia and repeat falls, with some moderate cognitive impairment and frequent rejection of care. The resident was independent with transfers and walking but required supervision for longer distances. The care plan identified the resident as at risk for falls related to a shuffling gait, weakness, and a history of falls, and it was later updated to instruct staff to observe and monitor the resident for 72 hours for latent injuries such as a change in mental status. From August 2025 through February 2026, Resident 10 sustained 15 falls, including four falls on the same day. Review of the fall investigations and medical record showed that vital signs and neurological checks were not completed according to the facility’s flow sheet timeline after multiple unwitnessed falls, including falls on 08/11/2025, 08/13/2025, 10/23/2025, 12/12/2025, 12/13/2025, 01/02/2026, and numerous falls on 01/15/2026. Alert or progress notes were also not completed every shift for at least 72 hours after several falls, and when the resident fell again while on neuro checks, the checks were not restarted at 15-minute intervals. Staff interviews confirmed that after an unwitnessed fall, neuro checks and alert charting were expected, but the nursing staff did not follow the facility process for monitoring the resident after the falls.
Dialysis Medications and Fluid Restrictions Not Properly Managed
Penalty
Summary
The facility failed to provide safe, appropriate dialysis care and services for residents who required dialysis. Surveyors found that medications were not given as ordered on days when residents were out of the facility for dialysis treatments, and that fluid restrictions for two residents were not documented or monitored accurately as ordered. The report identified this as affecting 3 of 3 sampled residents reviewed for dialysis care. Resident 48 had diagnoses including ischemic cardiomyopathy, heart failure, and ESRD, and received dialysis three times weekly. The resident also had an order for an 1800 ml/day fluid restriction. Review of the MAR showed multiple missed doses of medications including isosorbide, sevelamer, metoprolol, and tramadol on various dialysis days in January and February 2026. The fluid restriction intake monitor documented daily totals that were far below the ordered 1800 ml/day, including amounts ranging from 240 ml to 860 ml, but the record did not show accurate monitoring consistent with the ordered restriction. Resident 5 had ESRD, heart failure, and diabetes and was dependent on renal dialysis. The care plan directed staff to document before and after dialysis treatments in a dialysis communication book and to follow the ordered fluid restriction. The dialysis communication book was incomplete, with the dialysis portion blank on several dates, the facility portion blank on another date, and no communication sheets available for some dates. The MAR also showed calcium acetate coded as absent from the facility without the medication on multiple dates. Staff interviews showed inconsistent understanding of fluid restriction monitoring, with one NA stating there were no residents on fluid restriction and another stating fluids were given without documenting the amount consumed. Resident 4’s ESRD care plan directed staff to administer medications as ordered for dialysis three times weekly. The MAR showed multiple missed or undocumented doses of medications and treatments, including phosphate binders, hydralazine, omeprazole, renal vitamin, thiamine, insulin, eye drops, skin preparations, and other ordered medications, with several entries coded as absent from the facility or left blank. Staff interviews confirmed that dialysis residents’ medications were scheduled around dialysis, that some medications were expected to be given before or after dialysis, and that the dialysis communication forms were important for tracking vital signs, weights, and treatment information. The DON acknowledged that Residents 4 and 5 did not receive medications as ordered and that the dialysis communication forms needed to be completed and returned.
Expired Vaccines and Improper Medication Storage Temperatures
Penalty
Summary
The facility failed to ensure expired medications were disposed of timely and failed to maintain appropriate temperatures in 2 of 2 medication rooms. During observation of the [NAME] Medication room on 02/06/2026 at 12:35 PM, a fan was blowing and the room temperature was 82 degrees F, above the recommended controlled room temperature range. Review of refrigerator temperature logs from September 2025 through February 2026 showed the temperatures were not monitored consistently as required. During observation of the East Medication room on 02/06/2026 at 1:06 PM, the refrigerator contained influenza, hepatitis, and RSV vaccines, and the RSV vaccines had expired on 10/25/2025. Review of refrigerator temperature logs from November 2025 through February 2026 showed the temperatures were not monitored consistently as required. Staff AA, Staff W, and the DON stated that temperature monitoring was important because medications and vaccines could lose effectiveness if not stored within the proper range. On 02/12/2026, vaccines were still present in refrigerators that had not had temperatures monitored, and the [NAME] Medication room temperature was 80 degrees F.
Unclean kitchen, poor hand hygiene, and improper nourishment refrigerator monitoring
Penalty
Summary
The facility failed to follow food code regulations intended to prevent foodborne illness. During observations, the kitchen was found to be unclean, with a grimy and dingy floor, crumbs and food debris on the counter with the toaster, dried splashes of food debris and grease on the wall next to the stove, food crumbs around the plate warmer holding clean plates for lunch service, and soiled fronts and handles on plastic drawers and storage bins in the pantry area. During a later visit, the same areas were again observed with crumbs, food debris, dried splashes, grease, and soiled surfaces. During meal preparation, dietary staff did not perform hand hygiene when indicated during glove changes and food handling. A Nutrition Coordinator stopped plating food, handled food from the oven, removed gloves, changed gloves, and resumed meal service without hand hygiene. The same staff member later retrieved another pan of meatloaf, placed it on the steam table, changed gloves without hand hygiene, and resumed plating. The staff member also opened a dirty drawer to remove a utensil and then continued serving with the same gloves. In the nourishment rooms, both refrigerators had missing temperature log entries, and food was found unlabeled, expired, or improperly stored, including a Lunchables container dated 11/19/2025, unlabeled noodles and sauce, unlabeled slimy chicken, unlabeled sherbet and pistachio ice cream, plastic containers of a red substance with a resident name but no date, and chicken strips wrapped in a greasy paper napkin with no name or date.
