Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Alderwood Post Acute & Rehabilitation during CMS and state inspections, most recent first.
Staff failed to follow TBP for a resident on contact precautions. A CNA delivered a meal tray and touched the resident's bedside area without wearing a gown or gloves, an LPN later assisted the resident and handled the bed and air mattress without PPE and did not perform hand hygiene before touching a spoon from the med cart, and another CNA entered the room and touched the resident without PPE. The DON stated staff should read and follow the TBP sign, including hand hygiene and wearing a gown and gloves before entering and removing them before exiting.
The facility failed to revise and individualize care plans to reflect current needs and preferences for multiple residents, including one cognitively intact resident with hemiplegia, hemiparesis, and mononeuropathy who had bilateral shoulder surgery and could not tolerate BP measurements on the upper arms but preferred forearm readings. Despite repeatedly informing staff, this preference was not documented in the care plan or Kardex, and direct care staff and the RN/UM were unaware of it. Another cognitively intact resident with hemiplegia, contractures, and weakness reported they were supposed to get out of bed for two hours daily, but some NACs did not know this, even though the MAR/TAR contained an order to document times up and back to bed. The surveyors concluded that care plans were not accurately revised for several residents, placing them at risk for unidentified and unmet care needs and diminished quality of life.
Surveyors found that two residents with hemiplegia, hemiparesis, weakness, and contractures did not receive restorative nursing services, including ROM exercises and splint/brace or orthotic assistance, after therapy discharge. Although PT and OT discharge summaries documented established restorative ROM and transfer programs, recommended PROM to affected extremities, and recommended splint/brace use and assistance with orthotic wear, these recommendations were not entered as restorative referrals in the EHR. As a result, the residents’ care plans and records showed no restorative programs, and both residents reported that therapy and restorative exercises had stopped, while the DON, rehab director, and MDS coordinator confirmed they were unaware of and had not implemented the recommended restorative services.
A resident with diabetes, a right foot wound, depression, and moderate cognitive impairment was discharged home without complete discharge instructions, a discharge summary, or physician orders for wound care. The discharge packet lacked documentation that blood pressure, antidepressant, and insulin medications were provided, and there was no evidence that wound care supplies or training were given to the resident or family. Facility staff, including social services, an LPN nurse manager, and the DON, acknowledged that the discharge documentation was incomplete and that required wound care orders, education, and medications were not included.
A resident dependent on hemodialysis missed all scheduled treatments due to the facility's failure to accommodate their need for a closer HD center and a bed during treatment, despite repeated requests. Facility staff were unaware of the missed treatments, did not notify the provider or resident representative, and failed to document or monitor the resident's condition. The lack of coordination and documentation resulted in the resident being hospitalized in intensive care for volume overload and heart failure.
A resident was discharged AMA without receiving discharge instructions, a discharge summary, or arrangements for home health services or equipment. Staff confirmed that required discharge documentation was missing from the EHR and that no preparations were made until the issue was identified by a surveyor.
The facility did not have a full-time RN designated as the DON after the previous DON was terminated. A corporate nurse provided intermittent coverage, but no full-time DON was in place, as confirmed by staff interviews and review of personnel records.
A resident with cognitive and physical impairments reported an allegation of sexual assault, but the facility failed to conduct a thorough assessment, did not immediately suspend the alleged staff member, and did not ensure interventions such as female care only were followed. A subsequent injury of unknown origin was not investigated or reported, and documentation and follow-up were lacking.
A resident with moderate cognitive impairment and a recent allegation of sexual assault was found to have a new skin tear in a vulnerable area. Despite documentation of the injury, staff including the DON and LPN did not report or investigate the incident, and the Administrator was unaware until later. The event was not reported to the state survey agency, and no investigation was conducted.
A resident with cognitive and physical impairments reported a sexual assault by a CNA, but the facility failed to conduct a thorough investigation, did not immediately suspend the accused staff, and did not document a comprehensive skin check or alert monitoring. The resident later developed a new skin tear in a sensitive area, which was not reported or investigated, and key notifications to the resident's power of attorney and physician were missing.
A resident with stroke-related right-sided weakness developed a fixed right hand contracture and reduced mobility after the facility did not provide restorative services or other ROM interventions for the right upper extremity. The resident reported pain, worsening function, and inability to straighten the fingers or use the hand for tasks such as pressing the TV remote or call light buttons, while records showed no restorative program or therapy services and physician notes identified a moderate risk for contractures without adequate therapy.
The facility failed to designate a properly qualified director of food and nutrition services. The Dietary Services Manager was on leave, the facility did not have a full-time RD, and the Administrator confirmed the designated manager had not completed the required certification.
The facility failed to ensure the designated IP met the qualifications to oversee the IPCP. The Administrator identified an LPN/IP as the IP, but the facility initially provided only proof of Module 1 of the CDC Train IP program. Review of the CDC program showed completion required 23 modules, a test, and a certification letter. Later, the facility emailed completed modules, with the last module dated on the day of review, but no certificate of completion was provided.
Unpleasant odors, stained carpeting, damaged flooring, missing resident property, and excessive TV noise were observed on the 2nd floor. Surveyors noted musty, mildewy, and urine odors in the hallway, large carpet stains, and missing or lifting flooring transition pieces. A resident reported missing clothing and blankets without a documented grievance, and two residents complained that loud TVs from nearby rooms were heard almost constantly, including during quiet hours.
Failure to provide transfer notices, bed-hold information, and LTCO notifications. The facility did not document required bed-hold and transfer/discharge notices for residents who were sent to the hospital, discharged home, or left AMA. Records for several residents lacked evidence that the RN, social services, or medical records staff completed the required written notices or notified the state LTCO, despite facility policies requiring these steps.
Incomplete RAI and CAA Documentation: The facility failed to complete thorough RAI/CAA assessments for several residents. A resident with chronic pain syndrome, a resident with spinal stenosis and foot drop, a resident with post-stroke hemiplegia, and a resident with broken and loose teeth all had triggered CAAs that were blank or lacked comprehensive analysis of needs, goals, preferences, strengths, and contributing factors. The RN MDS nurse confirmed the pain CAA did not address all required issues, and the DON stated the MDS and CAA were expected to be complete and accurate.
PASRR screening was not completed correctly or updated for multiple residents with MH diagnoses or changes in condition. Residents had diagnoses such as depression, anxiety, PTSD, and mood disorder, and some were receiving psychotropic meds including antidepressants, antianxiety meds, antipsychotics, and hospice-related treatment, yet admission PASRRs were inaccurate or no new PASRR referral was submitted for reassessment. Staff acknowledged the PASRRs were incorrect or not updated and could not provide documentation showing the required follow-up was completed.
Incomplete and Non-Individualized Care Plans: The facility’s care plans did not reflect the actual needs of multiple residents. A resident with ESRD and a tunneled IJ dialysis catheter had a generic dialysis plan written for an AV fistula, a resident with pain had a generic opioid plan without non-pharm interventions, a resident with post-stroke contractures had no ROM/contracture plan, residents with depression/anxiety/PTSD had no person-centered behavioral goals or interventions, and residents with weight loss or severe malnutrition had nutrition plans lacking goals, preferences, and meaningful interventions.
A facility failed to accurately update care plans for two residents with foot skin issues and pressure-relief needs. One resident had a right heel pressure ulcer and an ordered heel floater/green boot, and another resident had redness and a heel protector boot in use, but neither care plan or Kardex documented the protective devices. Staff confirmed the boots should have been included.
Failure to Provide ADL Assistance and Ordered Splint Care: Multiple dependent residents did not receive scheduled bathing assistance, and one resident with a hand contracture did not have the ordered splint in place. Residents were observed with greasy or matted hair, one resident reported only receiving "spit baths," and staff interviews showed showers were assigned to floor NACs but were not consistently completed or documented in the EMR. Another resident with a stroke-related contracture was observed without the prescribed palm guard splint until a new one was later present.
Failure to provide pressure ulcer prevention and care affected three residents. One resident with a heel wound was repeatedly observed without the ordered heel protector boot while in bed, and the wound was later described as a DTPI and then unstageable. A second resident developed a new sacral pressure ulcer, but there were no new orders, no revised care plan interventions, and no documentation that the wound was reported or monitored. A third resident with high PU risk and an existing sacral injury was not documented as receiving ongoing skin checks, and later developed a red, non-blanchable pressure area under the O2 tubing on the cheek; the care plan did not include padding for the nasal cannula.
Expired and unsecured medications were found in multiple med carts, a med room, and at a resident’s bedside. Surveyors observed unlocked carts, a vial of Tuberculin left on top of a cart, and a resident’s ointment, eye drops, and topical creams kept at bedside without a documented SMP assessment. The yellow, blue, and pink carts and the second-floor med room also contained expired or undated meds, including Narcan, aspirin, vitamin D, laxatives, Dakin’s solution, and eye drops opened beyond the consultant pharmacist’s stated timeframe.
Failure to Provide and Follow Up on Dental Services: Multiple residents had broken, missing, loose, or ill-fitting teeth and dentures, but dental referrals, appointment scheduling, and documentation of offered or completed dental care were missing or delayed. Staff said social services handled referrals and scheduling, yet records showed no clear follow-up for residents with oral pain, missing dentures, broken teeth, or needed extractions, and one resident was not even on the dental provider’s list when expected.
Improper Storage of Resident Food in Nourishment Refrigerator: A nourishment refrigerator on the second floor was repeatedly found ajar with temps ranging from 48 to 58 degrees, while storing dairy items, sandwiches, juices, and a resident-labeled sushi container. The temp log was signed without a time and showed 39 degrees, but staff did not notice the door or temp issue when passing by. The Administrator later stated the fridge seal was broken.
Incomplete and inaccurate resident records were found for multiple residents. One resident returned from the hospital after coffee ground emesis, but the chart lacked documentation of the transfer, physician/family notification, and hospital communication. Another resident’s dental referral and extraction follow-up were not documented, a third resident had missing ordered weights, and a fourth resident’s urinary catheter was observed absent without any record of removal or discontinuation.
Infection control practices were not followed for residents on EBP and contact isolation, with staff entering a room without gown and gloves and no EBP signage or PPE posted for residents with wounds. Reusable equipment such as a Hoyer lift was observed moved without disinfection, two urinary drainage bags were left on the floor, and the facility had no formal water management plan; leadership and the IP stated they were unaware of the missing plan.
Advance directives were not obtained or documented for four residents reviewed. One resident had moderate cognitive impairment, another was cognitively intact, a third had moderate cognitive impairment, and a fourth was admitted for hospice care with cancer. The EHRs lacked AD documentation or evidence that ADs were discussed or assistance was provided, and care plans did not address ADs. For one resident, the facility had only a POLST, while the hospital record showed an AD existed.
The facility failed to properly review psychotropic medication use for two residents. One resident was given Seroquel for behaviors and insomnia despite no documented psychosis or insomnia, no consent in the chart, and no sleep monitoring. Another resident received Hydroxyzine for anxiety and insomnia, but the MAR did not show non-pharmacological interventions or sleep-hour monitoring, and staff acknowledged these items were not documented.
PASRR Level II Not Submitted After Hospital Exemption Ended: A resident with MDD with psychotic symptoms and anxiety had a PASRR Level I showing SMI and a need for Level II if discharge did not occur. The resident was initially covered by a hospital exemption, but once the stay changed to LTC, Social Services documented that a Level II was required for validation and confirmed that no Level II PASRR was submitted.
Unmarked Courtyard Step Led to Resident Fall: A wheelchair-bound resident admitted after orthopedic surgery fell in a therapy courtyard after backing toward what appeared to be a ramp and dropping off an unmarked step. The resident reported hitting their head and scraping both elbows. Observation showed the courtyard step had railings but no gate, barrier, or markings to identify the change in elevation, and the Administrator stated the facility had not previously identified the step as a hazard or provided supervision in the courtyard.
Inadequate weight monitoring and nutrition/hydration management: Two residents had poor intake and significant nutrition concerns, but records showed incomplete assessments, missing or infrequent weights, and limited documentation of intake. One resident was severely underweight with malnutrition, was ordered a pureed diet and supplements, yet the assessment listed the wrong texture and the care plan lacked key interventions. Another resident had repeated untouched meals, dental pain, limited fluid intake, significant weight loss, and no routine weight or fluid intake documentation, despite ongoing appetite decline and a regular texture diet that did not match chewing problems.
Inaccurate dialysis care planning and monitoring were identified for a resident with ESRD who had a tunneled IJ catheter for HD access. The care plan and TAR used generic AV fistula interventions, including bruit/thrill checks and dressing instructions that did not apply, while nursing documentation used unclear y/n entries and staff said they were confused about what the charting meant. The facility also used an inconsistent pre- and post-dialysis communication process with the dialysis center.
A resident with arthritis and right hip pain had PRN pain medication ordered and received it frequently, but staff did not provide non-pharmacological interventions before administration. An RN stated such interventions should be tried first, and an LPN nurse manager and the DON acknowledged they were not being provided for the resident.
An RN prepared to administer insulin to a resident with Type 2 DM using a vial that had already expired after opening. The RN believed the vial could still be used, while an LPN/unit manager confirmed it was only good for 28 days and was expired. The RN stated the injection would have been given if not stopped, and the DON said nurses were expected to check expiration dates before giving insulin.
A resident with iron deficiency anemia, pressure ulcer, cellulitis, and wounds was ordered weekly CBC and CMP testing, but the record showed missed or missing lab results for several weeks despite MAR entries indicating the labs had been obtained. The PA said weekly labs were intended, a unit manager had heard some weekly labs were missed, and the DON said the missed labs were an isolated event.
A resident with intact cognition and a documented need for large protein portions repeatedly received meal trays that did not match the tray card or menu selections. Observations showed missing or substituted items at lunch and breakfast, including pizza instead of meatballs/beef, fruit and cottage cheese instead of stuffed peppers and rice, bread instead of pancakes, and fewer breakfast meat items than listed. Staff and the admin acknowledged that tray cards and served meals sometimes did not match.