Failure to Document COVID-19 Vaccine Education and Offer
Penalty
Summary
The facility failed to provide education regarding the risks versus benefits of the COVID-19 vaccine and failed to offer the vaccine to 4 of 7 sampled staff members and 1 of 5 sampled residents reviewed for immunizations. Review of the employee files for Staff F, Staff I, Staff J, and Staff K showed no documentation that they were educated about the COVID vaccine or offered the vaccine. Review of Resident 63's medical record also showed no documentation that the resident was educated about the risks versus benefits of the COVID vaccine or offered the vaccine. Resident 63's quarterly assessment showed the resident's most recent admission to the facility was on 06/06/2025. During interviews, the Staff Development Coordinator stated new employees completed a vaccination questionnaire and that residents and staff were educated and offered vaccines during orientation, admission, and the annual immunization clinic, but acknowledged the files for Staff F, Staff I, Staff J, and Staff K contained no documentation of education or vaccine offer. The Infection Preventionist and Administrator both acknowledged that documentation of vaccine education and vaccine consent or declination should be documented, and the Infection Preventionist stated the facility was unable to hold the immunization clinic last October because of a facility illness outbreak.
Urinary Catheters Not Maintained in a Dignified Manner
Penalty
Summary
The facility failed to maintain indwelling urinary catheters in a dignified manner for 2 of 5 sampled residents reviewed for dignity. The facility policy titled, Indwelling Urinary Catheter Management, reviewed on 09/04/2025, instructed staff to keep the catheter bag off the floor, but it did not address dignity concerns when catheters were required. Resident 8 was admitted on 01/13/2026 with diagnoses including cancer, respiratory failure, and obstructive uropathy, and was dependent on staff for toileting with severe cognitive impairments. During observations on 02/05/2026, 02/06/2026, and 02/10/2026, the resident's urine collection bag was visible from the doorway and was not covered by a privacy bag. Resident 65 had diagnoses including BPH and obstructive uropathy, was dependent on staff for toileting, and could make needs known. During multiple observations on 02/05/2026, 02/06/2026, 02/10/2026, and 02/11/2026, the resident's urine collection bag was not in a privacy bag, was visible from the doorway, touched the ground while the resident sat in the dining room, and dragged on the ground when the resident wheeled out of the dining room. Resident 65 stated they preferred staff covered the catheter if they had something to cover it with.
Missing Personal Property Documentation
Penalty
Summary
The facility failed to exercise reasonable care to protect a resident’s personal property from loss or theft. Resident 17 was admitted with a diagnosis that included cancer, was cognitively intact, and was documented as valuing the ability to choose clothing and care for personal belongings. The resident stated in interview that a bag of clothes went missing, staff were informed, and the items were not found, replaced, or reimbursed. Record review showed no personal effects inventory form for Resident 17 in the medical record or in the unit inventory binder. The facility policy required personal items to be documented on admission and updated when additional items were brought in, but no documentation was found for this resident’s belongings or for the missing clothing. The grievance log from August 2025 through January 2026 showed 12 of 16 grievances were related to missing items, and no documentation of Resident 17’s missing clothing was found.
Baseline care plans missing key admission instructions
Penalty
Summary
The facility failed to develop and implement a baseline care plan that included instructions needed to provide effective and person-centered care within 48 hours of admission for 2 of 4 sampled residents, Residents 8 and 73. The facility policy titled, Baseline Care Plan, required a baseline care plan for each resident within 48 hours of admission, to be updated as needed until the comprehensive care plan was developed, and to be reviewed with the resident and/or representative with a copy provided. Resident 8 was admitted with diagnoses including respiratory failure and obstructive uropathy and had an indwelling catheter. Admission orders included catheter care every shift, flushing the Foley catheter twice a day, straight drainage with changes for infection, obstruction, or compromised closed system, and oxygen at 3 L per minute via nasal cannula. The baseline care plan initiated on admission did not document that Resident 8 was at risk for respiratory complications or had a Foley catheter, and it contained no interventions for staff to implement. Resident 73 was admitted with muscle weakness and difficulty walking, had falls in the month before admission, fractures related to falls in the prior six months, and was cognitively intact. The hospital discharge summary noted a history of multiple falls with worsening shortness of breath over the past couple of days. The care plan initiated on admission did not document that Resident 73 was at risk for falls, had a history of falls, or include fall prevention interventions. The facility incident log showed Resident 73 sustained a fall later in the month, and nursing progress notes documented orthostatic hypotension and residual debility requiring therapy services.