Failure to provide ordered rehab services for a resident with a hx of stroke, L-sided weakness, and significant ADL dependence. PT, OT, and ST evals recommended frequent skilled tx and documented good to excellent rehab potential, but the resident reported no tx after the initial evals. Staff stated therapy was withheld because there was no insurance authorization/payor source, and approval for limited PT/ST visits was not obtained until later.
The facility did not maintain adequate nursing staff on two units, leading to delayed medication administration and slow responses to call lights. Nurses were required to cover multiple medication carts and had more residents than they could manage, resulting in late medication passes and insufficient supervision of nursing assistants. Residents and family members reported frequent delays in receiving care and medications, and staff confirmed ongoing staffing shortages that prevented timely completion of duties.
The facility failed to develop and document patient-centered discharge plans for two residents, including one who was cognitively intact and another with moderate cognitive impairment. Neither resident nor their families were adequately involved or informed about the discharge process, and there was no evidence of interdisciplinary team planning or communication. This resulted in residents being unprepared for discharge and lacking necessary support and information.
Surveyors identified that two nurses administered medications outside of scheduled times, resulting in a 27% medication error rate. Multiple residents received medications such as Levothyroxine, Acetaminophen, and Hydrocortisone cream significantly later than ordered, and the facility lacked a policy specifying the acceptable administration window.
The facility did not maintain a completed state reporting log for two months, with incidents being logged only at the end of each month instead of within five days of discovery. This delay was attributed to a new DNS and lack of oversight during the DNS's absence, as confirmed by the administrator.
The facility did not have a qualified Infection Preventionist (IP) during a viral respiratory disease outbreak. Staff B was acting as the IP without the necessary training or certification. Interviews confirmed that Staff B was hired for the IP/Staff Development Coordinator role but had not been enrolled in a certification program. The facility's key personnel list showed no official IP designation, risking infection transmission among residents and staff.
A resident was transferred to a hospital due to neurological changes, but the facility failed to notify the emergency contact as required by policy. The family discovered the hospitalization only after visiting the facility the following day. The administrator confirmed the oversight, with no documentation of notification found.
The facility failed to ensure the Director of Nursing (DON) had an active professional license, placing residents at risk. Staff B, the new DON, was responsible for supervising the nursing department despite having a suspended and expired RN license. Staff members confirmed Staff B's role, and the administrator was aware of the license issue.
A facility failed to complete a background check for a newly hired DON, identified as Staff B, who was observed interacting with surveyors and moving unaccompanied in resident areas. The administrator confirmed the incomplete background check and lack of supervision, placing residents at risk of interactions with unqualified staff.
The governing body failed to ensure the DNS had a completed background check and an active professional license before employment. The DNS was hired despite an incomplete background check and a suspended RN license. The Administrator was aware of these issues, but the decision to hire was made by the governing body.
The facility failed to administer services effectively, impacting residents' well-being. The administration did not ensure thorough investigations of allegations or address repeated concerns about long call light wait times documented in Resident Council meeting minutes. Despite receiving these minutes monthly, the administrator did not implement corrective actions. The facility also had repeat deficiencies in areas such as resident rights and abuse prevention.
The governing body failed to provide adequate oversight of the facility's Administrator, resulting in repeated deficiencies in critical areas such as Abuse/Neglect, Resident Rights, and Infection Control. The governing body did not participate in QAPI meetings or communicate effectively with the Administrator, leading to a lack of clinical systems and insufficient staffing to meet residents' needs.
The facility failed to address concerns raised by the Resident Council, including slow call light response times and incorrect food orders. Despite documentation of these issues, there was no evidence of investigation or resolution, leading to unmet care needs and diminished quality of life for residents.
The facility failed to recognize, record, and resolve grievances for five residents, leading to unresolved issues such as malfunctioning equipment, missing medications, and personal belongings. Despite reporting these issues, no grievances were logged, and staff were unaware of the grievance process. This systemic failure placed residents at risk for anxiety and diminished quality of life.
Failure to Follow Contact Precautions
Penalty
Summary
The facility failed to ensure staff followed transmission-based precautions for a resident on contact precautions. The resident had an order for contact precautions initiated on 02/24/2026, and the care plan identified contact precautions related to wounds. A contact precaution sign at the doorway directed staff and visitors to clean hands before entering and leaving the room and to wear gloves and a gown before entering. The resident was observed in the room with a wheelchair and later in the hallway near the nurse's station and near the elevators on the first floor. During observations, a CNA delivered the resident's lunch tray without wearing gloves or a gown and touched the resident's bedside table and items on the bed. Later, an LPN assisted the resident back to the room without wearing a gown or gloves, touched the bed and air mattress, and then exited the room without performing hand hygiene before handling a spoon from the medication cart and returning to the room. Another CNA also entered the room without gown or gloves and placed a hand and forearm on the resident's shoulder while talking with them. The DON stated residents on contact precautions should remain in their room and that staff should read and follow the TBP sign, including hand hygiene and wearing a gown and gloves before entering and removing them before exiting.
Failure to Revise Care Plans to Reflect Resident Needs and Preferences
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize comprehensive care plans to reflect residents’ current needs and preferences, as required by its own care planning policy. For one resident with hemiplegia, hemiparesis following cerebrovascular disease, and mononeuropathy of the upper limb, the admission MDS showed intact cognition and upper extremity impairment. This resident reported having bilateral shoulder surgery and an inability to tolerate blood pressure measurements on the upper arms due to pain, and stated a preference for BP measurements on the forearms. The resident reported having informed multiple nursing staff of this preference, but staff continued to place the cuff on the upper arms. Review of the resident’s care plan and Kardex showed no interventions or instructions regarding forearm BP cuff placement. A NAC confirmed they were unaware of the preference until the resident told them directly and that this instruction was not documented in the Kardex. The RN/Unit Manager, who stated they were responsible for revising and reviewing care plans when there were changes, also confirmed they were not aware of the resident’s preference and that it should have been updated in the care plan. Another resident, readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, contracture of the left hand, and weakness, was cognitively intact and required maximum assistance for bed mobility per a quarterly MDS. This resident stated they were supposed to get out of bed for two hours every day, but some NACs were not aware of this care requirement. Review of the resident’s March 2026 MAR/TAR showed an order to document the time the resident got up and the time they returned to bed daily. The report states that, overall, the facility failed to revise care plans accurately to reflect residents’ needs for three of four residents reviewed for care plan revision, placing them at risk for unidentified and unmet care needs and a diminished quality of life.
Failure to Implement Restorative Nursing and Splint/Brace Programs After Therapy Discharge
Penalty
Summary
The deficiency involves the facility’s failure to provide restorative nursing services, including range of motion (ROM) exercises and splint/brace assistance, to maintain or prevent decline in mobility and contractures for two residents with significant motor impairments. The facility’s undated Restorative Nursing Services policy stated that residents would receive restorative care as needed to achieve and maintain optimal functioning and that residents may initiate a restorative program upon discharge from rehabilitative care. Despite this, surveyors found that residents with documented hemiplegia, hemiparesis, weakness, and contractures were not placed on restorative programs and had no restorative interventions documented in their electronic health records (EHRs). Resident 1 was admitted with hemiplegia and hemiparesis following cerebrovascular disease, a left lower leg fracture, and weakness, and the admission MDS showed intact cognition, moderate assistance needs for bed mobility and transfers, and one-sided upper and lower extremity impairment. During observation, the resident was seen lying in bed with a bent inward left forearm and hand and reported no longer receiving therapy or nursing-assisted exercises. The care plan initiated in January showed no restorative services, and the care plan history and EHR contained no restorative nursing interventions. However, the PT discharge summary from February documented that restorative ROM and transfer programs had been established and trained, including PROM to the left upper and lower extremities and stand-by assist with transfers, and the OT discharge summary recommended a splint/brace to prevent contracture. The OT stated that the splint/brace was not tried due to lack of time before insurance was discontinued, and both the Director of Rehab and the MDS coordinator confirmed there was no restorative referral in the EHR and they were unaware of the recommendations. Resident 2 was readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, a left-hand contracture, and weakness, and the quarterly MDS showed intact cognition, maximum assistance needs for bed mobility, total assistance for transfers, bilateral upper and lower extremity impairment, and no therapy or restorative programs. The resident reported that therapy had been discontinued months earlier and that no restorative staff were assisting with exercises. The care plan and EHR showed no restorative services. OT evaluation documented left upper extremity ROM impairment, a left-hand contracture, and prior use of a left orthotic to manage flexion tone, and the OT discharge summary recommended restorative care and assistance with donning/doffing the orthotic. The PT discharge summary recommended restorative programs if Medicaid Part B services did not continue. The Director of Rehab confirmed therapy was discontinued and that restorative nursing programs were recommended, but both the Director of Rehab and the MDS coordinator stated there were no restorative referrals in the EHR after readmission, and the MDS coordinator confirmed the resident had no restorative programs since readmission.
Failure to Provide Complete Instructions, Medications, and Wound Care Preparation at Discharge
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe and adequately prepared discharge for a resident with multiple medical needs. The resident was admitted with diagnoses including diabetes, a right foot wound, and depression, and had moderate cognitive impairment per the Minimum Data Set. The resident was discharged home with family, but review of the electronic health record showed the discharge instructions and discharge summary were incomplete. The discharge packet did not contain discharge instructions, a discharge summary, or physician orders for wound care to the resident’s right foot. There was no documentation that wound care training had been provided to the resident or family prior to discharge. Further review of the resident’s records showed that the document titled “Medications discharged with Resident” did not list blood pressure, antidepressant, or insulin medications. The discharge packet also lacked documentation that wound care supplies, blood pressure medication, antidepressants, and insulin were sent with the resident. In interviews, the resident’s family contact stated they were not educated on wound care and did not receive wound care supplies or insulin. Social services staff and the nurse manager acknowledged that the discharge instructions and summary were incomplete and that there were no wound care orders, no documentation of wound care training, and no documentation of the necessary medications being provided at discharge. The DON confirmed that the discharge packet was missing the required discharge documents, medication listings, wound care orders, and documentation of wound care supplies and training, despite facility expectations that discharged residents receive these items.
Failure to Ensure Scheduled Hemodialysis Leading to Resident Harm
Penalty
Summary
The facility failed to ensure that a resident with end stage renal failure received scheduled hemodialysis (HD) treatments as ordered. The resident was admitted and readmitted with a diagnosis requiring regular HD, but missed all scheduled treatments since admission. Interviews with collateral contacts and the resident revealed that the facility did not notify the resident’s representatives about missed HD sessions, nor did they attempt to accommodate the resident’s need for a closer HD center or a bed during treatment, despite repeated requests. The resident was unable to tolerate sitting for extended periods due to weakness and repeatedly communicated these needs to facility staff, but no action was taken to change the HD center or transportation arrangements. Facility staff, including the physician assistant, social worker, business office manager, and unit manager, were unaware that the resident had missed all HD treatments until notified by the HD center or after the resident was hospitalized. There was no documentation of the resident’s preferences, reasons for missed appointments, or any risk and benefit discussions with the resident or their representative. Additionally, there was no evidence of notification to the provider, resident representative, or facility management regarding missed HD treatments, nor was there documentation of ongoing monitoring or medical management for the resident’s condition due to missed treatments. Review of the resident’s care plan and progress notes showed a lack of interventions addressing the resident’s preferences, coordination with the HD center, or follow-up for missed treatments. The care plan did not include a focus area for missed HD treatments, and progress notes failed to document arrangements for rescheduled sessions or monitoring of the resident’s condition. The resident ultimately experienced harm, requiring hospitalization in the intensive care unit for volume overload and heart failure, conditions attributed to missed HD treatments.
Failure to Provide Safe Discharge Planning and Documentation
Penalty
Summary
The facility failed to ensure proper preparations were made for a safe discharge for one resident who left the facility against medical advice. According to the facility's policy, nursing services and/or social services are responsible for obtaining discharge orders, arranging recommended services and equipment, preparing medications for discharge, and providing the resident or representative with required documents such as a discharge summary and plan. However, review of the resident's electronic health record showed that no discharge instructions or discharge summary were completed at the time of discharge. Interviews with facility staff confirmed that discharge instructions and summaries are typically completed in the electronic health record, but in this case, none were present. Additionally, no arrangements for home health services or equipment needs were made prior to the resident's departure. The lack of discharge planning and documentation was only identified after the surveyor brought it to the facility's attention.
Failure to Maintain Full-Time DON Coverage
Penalty
Summary
The facility failed to designate and ensure a full-time Registered Nurse (RN) to serve as the Director of Nursing (DON) as required. Upon entry, the receptionist confirmed that there was no current DON, and a review of the facility's key personnel list also showed the absence of a full-time DON. The Administrator stated that the previous DON had been terminated the previous week and that a corporate nurse was temporarily covering the DON position as needed, but not on a full-time basis. In a follow-up interview, the Administrator confirmed that the facility still did not have a full-time DON, although an offer had been made to a potential candidate. The corporate nurse continued to provide coverage, but not in a full-time capacity.
Failure to Protect Resident from Abuse and Neglect
Penalty
Summary
The facility failed to protect a resident from abuse and neglect by not following its own policies after an allegation of sexual assault. The resident, who had moderate cognitive impairment, hemiplegia, hemiparesis, and required substantial assistance with toileting, reported an allegation of sexual assault. Despite the facility's policy requiring immediate assessment, notification, and protection, there was no documentation of a thorough assessment or skin check following the allegation. Additionally, the resident was not offered an emergency room evaluation after the report. The staff member accused in the allegation was not immediately suspended as required. Documentation showed that the staff member continued to work a full shift after the allegation was reported, and the suspension form was not reviewed with the employee until several days later. The investigation summary was unsigned and completed days after the incident, and staff statements were not obtained promptly. The facility also failed to ensure that interventions, such as female care only and care in pairs, were consistently implemented, as male staff continued to provide care and document treatments for the resident. A new skin tear was later discovered on the resident's labia, but there was no documentation of a thorough skin check or investigation into this injury of unknown origin. The injury was not reported to the state, and no further documentation or follow-up was found in the resident's record. Staff interviews confirmed that required reporting and investigation steps were not taken, and interventions to prevent further abuse were not consistently followed.