Respiratory equipment was not kept sanitary for two residents
Penalty
Summary
The facility failed to maintain respiratory care equipment in a sanitary manner for 2 residents who required oxygen therapy and, for one resident, CPAP use. Resident 8 was admitted with diagnoses including cancer, pneumonia, and respiratory failure and required continuous oxygen. An order dated 12/31/2025 directed staff to clean the oxygen concentrator filter with soap and water and let it air dry weekly on Sundays, and the care plan instructed staff to administer oxygen therapy as ordered. However, during multiple observations from 02/05/2026 through 02/12/2026, Resident 8's oxygen concentrator filter was repeatedly observed covered in thick dust debris. In interviews, an RN stated oxygen filters were cleaned every 72 hours, while the DNS stated they were cleaned weekly to prevent dust debris from entering the machine. Resident 12 had diagnoses including respiratory failure and required supplemental oxygen equipment. The care plan directed staff to administer oxygen therapy and apply CPAP nightly per orders. Provider orders required oxygen tubing to be changed weekly every Sunday on night shift, the CPAP reservoir to be cleaned every 7 days, and the CPAP mask to be cleaned as needed. Review of the TAR showed no documentation that oxygen tubing was replaced or CPAP was cleaned on multiple scheduled dates, and the January 2026 TAR showed the mask had not been cleaned all month. During observations, the CPAP mask was seen with a greasy film, cloudy and unclean, and the front of the CPAP machine was covered with dust and debris. The resident stated staff did not wash the mask, and staff interviews reflected conflicting statements about who was responsible for changing and cleaning the equipment and when it should be done.
Pharmacy Recommendation for Inhaler Order Not Implemented
Penalty
Summary
The facility failed to ensure a licensed pharmacist’s monthly drug regimen review recommendation was addressed in a timely manner for Resident 11. Resident 11’s record showed diagnoses including COPD, and a physician order dated 11/12/2025 for Arnuity Ellipta once daily beginning 11/13/2025. A pharmacy consultation report dated 12/17/2025 recommended updating the Arnuity Ellipta order to include rinsing the mouth with water after use to prevent thrush. On 02/10/2026, review of the orders showed the pharmacy recommendation had not been implemented. In an interview that same day, the DON acknowledged that some pharmacy recommendations had been missed and stated that timely implementation was expected.
Medication Administration Error Rate Exceeded Allowed Limit
Penalty
Summary
Medication administration errors exceeded the facility’s allowable rate, with 3 of 25 medications observed to be given incorrectly for an error rate of 12 percent. The deficiency involved 3 of 7 sampled residents, including a resident with cancer, heart failure, and diabetes who was cognitively intact and able to make needs known, a resident with cancer, respiratory failure, and obstructive uropathy, and a resident admitted earlier in the month. During observation, one resident received a multivitamin with minerals instead of the ordered Preservision AREDS, which had been prescribed to slow progression of vision loss. The Director of Nursing stated these were different medications and said the facility had communicated with providers about substituting comparable medications, but documentation of that communication was not provided. Another resident’s ordered lansoprazole delayed release disintegrating tablet was placed in a medication cup, then placed in a plastic bag and crushed before administration. The DON stated staff needed to look up medications to determine whether they could be crushed and that it was important not to crush this medication because it would be absorbed too quickly. For the third resident, ordered weekly alendronate was not available at the time of administration; the RN attempted to locate it, checked the electronic emergency medication machine, and omitted the dose when it was not available. The RN stated the pharmacy would need to be called and the provider notified that the medication was unavailable, and the DON and Administrator stated they expected medications to be administered as ordered.
Failure to Monitor and Document Surgical Wound Leading to Infection and Hospitalization
Penalty
Summary
The facility failed to adequately monitor and document the condition of a surgical wound for one resident who had undergone amputation of the right fingertips due to dry gangrene. Upon admission, the resident had a dressing on the right hand that was not to be removed until a follow-up with the surgeon. After the initial follow-up, daily wound care was ordered and documented as completed on the Treatment Administration Record (TAR), but there was no corresponding documentation in the nurse progress notes regarding the wound's condition or any changes observed during this period. Subsequent surgical follow-ups revealed the development of a large blister and signs of soft tissue infection on the resident's right hand, leading to new wound care orders and antibiotics. While the TAR indicated that wound care was performed, there was no documentation showing that the wound was monitored for increased redness or signs of worsening infection as ordered. Nurse notes contained only brief references to the wound's appearance and infection status, with no detailed assessments or ongoing monitoring documented, especially in the days leading up to the resident's transfer to the hospital for a worsened infection. Interviews with facility staff revealed inconsistent practices and a lack of clarity regarding wound monitoring responsibilities, particularly for surgical wounds. Staff members were either unfamiliar with the resident's wound or had not observed it directly, and the Director of Nursing stated that wound observation forms were not used for surgical incisions at the time. The lack of thorough assessment and documentation contributed to the resident's condition worsening, ultimately resulting in hospitalization and further amputation.