Failure to Report and Investigate Injury of Unknown Origin in Resident with Recent Abuse Allegation
Penalty
Summary
The facility failed to report to the state survey agency an allegation of injury of unknown origin in a vulnerable area for a resident with a recent history of alleging sexual assault. The resident, who had moderate cognitive impairment and required substantial to maximum assistance with toileting, was found to have a new skin tear around her left labia, as documented in a nursing progress note. There was no further documentation regarding this injury, and no investigation was initiated or reported to the appropriate authorities. Interviews with facility staff revealed that the former DON was unaware of the injury and stated it should have been reported and investigated, especially given the resident's recent allegation of sexual assault. The LPN/Nurse Manager acknowledged being notified of the injury but did not report or investigate it. The Administrator also confirmed that this was the first time they were made aware of the incident and that it should have been reported and investigated. No investigation was conducted, and the incident was not reported to the state survey agency.
Failure to Investigate Sexual Assault Allegation and Protect Resident
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual assault involving a resident with moderate cognitive impairment and significant physical limitations, including hemiplegia and hemiparesis. The resident reported to a therapist that a male CNA straddled them and reached into their pants with an ungloved hand. The facility's investigation did not include interviews or witness statements from the resident or staff who worked directly with the resident at the time of the alleged incident. Additionally, the investigation summary was unsigned, and there was no documentation of a thorough skin check or alert monitoring for psychosocial harm following the allegation. The staff member accused was not immediately suspended as required; instead, they continued to work a full shift after the allegation was reported. The suspension form was completed by the administrator without the staff member's knowledge or signature, and the staff member was not informed of the suspension until several days later. The staff member also stated that they were not interviewed or asked for a statement regarding the incident until after their scheduled days off, and only then received the suspension form. Further, there was no documentation that the resident's power of attorney or physician was notified of the allegation. A new skin tear was later found on the resident's labia, but this injury was not reported or investigated, and no thorough skin check was documented. The nurse manager acknowledged that the injury should have been reported and investigated due to its location and the recent allegation, but this did not occur. The investigation lacked critical elements such as timely suspension of the accused staff, comprehensive interviews, and proper documentation of resident assessment and notifications.
Failure to Address Declining ROM and Hand Contracture
Penalty
Summary
The facility failed to provide appropriate treatment, services, and interventions to prevent an avoidable reduction in range of motion for a resident with right hemiplegia and hemiparesis following a stroke. The resident was readmitted with diagnoses including stroke-related weakness, and the facility’s quarterly MDS dated 06/06/2025 indicated the resident was cognitively intact, had no diagnosis of contracture or impaired joints, and received no restorative programs or therapy services. The facility policy stated that the resident’s ROM status, limitations, contractures, pain, and contributing factors should be identified and that the care plan should include specific interventions, exercises, therapies, equipment, and measurable goals to maintain or improve ROM. During observation and interview, the resident stated the facility had not provided any exercise or service for the right hand and arm and could not straighten the fingers on the right hand. The resident was observed with the right elbow bent in a rigid position close to the body and the right hand closed tightly in a fist, with the second, third, and fourth fingers bent in a fixed position. The resident stated the right hand could no longer be used to press the TV remote or call light buttons and reported pain when trying to open the hand or move the right elbow and shoulder. Later interviews documented that the resident had never received restorative services for the right upper extremity and had reported worsening pain and function. Physician notes documented the resident had a moderate risk for developing contractures if not receiving adequate therapy.
Unqualified Dietary Services Manager Designation
Penalty
Summary
The facility failed to designate a person to serve as the director of food and nutrition services with the proper qualifications. During review of the key personnel list provided at the entrance conference on 08/13/2025, Staff C was listed as the Dietary Services Manager, but Staff C was on leave of absence. In an interview on 08/20/2025 at 09:15 AM, the Administrator confirmed that the facility did not have a full-time registered dietician and that Staff C was designated as the facility Dietary Services Manager. The Administrator also acknowledged that Staff C had not yet completed the required certification for Dietary Services Manager.
Infection Preventionist Lacked Required Training Documentation
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP) met the qualifications for experience, education, training, or certification to be responsible for the Infection Prevention and Control Program (IPCP). The facility policy stated that the Infection Preventionist would oversee the IPCP and report to the Infection Prevention and Control Committee and/or QAPI committee, with the Administrator responsible for oversight of the program. During the entrance conference, the Administrator identified Staff D, an LPN/IP, as the designated Infection Preventionist and said credentials would be provided. The facility later provided only a certificate showing completion of Module 1 of the CDC Train Infection Preventionist Program. Review of the CDC program showed completion required 23 individual modules, a test, and a certification letter. When asked for the remaining modules and certificate, Staff D stated they had already completed them, and the DNS stated they believed the course had been completed. The facility later emailed completed modules, with the last module dated 08/19/2025, but no certificate of completion for the course was provided.
Unpleasant odors, damaged flooring, missing resident property, and excessive TV noise
Penalty
Summary
The facility failed to maintain the second-floor environment in a clean, comfortable, homelike, and safe condition. Surveyors observed a strong unpleasant odor in the hallway outside rooms 228 to 239 on 08/12/2025, along with a one-foot by one-foot dark stained spot on the carpet. On later observations, the same hallway continued to have odors described as mildewed clothes and urine, and the second-floor carpeted hallways were noted to have a strong musty, mildewy odor throughout. Surveyors also observed large dark spill stains in the lounge room carpet, dark staining outside multiple resident rooms, and dark staining extending from the hallway into a resident room near the sink area. The second floor also had flooring issues. On 08/15/2025, the TV lounge doorway was observed to be missing a flooring transition piece where the laminate hallway flooring met the carpet in the lounge. Missing transition pieces were also observed at resident rooms, and one transition piece that was present was separated and lifting at the hinge side of the door. These observations were made while the hallway carpet remained stained and odorous. The facility also failed to ensure security of resident property and control noise levels for residents who complained. Resident 26 stated that clothing and blankets were missing and staff were aware of the missing items, but the grievance log for August 2025 did not show a grievance for those items. Staff later acknowledged the missing items had not been found and that no grievance form had been completed. Resident 102 and Resident 4 reported loud televisions from nearby rooms, with Resident 102 stating the noise was heard almost all the time, day and night, and that it made them nauseous. Staff observed the televisions could be heard clearly in the hallway and at the nurses' station, and staff acknowledged the loud TV concerns.
Failure to Provide Transfer Notices, Bed-Hold Information, and LTCO Notifications
Penalty
Summary
The facility failed to provide required transfer and discharge documentation, including bed-hold notices and written transfer notices, for residents who were hospitalized or otherwise discharged. The report states that for 5 of 5 residents reviewed for hospitalization or discharge, the facility did not offer bed holds, did not provide written transfer notices, and did not notify the Office of the State Long Term Care Ombudsman (LTCO) as required. The facility’s own policies required residents or their representatives to be informed in writing of bed-hold and return policies before transfers or therapeutic leaves, with a second written notice at the time of transfer or within 24 hours for emergency transfers. Resident 82 returned from the hospital after being sent out the previous night for coffee ground emesis. The record showed no documentation that the resident had been transferred to the hospital, and there was no documentation of bed holds, transfer notice, physician or family notification, or a report to the receiving hospital for continuity of care. Staff P stated the medical record did not include that the resident was sent to the hospital or that the bed hold or transfer notice was provided, and said the nurse should document the reason for transfer, notify family and the physician, obtain the bed hold, provide discharge paperwork, and call the emergency department with a report. Resident 12 was discharged to the hospital, and the progress note documented that a family member was aware of the situation and agreed to the transfer, but there was no documentation of the bed-hold policy or notice of transfer and discharge to the responsible party. Resident 10 was transferred to the hospital, Resident 108 was discharged home, and Resident 109 left against medical advice, but the electronic chart did not show documentation that the facility notified the LTCO of these discharges. Staff from medical records and social services stated that discharge packets or transfer notices should be scanned into the chart and faxed to the state ombudsman, but they could not provide documentation showing that these notifications were completed for the residents reviewed.
Incomplete RAI and CAA Documentation
Penalty
Summary
The facility failed to ensure the Resident Assessment Instrument (RAI) and Care Area Assessments (CAA's) were completed with thorough summaries that analyzed the resident's needs, strengths, goals, and preferences for 4 of 6 residents reviewed for comprehensive assessments. The report states the RAI should include the MDS assessment, the CAA process, and utilization guidelines, and the facility policy required CAA documentation to include causes and contributing factors, the nature of the condition, complications, risk factors, factors considered in care planning, and any need for further evaluation by another healthcare provider. For Resident 33, admitted with chronic pain syndrome, the admission MDS triggered a pain CAA, but the MDS assessment dated 06/06/2025 showed the CAA did not contain comprehensive summaries or analysis of current goals, preferences, strengths, or needs. For Resident 98, admitted with spinal stenosis, bilateral foot drop, and lymphedema, the admission MDS dated 08/01/2025 triggered a pain CAA, but the pain CAA was blank except for one line stating the resident complained of pain during interview. Staff R, RN MDS Nurse, stated the CAA's should address anything triggered and confirmed the pain CAA's did not address all issues, including pain medications and possible adverse side effects. For Resident 4, readmitted with right hemiplegia and hemiparesis following cerebrovascular disease, the annual MDS showed the Functional Abilities (Self-care and Mobility) CAA was blank, and other triggered CAAs including communication, urinary incontinence and indwelling catheter, nutritional status, dehydration and fluid maintenance, dental care, and pressure ulcer/injury did not contain comprehensive assessments. For Resident 3, admitted with broken or loose teeth, the admission nursing collection tool and MDS documented broken teeth, inflamed or bleeding gums, loose natural teeth, and mouth or facial pain, but the Dental Care CAA was blank; other triggered CAAs also lacked comprehensive assessments. Resident 3 was observed with broken upper front teeth, missing upper and lower back teeth, and loose lower front teeth, and Staff R stated the CAAs were supposed to include analysis of findings, dental assessment, oral care, assistance level, and referral if needed. Staff B, DON, stated they expected the MDS assessment and CAA to be complete and accurate. This was identified as a repeat deficiency from the prior SOD dated 11/15/2024.
PASRR Screening Not Completed or Updated for Residents With Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure PASRR screening was completed prior to admission and updated according to resident condition for 5 of 5 sampled residents reviewed for PASRR. The report states that incomplete or inaccurate PASRRs placed residents at risk for inappropriate placement and/or lack of access to specialized services for residents with identified mental health diagnoses or disability. The facility policy required preadmission screening to ensure Medicaid-eligible individuals met level of care criteria and that people with known or suspected mental illness, intellectual disabilities, and/or related conditions were not inappropriately institutionalized or marginalized. One resident was admitted with diagnoses including generalized anxiety disorder, PTSD, and later major depressive disorder, but the admission Level 1 PASRR did not show SMI. The record included a social services note stating the PASRR was being sent for invalidation, and staff stated the PASRR was incorrect but could not provide documentation showing the follow-up was completed. Another resident was admitted with depression and had moderate depression on the admission MDS, yet the admission PASRR stated there were no mental health concerns and no Level 2 evaluation was completed. Additional residents had changes or diagnoses that were not reflected in PASRR documentation. One resident developed anxiety and later had a significant change with hospice services and two antipsychotic medications, but no PASRR updates were made. Another resident admitted with anxiety and PTSD had a Level 1 PASRR that did not select anxiety, despite hospital discharge diagnoses, antipsychotic use, and MDS documentation showing anxiety and PTSD. A fifth resident admitted with depression and sleep disorder had anxiety medication ordered, depression documented on the MDS, and a Level 1 PASRR that did not select mood disorder or anxiety; no new PASRR referral was submitted for reassessment.
Incomplete and Non-Individualized Care Plans
Penalty
Summary
The facility failed to develop comprehensive, individualized care plans that reflected residents’ current medical status and the nursing services being provided for multiple residents. The report identified deficiencies in care planning for dialysis management, pain management, mobility, mood and behaviors, and nutrition. Facility policy required individualized comprehensive care plans, including specific interventions, measurable goals, and time frames, but the records reviewed did not consistently show those elements for the affected residents. Resident 22 had diagnoses including generalized anxiety disorder, PTSD, and major depressive disorder, but the care plan only included a PASRR focus and did not include person-centered goals or interventions for the psychiatric diagnoses. The nutritional/hydrational care plan for this resident also lacked person-centered goals or interventions to monitor or prevent weight loss, and only included encouragement to eat and an RD consult as needed. Staff from Social Services and Nursing acknowledged that the PASRR care plan was incomplete and not person centered, and that the nutrition care plan was not resident centered. Resident 26 had diagnoses including arthritis and right hip pain, but the opioids care plan was not personalized and contained generic interventions without non-pharmacological interventions. Resident 101 had end stage renal disease and a tunneled IJ dialysis catheter, but the dialysis care plan used generic interventions for an AV fistula, including monitoring for bruit and thrill, rather than reflecting the resident’s actual access. Resident 4 had right hemiplegia and hemiparesis after a stroke and was observed with contractures and limited movement of the right hand, elbow, and shoulder, yet the care plan did not include a ROM or contracture management focus or interventions. Resident 1 had depression and was receiving duloxetine, but the care plan did not include person-centered goals or interventions for depression. Resident 3 had significant weight loss during the stay, and Resident 81 had severe protein-calorie malnutrition with a BMI of 10.6 and no teeth, but their nutrition care plans did not include the resident goals, food preferences, or other interventions beyond limited or generic entries.