Improper Hand Hygiene and Hair Covering in Food Service
Penalty
Summary
The facility failed to ensure proper hand hygiene and hair coverings were worn and implemented during food service, which placed residents at risk for foodborne illness. Observations revealed that a Dietary Aide, Staff Z, participated in the breakfast tray line with visible facial hair and no beard covering. Additionally, a Cook, Staff Y, was observed with a pink bandana that failed to contain their hair, allowing hair to flow down their forehead and around the sides and back of their head. Staff Y was also seen engaging in improper hand hygiene practices, such as wiping their head with gloved hands, using the same gloves to take food temperatures, and washing their hands for only seven seconds before using a paper towel to wipe down the steamer table. The facility's policy required kitchen staff to always wear head and beard coverings, regardless of their activities, and to wash hands thoroughly for at least 30 seconds. However, Staff Y did not adhere to these guidelines, as evidenced by their inadequate handwashing and improper use of a paper towel. The Dietary Manager, Staff X, confirmed the requirement for head and beard coverings and proper hand hygiene, acknowledging that Staff Y's actions did not comply with the facility's standards. Further observation showed Staff Y wearing a hairnet incorrectly, with hair exposed below the hairnet line.
Failure to Obtain Accurate and Timely Medication Consents
Penalty
Summary
The facility failed to ensure that psychotropic medication consents were accurate and obtained prior to administration for several residents. For Resident 3, the consent form for the medication sertraline was inaccurately documented as being used for somatization instead of depression, as per the physician's order and care plan. This discrepancy was acknowledged by the facility's administrator. Resident 13 was administered lorazepam for anxiety related to dialysis without a consent form being signed prior to the medication's initiation. The consent was only obtained nearly two months later, which was confirmed by the Director of Nursing. This oversight meant that the resident's representative was not informed of the medication's risks and benefits before administration. For Resident 27, the consent for medications Lexapro and Zyprexa was signed by a representative who was also a resident of the facility and had moderate cognitive impairments. This representative was unaware of the medications and their associated risks and benefits. Additionally, Resident 39 received Trazodone for insomnia before the consent was signed, which was acknowledged as a mistake by the Resident Care Manager and the Director of Nursing.
Deficiencies in ADL Assistance and Hygiene
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADLs) for four residents, leading to deficiencies in cleanliness and grooming. Resident 44, who was cognitively intact and dependent on staff for bathing, reported receiving baths only once a week despite a care plan indicating twice-weekly baths. Documentation confirmed the lack of adherence to the care plan, with no records of baths on specified dates. Resident 37, with severe cognitive impairment and paralysis, required assistance for personal hygiene and showering. The care plan specified twice-weekly showers, but records showed only weekly showers were provided. Additionally, Resident 37 was observed with unshaven facial hair and unkempt hair, despite expressing a preference for being clean-shaven with a mustache. Staff interviews revealed inconsistencies in shower scheduling and shaving practices. Resident 9, with moderate cognitive impairments, required substantial assistance for personal hygiene, including nail care. Observations noted unclean nails with a brown substance and protruding nasal hair, which the resident was unaware of. Resident 19, cognitively intact, also reported receiving fewer showers than care planned, with documentation supporting this claim. Staff interviews highlighted the importance of regular showers for hygiene and dignity, yet the facility failed to meet these standards.
Deficiencies in Elopement, Fall Prevention, and Smoking Supervision
Penalty
Summary
The facility failed to ensure that residents identified at risk for elopement were accurately assessed and interventions implemented to prevent elopement for four of five sampled residents. Specifically, Residents 7, 27, 25, and 254 were not properly included in the Elopement Book, which is used to alert staff of residents at risk for elopement. Despite care plans indicating these residents were at risk, the Elopement Books at various locations in the facility did not contain their information, leading to a lack of awareness among staff about their elopement risk. Additionally, the facility did not provide adequate supervision and interventions to prevent falls for Resident 41. The resident, who had a history of falls and was identified as having poor balance and safety awareness, experienced multiple falls outside the facility. Despite these incidents, the care plan was not updated with new interventions to prevent further falls, and there was no documentation of a referral to therapy services to address the resident's mobility and safety issues. The facility also failed to supervise two residents, Residents 24 and 41, who were identified as smokers. Despite the facility's non-smoking policy, these residents were observed smoking outside the facility without staff supervision. Resident 24, who had limited mobility, was seen smoking in unsafe areas, and Resident 41, who was cognitively intact but had physical limitations, was observed smoking on the main road and in the facility's driveway. The care plans for these residents did not provide clear instructions on the supervision required or the safe storage of smoking materials.
Medication Storage and Disposal Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and timely disposal of medications and medical supplies, as observed in two medication carts and two medication storage rooms. Expired medications, including insulin pens and allergy nasal spray, were found in the medication carts, and some insulin pens lacked usage dates. Additionally, anti-anxiety medications were not stored behind the required two locks, and the narcotic logs were not consistently signed by nursing staff at shift changes. These lapses in protocol placed residents at risk of receiving compromised or ineffective medication and increased the potential for drug diversion. In a room called The Bistro, unsecured lab supplies, including intravenous needles and unsealed bottles of red liquid used for stool sample transport, were found in unlocked cabinets and drawers. The room was used for family visits, staff breaks, and corporate visits, and although no residents were wandering in the area, the unsecured items posed a potential safety risk. Furthermore, the temperature logs for the medication storage rooms had multiple omissions, which could affect the effectiveness of stored vaccines. Staff interviews confirmed awareness of these issues, acknowledging the importance of proper storage and monitoring to ensure medication viability and safety.
Failure to Accommodate Resident's Bedtime Preferences
Penalty
Summary
The facility failed to accommodate the bedtime routine preferences of a resident, identified as Resident 44, which was a violation of their right to self-determination and choice. The facility's policy on Person Centered Planning required the development of a care plan that included the resident's goals, preferences, values, and practices, with the resident's participation. However, the care plan for Resident 44 did not reflect their stated preferences for waking and bedtime hours. The resident expressed a desire to be woken up at or before 6:00 AM to remove their bi-pap equipment and preferred to go to bed around 8:00 PM. Despite this, the quarterly assessment and activities evaluation indicated different preferred times, and these preferences were not documented in the care plan. Interviews with staff, including Staff L, the Activities Coordinator, confirmed that the process for identifying and documenting resident preferences was not followed in this case. Staff L acknowledged that although they were responsible for gathering information on resident preferences and adding it to the care plan, Resident 44's care plan did not include instructions for their preferred waking or bedtime hours. This oversight placed the resident at risk for a diminished quality of life, as their preferences were not accommodated or communicated to the staff.
Failure to Provide Secure Storage for Resident Valuables
Penalty
Summary
The facility failed to provide a secure place for residents to store their valuables, as evidenced by the case of a resident who reported missing jewelry. The resident, who had dementia and depression, expressed the importance of having a secure place for their belongings. Upon admission, the facility's policy required personal clothing to be marked and returned to the resident, but it did not address the security of other personal belongings. The resident reported missing a wedding ring and two diamond bracelets, which were not documented on the personal belonging inventory sheet. The resident mentioned the possibility of losing the jewelry at dialysis but was unsure of its whereabouts. Interviews with staff revealed that not all rooms had locked drawers, and newer residents were asked if they wanted a lock box, but this was not consistently communicated to all residents. The resident's room was inspected, and it was confirmed that there were no lock boxes or locking mechanisms available for securing personal items. The staff acknowledged the oversight and indicated that arrangements would be made to provide a lock for the resident's belongings. The grievance logs did not contain any entries related to the missing jewelry, indicating a lack of documentation and follow-up on the resident's concerns.
Failure to Report and Investigate Abuse Allegations
Penalty
Summary
The facility failed to implement its Abuse and Neglect Prohibition Policies and Procedures, specifically in reporting allegations of abuse to the State Agency (SA) within the required timeframe and conducting thorough investigations. This deficiency was identified in the case of one resident, who was cognitively intact but exhibited verbal and behavioral symptoms such as yelling, threatening, and making disruptive sounds. Despite these behaviors, the facility did not document investigations into the psychological impact on other residents or implement protective measures to prevent recurrence. The facility's policies required immediate reporting of abuse allegations to the SA, but incidents involving the resident's verbal aggression were not logged or reported within the specified timeframe. Progress notes indicated multiple instances of verbal aggression and disruptive behavior, yet there was no documentation of investigations or measures taken to address these incidents. The facility's failure to follow its policies placed the resident and others at risk for repeated abuse, as acknowledged by the facility's administrator.
Failure to Notify Ombudsman of Resident's Hospital Transfer
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman about a hospital transfer for one of the residents, identified as Resident 51. This deficiency was identified through interviews and record reviews. Resident 51, who was cognitively intact and had diagnoses including anxiety and opioid dependence, was observed in the early morning hours to be pulling their hair and experiencing severe jerking movements. Following an assessment and direction from the on-call provider, the resident was transferred to the hospital for evaluation. However, there was no documentation indicating that the Ombudsman had been notified of this transfer. Interviews with facility staff revealed a breakdown in the process of notifying the Ombudsman. Staff E, responsible for medical records, stated that the Notice of Transfer or Discharge form should have been filled out and sent to the Ombudsman by Staff F, the receptionist. Upon reviewing Resident 51's record, both Staff E and Staff F confirmed that the form was missing. Staff F explained that once the form was sent to the Ombudsman, it was supposed to be filed in the resident's record, but this step was not completed for Resident 51.
Failure to Provide Bed-Hold Notice
Penalty
Summary
The facility failed to provide a bed-hold notice to a resident or their representative at the time of discharge or within 24 hours of transfer to the hospital. This deficiency was identified for one of the two sampled residents, who was reviewed for hospitalization. The resident, identified as Resident 51, was cognitively intact and had diagnoses including anxiety and opioid dependence. On the early morning of August 29, 2024, the resident exhibited severe jerking movements and was observed pulling their hair, leading to a hospital transfer for evaluation as directed by the on-call provider. Upon review of Resident 51's records, it was found that there was no documentation of a bed-hold notice being provided, as required. Interviews with the Director of Nursing and Medical Records staff revealed that bed-hold notices were supposed to be completed upon admission and again when a resident was transferred to the hospital. However, the Medical Records staff confirmed that the electronic form for the bed-hold notice was not present in the resident's record, indicating it was not completed.
Failure to Implement PASARR Level 2 Recommendations
Penalty
Summary
The facility failed to incorporate specific recommendations from a PASARR Level 2 evaluation for a resident with medically complex conditions, including depression and bipolar disorder. The PASARR Level 2 evaluation recommended environmental and communication strategies to support the resident's mental health needs, such as keeping the room free of obstacles, ensuring it is well-lit during the day, and maintaining a quiet, dark, and cool environment at night. Additionally, the evaluation advised on clear communication, monitoring for changes in behavior, and early intervention to prevent manic episodes. Despite these recommendations, the facility did not document or implement them in the resident's care plan. An observation of the resident's room revealed the absence of a clock or daily schedule in a visible location, as suggested by the PASARR Level 2 evaluation. The deficiency was acknowledged by the facility's administrator, who confirmed that the recommendations should have been incorporated into the care plan.