Care Plans Did Not Reflect Ordered Heel Protection
Penalty
Summary
The facility failed to revise quarterly care plans accurately to reflect the needs of 2 residents, including Resident 12 and Resident 72. The facility’s policy stated that the interdisciplinary care planning team is responsible for reviewing and updating care plans when needs change, when goals are not met, after hospital readmission, and at least quarterly and after each MDS assessment. Resident 12 was readmitted from the hospital with right leg pain, and an MDS dated 07/01/2025 documented an unstageable pressure ulcer to the right heel. A physician order beginning 06/26/2025 directed staff to apply a right heel floater, and staff interviews confirmed the resident should have had a green pressure-relieving boot on the right foot for wound healing. However, the care plan dated 06/12/2025 did not include the pressure-relieving device, and staff confirmed it was not documented in the care plan or Kardex. Resident 72 was observed with redness to both feet and later with a heel protector boot on the right foot; the care plan documented skin impairment to both feet but did not include the heel protector boot. Physician orders directed staff to apply skin prep to both heels and toes every day and evening shift for redness, and staff confirmed the boot was not documented in the care plan or Kardex.
Failure to Provide ADL Assistance and Ordered Splint Care
Penalty
Summary
The facility failed to provide assistance with activities of daily living for dependent residents, including bathing and splint placement. The deficiency involved 5 of 5 sampled residents reviewed for ADLs: Residents 1, 33, 81, 98, and 99. The report states these failures placed the residents at risk for embarrassment, poor hygiene, unmet care needs, and a diminished quality of life. Resident 1 was admitted with a history of stroke affecting the left upper side of the body. The resident stated they had not been given a shower since admission, and observation showed disheveled, greasy hair. The shower schedule showed the room was to receive showers every Monday and Thursday on day shift, but the documentation report showed no showers documented from admission through the review period. Staff interviews indicated the floor NACs were responsible for showers and that refusals or completed showers should be documented in the EMR. Resident 33 was admitted with open wounds to both legs and did not reject care. The care plan scheduled showers every Monday and Thursday on day shift, but the shower schedule document did not assign the room to a bathing schedule, and the documentation report showed no showers documented on multiple dates. Staff interviews indicated there was a discrepancy between charting and actual care, but no further documentation was provided. Resident 81, admitted with chronic lung disease, severe protein calorie malnutrition, anxiety, and pain, was observed repeatedly with messy, greasy hair and later with matted tangles. The resident stated they had only had "spit baths," wanted a bath, and wanted their hair washed. The shower schedule assigned showers twice weekly, but the 30-day shower record showed no showers in July and only one bed bath on 08/01/2025 as of the review date. Resident 98, admitted with spinal stenosis, bilateral foot drop, and lymphedema, did not reject care and was scheduled for showers every Monday and Thursday on evening shift. The documentation report showed bathing only on 07/31/2025 and 08/07/2025, while the resident stated they missed several scheduled baths and had reported the concern to the DON. Resident 82, admitted with cancer and not rejecting care, had no showers or bathing documented for July and August 2025. Resident 99, admitted with stroke, hemiplegia, and left-hand contracture, was care planned for a palm guard splint due to risk of worsening contracture, pain, and skin breakdown. The resident was observed without the splint on multiple occasions, stated they used to have one but had not had it in a while, and staff later stated the splint should have been on and that the one currently in place was new.
Failure to Provide Pressure Ulcer Prevention and Care
Penalty
Summary
Failure to provide pressure ulcer care and prevent new ulcers from developing was identified for three residents reviewed for pressure ulcers. The facility policy stated that prevention included frequent repositioning, use of pressure reducing devices, and adequate nutrition, and that care plans should address residents at risk for pressure injury and promote healing of existing wounds. The report also cited guidance to inspect skin daily, assess pressure points, and reposition individuals at risk based on support surfaces and individual preference. For one resident with diagnoses including heart failure, diabetes, and peripheral vascular disease, a right heel blood blister was documented, and an order directed staff to apply skin prep to the right inner heel blister twice daily and ensure both legs were separated and floated to reduce pressure. Observations showed the resident repeatedly in bed or in a wheelchair without the heel protector boot in place, including times when both heels were directly on the bed. The wound provider later assessed the heel wound as a deep tissue pressure injury and then unstageable, and a PA-C stated the heel protector boot should have been on while the resident was in bed. Staff stated the boot was to be worn in bed, but it was not included in the care plan or Kardex. For another resident who was dependent on staff for all activities of daily living and had diabetes and schwannomatosis, a weekly wound evaluation documented a new sacral pressure ulcer injury. The physician orders reviewed showed a preventive ointment order for the coccyx, but there were no new orders related to the new sacrum wound. The care plan was revised to note a new pressure ulcer to the sacrum, but no new goals or interventions were added for that wound. Progress notes showed no documentation that the new sacrum wound was reported, treated, monitored, or that the provider was notified. Staff interviews indicated the expected process was to notify the wound nurse, start treatment, notify the provider, and monitor the wound, but staff could not provide documentation that this occurred. For a third resident with severe protein-calorie malnutrition and chronic lung disease, the admission assessment documented a stage I sacral pressure ulcer and a high Braden risk score. The resident’s care plan addressed risk for pressure ulcers and an unstageable coccyx injury, but did not include the sacral pressure ulcer or padding for the oxygen nasal cannula. Weekly skin documentation did not show ongoing skin checks, and the resident was later observed with an indented red line under the oxygen tubing on the left cheek and reported pain in the area. Staff later assessed the area as a red, non-blanchable wound and added oxygen tubing padding. Nursing documentation did not show ongoing assessment, implementation of interventions, or re-evaluation consistent with professional standards.
Expired and Unsecured Medications Found in Carts, Medication Room, and at Bedside
Penalty
Summary
The facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted principles, with expired and unsecured medications found in medication carts, a medication room, and at a resident’s bedside. Surveyors observed the yellow medication cart unlocked while the RN was away from direct visualization, and later observed the 120-hall medication cart unlocked while no staff or residents were present. A vial of Tuberculin solution was also left unattended on top of the 120-hall cart. Staff acknowledged the carts should have been locked and the medication secured. Surveyors also found medications left at Resident 33’s bedside on multiple observations, including prescription ointment, artificial tears eye drops, and later eye drops and topical creams on the overbed table and nightstand. Staff stated there had been no self-medication assessment completed for the resident, and that the resident’s spouse sometimes brought items from home. Staff further stated the resident was aware of their medications, but there was no documented self-medication assessment noted in the report. Expired and undated medications were found in multiple storage areas. The yellow cart contained expired Narcan spray, calcium, vitamin D, aspirin, and an undated bottle of iron. The blue cart contained 16 expired laxative suppositories. The pink cart contained an undated bottle of iron, expired Dakin’s solution, and eye drops that had been opened beyond the consultant pharmacist’s stated 28 to 30 day timeframe. The second-floor medication room contained expired vitamin E, vitamin D, aspirin, prenatal vitamins, and liquid multivitamin. Staff and the DNS confirmed these medications were expired and should not have been in the carts or medication room. The report states this was a repeat deficiency from 11/15/2024.