Failure to Complete Required PASARR Screenings
Penalty
Summary
The facility failed to ensure that a PASARR Level 1 screening was completed as required for two residents, placing them at risk for inappropriate placement and not receiving necessary mental health services. Resident 3 was readmitted to the facility with complex medical conditions, including depression and anxiety disorder, but the medical record lacked a current PASARR Level 1. An outdated PASARR Level 1 from 2020 was presented, which did not recognize the resident's current diagnoses. The administrator and director of nursing acknowledged the oversight and the need for an updated PASARR Level 1. Resident 27 was admitted with diagnoses of depression, anxiety, and dementia. Although a PASARR was completed prior to admission, it failed to indicate the need for a Level II evaluation despite documenting anxiety and a mood disorder. The absence of a Level II evaluation was confirmed by the administrator, who acknowledged the necessity of a referral to meet the resident's care needs.
Failure to Notify Provider of Possible Seizure Activity
Penalty
Summary
The facility failed to notify the provider when a resident, who had no previous diagnosis of seizures, exhibited possible seizure activity. The incident involved a resident with dementia and paralysis from a stroke, who was observed having seizure-like movements while in the dining room with family. Despite the resident's vital signs being within normal limits, there was no documentation of these vital signs in the electronic medical record for the date of the incident. Furthermore, the provider was reportedly notified via a communication binder, but no entry was found in the binder, and no provider progress notes were documented after the incident. Staff interviews revealed that the absence of the notification document made it difficult to confirm whether the provider was aware of the resident's possible seizure. Staff acknowledged that a seizure would constitute a change of condition requiring provider notification. The Director of Nursing later confirmed that the notification sheet could not be located, and the provider was scheduled to evaluate the resident ten days after the initial event. This oversight placed residents at risk of not being assessed for potential decline by their provider, leading to unintended health consequences and decreased quality of life.
Failure to Monitor and Document Pressure Ulcer Development
Penalty
Summary
The facility failed to identify and monitor a pressure ulcer for a resident who was at risk due to decreased mobility and a history of paralysis and a fractured femur. Upon admission, the resident had no pressure ulcers, but a significant change assessment later documented an unstageable pressure ulcer on the resident's left heel. The care plan included interventions such as providing a pressure-relieving mattress and wheelchair cushion, conducting weekly skin checks, and notifying relevant staff if the resident refused care. However, the facility did not document refusals of care or skin assessments, and the pressure ulcer was not identified until a nurse noticed it weeks after admission. The resident had a history of refusing care and was resistant to skin checks, which was not adequately documented by the facility. Hospital records indicated the presence of wounds on both heels prior to admission, but the facility staff were unaware of these wounds. The resident's care plan was updated to address the unstageable pressure ulcer, but the lack of initial documentation and monitoring contributed to the deficiency. The resident's refusal to wear foam boots and the discomfort caused by a leg brace further complicated the situation, leading to the development of the pressure ulcer. Interviews with staff revealed that the resident's refusals were not documented, and the facility did not have a complete understanding of the resident's condition upon admission. The Director of Nursing acknowledged the lack of documentation and stated that a full skin assessment was conducted only after the wound was identified. The facility's failure to document refusals and monitor the resident's skin condition led to the deficiency, as the pressure ulcer was not addressed in a timely manner.
Failure to Implement and Monitor Orthotic Devices for Resident
Penalty
Summary
The facility failed to properly implement and monitor the use of orthotic devices for a resident, identified as Resident 10, who was at risk for contractures due to a progressive neurological condition. Despite being part of a Restorative Nursing Program, Resident 10 was observed using rolled washcloths instead of the prescribed orthotic devices. The resident reported discomfort with the splints, leading to the use of washcloths, which were not consistently effective as one often fell out of the resident's hand. Staff interviews confirmed the use of washcloths to prevent the resident's nails from digging into their palms and to cushion their arms. The care plan for Resident 10 included instructions to apply orthotics to both hands for up to six hours a day, with skin checks each shift. However, there was no documentation of the application, monitoring, or management of the orthotics, nor any record of the resident's refusals or the reasons for them. The Director of Nursing acknowledged the lack of monitoring and documentation regarding the orthotics and the absence of an order in the treatment administration record to ensure compliance with the care plan.
Failure to Implement Toileting Program for Resident
Penalty
Summary
The facility failed to provide necessary care and services to Resident 18, who was admitted with a stroke and moderate cognitive impairment, to maintain and avoid loss of bowel and bladder functions. The resident required substantial assistance for toileting and was frequently incontinent of bowel and bladder. Despite assessments indicating the need for a timed or scheduled voiding program, no such program was implemented. Observations revealed that the resident was often left in bed without timely assistance to use the bathroom, leading to incontinence episodes. The resident expressed a preference for using the bathroom but was unable to do so due to delayed staff response and lack of a structured toileting program. The facility's documentation showed inconsistencies in the assessment of the resident's incontinence and the interventions provided. Various assessments identified different types of incontinence, such as urge, functional, and stress incontinence, but failed to result in a consistent care plan. Although referrals to occupational and physical therapy were made, there was no documentation of evaluations or interventions to address the resident's incontinence. The care plan did not include interventions for a timed or scheduled voiding program, despite the resident meeting the criteria for such a program in multiple evaluations. The Director of Nursing acknowledged the lack of interventions and the conflicting assessment results.
Failure to Maintain Clean Respiratory Equipment
Penalty
Summary
The facility failed to maintain clean oxygen delivery equipment for two residents, leading to potential risks of respiratory complications and infection. Resident 19, who had heart failure and obstructive sleep apnea, required a CPAP machine. Despite a physician's order to clean the CPAP mask daily, observations revealed that the mask was unclean with white splatter inside, and the resident reported that staff had not been cleaning it. The CPAP was also stored in a drawer full of crumbs, indicating a lack of proper hygiene and maintenance. Resident 38, diagnosed with chronic respiratory failure and asthma, required oxygen therapy. The physician's order specified that the oxygen concentrator filter should be cleaned weekly. However, an observation found the filter covered in thick dust debris. The Director of Nursing confirmed the importance of cleaning the equipment to prevent interruptions in oxygen flow and potential breathing difficulties. These observations highlight the facility's failure to adhere to prescribed cleaning protocols for respiratory equipment.
Inconsistent Dialysis Care for Two Residents
Penalty
Summary
The facility failed to provide consistent dialysis care in accordance with professional standards for two residents. Resident 13, who had paralysis and end-stage kidney disease, was not consistently evaluated post-dialysis. The facility's policy required staff to check vital signs and document the resident's status in the Dialysis Communication Binder after each session. However, there were nine instances in September and October 2024 where the post-dialysis evaluation was not completed. Staff D, the Resident Care Manager, acknowledged the importance of these evaluations to monitor for adverse reactions and maintain communication with the dialysis center. Resident 19, diagnosed with heart failure and end-stage kidney disease, did not receive their morning medications on dialysis days. The care plan required blood sugar checks and medication administration at least two hours before or after dialysis. However, the October 2024 medication administration record showed no blood sugar checks before dialysis and inconsistent medication administration on dialysis days. Staff B, the Director of Nursing, confirmed the necessity of monitoring blood sugars and administering medications appropriately. The dialysis clinic stated they did not check blood sugars unless symptomatic and did not administer facility-prescribed medications.
Failure to Provide Trauma-Informed Care
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for two residents, Resident 3 and Resident 25, who were reviewed for trauma-informed care. For Resident 3, the facility did not adequately assess and identify potential triggers that could re-traumatize the resident, nor did it develop and implement a comprehensive Trauma Informed Care Plan. Despite Resident 3's history of physical assault and severe human suffering, the facility's evaluation did not list any triggers, and staff were unaware of what could trigger re-traumatization. An incident involving a male staff member who exhibited intimidating behavior was reported, but the facility did not monitor Resident 3 for adverse reactions until two days later. Resident 25, who was assessed as cognitively intact and had a history of mental illness, also did not receive adequate trauma-informed care. The facility's evaluations identified that Resident 25 had experienced a very stressful event but failed to document what the event was or identify specific triggers. The resident exhibited several disruptive behaviors, including yelling, banging, and verbal aggression, but the care plan lacked trigger-specific interventions to prevent re-traumatization. The facility did not involve family members or representatives in the evaluation process, and the care plan did not provide guidance to staff on how to address the resident's reactions. The deficiencies were acknowledged by the facility's Administrator and Director of Nursing, who recognized the lack of interventions and guidance in the care plans for both residents. The facility's failure to identify triggers, coping mechanisms, and strategies to manage re-traumatization placed the residents at risk for re-traumatization and a diminished quality of life.
Failure to Monitor Vital Signs Before Medication Administration
Penalty
Summary
The facility failed to ensure proper monitoring of blood pressures and heart rates, leading to the administration of medications against prescribed parameters for two residents. Resident 10 had an order for metoprolol, which was to be held if the pulse was below 60 beats per minute. Despite this, the medication was administered on multiple occasions when the resident's pulse was below the threshold. This oversight was acknowledged by Staff D, a Registered Nurse/Resident Care Manager, who confirmed that the medication should have been withheld on those days. Resident 22, who had diagnoses including hypertensive kidney disease and dementia, was prescribed Carvedilol with instructions to hold the medication if the systolic blood pressure was less than 110 or the heart rate was below 60 beats per minute. However, the facility's Medication Administration Record (MAR) lacked a section for documenting vital signs, and the resident received the medication without proper monitoring. Staff J, an LPN, confirmed that there was no place to document the vital signs on the MAR, and vital signs were only taken every other day. Staff D admitted that the monitoring requirement had been overlooked, leading to the administration of the medication without verifying the necessary parameters.
Inadequate Infection Control and Water Management
Penalty
Summary
The facility failed to develop a comprehensive water management plan to address the risk factors associated with Legionnaire's Disease. The plan, last reviewed on March 11, 2024, was incomplete, lacking essential components beyond identifying the facility's water source, contacts, and characteristics. This deficiency was confirmed by the facility's administrator, who acknowledged the need for a more detailed plan. Additionally, the facility did not ensure proper handling of soiled linens, as observed when a nursing assistant transported a soiled gown without placing it in a bag, contrary to infection control protocols. Furthermore, the facility failed to maintain sanitary conditions for oxygen administration for a resident with chronic respiratory failure. The resident's nasal cannula was found on the floor, and a nursing assistant placed it back in the resident's nose without cleaning or replacing it, which was identified as an infection control concern by the infection preventionist.
Failure to Maintain Clean Wheelchairs for Residents
Penalty
Summary
The facility failed to maintain wheelchairs in a clean manner for two residents, which was observed during a survey. Resident 14, who had a history of stroke and hemiplegia, was noted to have moderate cognitive impairments and required substantial to total assistance for all care. Observations on multiple occasions revealed that the resident's wheelchair was unclean, with the left armrest covered in sheepskin and netting that had brown and red substances on it. Additionally, food debris was crusted on the cushion and bottom of the chair. These observations were made over several days, indicating a persistent issue with maintaining cleanliness. Similarly, Resident 19, who was cognitively intact and required substantial to total assistance, was observed with an unclean wheelchair containing food debris. This was noted on several occasions over a few days. An interview with the Director of Nursing confirmed that wheelchairs were supposed to be cleaned weekly, and failure to do so was considered a dignity issue for the residents. The lack of cleanliness in the wheelchairs for these residents was a deficiency in maintaining a safe and dignified environment.
Failure to Follow Transfer Protocol Results in Resident Injury
Penalty
Summary
The facility failed to ensure that a resident was transferred according to their care plan, resulting in harm. The resident, who had a history of a stroke affecting their right side and required substantial assistance with transfers, was supposed to be transferred by two staff members using a gait belt or a sit-to-stand lift. However, Staff A attempted to transfer the resident alone using a gait belt. During the transfer, the resident's legs gave out, and Staff A assisted them to the floor. The wheelchair brake was inadvertently released, causing the wheelchair to slide back, and the resident landed on the floor. Initially, the resident did not report any pain or abnormalities, but later complained of pain, and an x-ray revealed a fractured right arm and clavicle. Staff B, a Registered Nurse, confirmed that Staff A did not review the resident's Kardex, which indicated the need for two staff members for transfers. The Director of Nursing acknowledged that Staff A did not follow the care plan, leading to the resident's injuries.
Failure to Address Dietary Grievances
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve grievances related to dietary issues for eight out of nine residents. Residents reported that their food preferences, as indicated on meal cards, were not being honored. This included not receiving the food they ordered, being served items they disliked, and in some cases, receiving food they were allergic to. Despite attending food committee meetings and voicing their concerns, residents felt that their grievances were not addressed, leading to ongoing dissatisfaction with the dietary services provided. Interviews with residents revealed consistent issues with the facility's food service. Residents expressed frustration over not receiving the meals they selected, with some resorting to purchasing their own food due to dissatisfaction. Specific grievances included being served cold food, not receiving required dietary supplements, and experiencing rude behavior from staff when rejecting meals. The facility's grievance records corroborated these complaints, showing repeated concerns about the kitchen staff not adhering to residents' meal preferences and dietary needs. Staff interviews indicated a lack of effective communication and follow-through on resolving the dietary issues. The Dietary Manager acknowledged the problems but attributed them to misunderstandings about menu processes and a lack of time for cooks to review individual dislikes. Despite attempts to educate staff and involve them in food committee meetings, the issues persisted, with residents continuing to feel that their concerns were not being adequately addressed.
Failure to Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse and/or neglect for four residents, which placed them at risk for further abuse and/or neglect. Resident 4, who had heart disease, filed a grievance about a Licensed Practical Nurse (LPN) being rough and rude. The Director of Nursing (DNS) documented speaking with the resident and ruling out abuse/neglect, but there was no evidence of a thorough investigation, including interviews with the resident and staff. Resident 5, diagnosed with diabetes and paraplegia, reported grievances about two nurses being rude and not being assisted out of bed for three days due to staff unavailability and lack of training with the Hoyer lift. The facility's response involved speaking with the resident and adjusting staffing, but there was no documentation of a comprehensive investigation into the allegations. Similarly, Resident 6, with respiratory disease, reported a lack of staff availability when they were sick, but the facility's response did not include a thorough investigation. Resident 7, with a central nervous system disease, filed a grievance about inadequate staffing and a delayed response to their call light. The facility's response indicated that staffing was adequate, but there was no documentation of a detailed investigation. Interviews with staff revealed that grievances were logged and assigned to relevant departments, but allegations of abuse and/or neglect were not investigated as required, and the grievances were not treated as such.
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 190 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Spokane
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Touchmark On South Hill Nursing | 1.8 mi | — | 0 | 0 |
| Spokane Veterans Home | 2.3 mi | ★★★★★ | 1 | 0 |
| South Hill Rehabilitation And Care Center | 2.3 mi | ★★★★★ | 2 | 0 |
| Rockwood South Hill | 3.3 mi | ★★★★★ | 1 | 0 |
| Sunshine Health & Rehab | 4.2 mi | ★★★★★ | 13 | 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.