Failure to Provide and Follow Up on Dental Services
Penalty
Summary
The facility failed to provide dental services for 6 of 6 Medicaid residents reviewed for dental services. The report describes missed or delayed follow-up on dental referrals, incomplete scheduling, and lack of documentation showing that residents were offered, referred for, or seen for needed dental care. Staff interviews showed that social services was responsible for scheduling dental appointments and following up on referrals, while the dental hygienist and contracted dental provider were used for routine in-facility visits and outside referrals when needed. Resident 3 had broken, missing, and loose teeth since admission, reported front teeth pain, and said it was hard to chew. The resident was observed with broken upper front teeth, missing upper and lower back teeth, and loose lower front teeth. The record showed broken or loose teeth on admission and later documented obvious cavities or broken natural teeth, inflamed or bleeding gums or loose natural teeth, and mouth or facial pain. The clinical record contained no documentation that the resident was referred to a dentist, seen by a dentist, or offered help arranging dental services. Resident 3 also stated they did not have toothbrushes and did not brush their teeth, and staff noted oral care instructions were missing from the Kardex. Resident 12’s admission MDS documented obvious or likely cavity or broken natural teeth, and observation showed missing and discolored teeth. The care plan identified oral/dental health problems and included a referral to a dentist as indicated, but the clinical record did not show documentation of dental services being offered, refused, or completed. Staff confirmed the resident should have been on the list for the in-house dental provider, but the resident was not on that day’s dental services list. Resident 79 had full upper and lower dentures on admission, but a dental visit note documented that the lower denture had been missing for several months and recommended re-lining the upper denture and replacing the lower denture. The resident stated the lower denture had been missing for quite a while and made eating difficult, but there was no documentation showing what was being done to replace it. Resident 81 was admitted with severe protein-calorie malnutrition, had no teeth, and was documented as having poor oral intake and poor dentition. The resident reported that prior dentures were lost or in bad shape and were cutting into the gums, and later stated they still did not have dentures and could not eat ham because they had no teeth. Resident 85 wanted dentures, had only three upper teeth, and an outside dental note showed the resident wanted extractions. Staff stated the resident was on a waiting list for hospital extractions and that documentation of communication and follow-up could not be found in the record. Resident 101 had a broken tooth identified by the dental provider, with a recommendation to refer to a dentist, and the resident reported pain when chewing hard foods and no follow-up information. Staff confirmed they were responsible for referrals and appointments but did not have documentation showing the referral status or follow-up communication.
Improper Storage of Resident Food in Nourishment Refrigerator
Penalty
Summary
The facility failed to store food for residents in accordance with professional standards in 1 of 2 nourishment refrigerators reviewed on the second floor. During an observation, the nourishment refrigerator door was found ajar and the thermometer inside the door read 55 degrees. The refrigerator contained cheese, yogurts, milk, puddings, sandwiches, pitchers of fruit juices, and a plastic container of sushi labeled 08/13/2025 with a resident's name. The temperature log for 08/15/2025 was already signed with no time documented, and the temperature was recorded as 39 degrees. On follow-up observations the same day, the refrigerator door was again found ajar and the thermometer read 58 degrees, with items inside not feeling cold to touch. A CNA who passed the nourishment room stated they had not noticed any issue with the refrigerator door or temperature. Later, the refrigerator was observed closed with the temperature decreased to 48 degrees, then slightly open again with the thermometer reading 50 degrees. The Staffing Coordinator reviewed the temperature logs and stated they would call maintenance to look at the refrigerator. The Administrator later stated the refrigerator seal was broken and the entire refrigerator was replaced, and the food items had been removed.
Incomplete and inaccurate resident records
Penalty
Summary
The facility failed to maintain complete and accurate resident medical records for residents reviewed for physician visits, unnecessary medications, and hospitalizations. The report states that records were incomplete, inaccurate, and not accessible for 2 residents reviewed for physician visits, 1 resident reviewed for unnecessary medications, and 1 resident reviewed for hospitalizations. The deficiency was cited under WAC 388-97-1720(1)(i-iv)(b) and was identified as a repeat deficiency from a prior survey. For Resident 82, the record showed the resident returned from the hospital after being sent out for coffee ground emesis, but the progress notes for the prior day did not document that the resident had been transferred to the hospital, that the physician and family were notified, or that a report was given to the receiving hospital. Staff confirmed the record lacked documentation of the transfer, and the clinical record also did not contain hospital records from that hospitalization. The administrator stated nurses needed to document why the resident was sent out and the physician and family notification. For Resident 85, the resident stated they wanted dentures and would need teeth extracted at a hospital. A contracted dental clinic document showed the resident wanted extractions, and social services stated they were responsible for scheduling dental appointments and following up on the referral. However, staff could not find documentation of the contracted dental visit, communication with the hospital, or attempts to schedule the extraction appointment in the resident record. For Resident 72, an order required weights on admission, weekly times 3, then monthly, but the record showed only two documented weights and missing entries on ordered dates. For Resident 9, the resident had an active order and care plan for a urinary catheter, but the catheter was observed absent and the record contained no documentation of removal or discontinuation; staff later stated the catheter had been removed at a urology appointment, but that information was not documented in the medical record.
Infection Control, Equipment Disinfection, Drainage Bag Placement, and Water Management Failures
Penalty
Summary
The facility failed to ensure staff followed infection prevention and control practices for residents on transmission-based precautions and enhanced barrier precautions. Resident 12 had an open right heel wound and was confirmed by the contracted wound care provider and an LPN to require Enhanced Barrier Precautions, but there was no signage or PPE outside the room to alert staff. Resident 2 had a chronic open wound to the right lower leg, and an observation of wound care confirmed that Enhanced Barrier Precautions were not in place. Staff D, the LPN/Infection Preventionist/Staff Development Coordinator, and the DNS stated that residents with wounds should have EBP and that a sign with PPE should be posted outside the room. Resident 116 had diagnoses including a stage 4 sacral pressure ulcer, UTI, and resistance to multiple organisms. The care plan documented isolation for infection to the sacral wound with interventions to wear appropriate PPE, and the room had a contact isolation sign and PPE bin outside the door. During observation, a NAC entered the room with a lunch tray without wearing a gown or gloves, then returned to read the sign and stated they did not know the resident was on contact isolation and should have worn PPE before entering. Staff D later stated the expectation was for staff to wear gown and gloves before entering rooms on contact isolation precautions. The facility also failed to ensure reusable resident equipment was disinfected after use and failed to keep urinary drainage bags off the floor. A Hoyer lift was observed taken from a resident room and placed in the hallway without disinfection by two NACs on separate observations, and Staff AA stated reusable equipment was only sanitized if used on a resident on precautions. Resident 82’s nephrostomy drainage bag and Resident 96’s urinary catheter drainage bag were both observed directly on the floor without a privacy cover. In addition, the facility did not have a water management plan; the Administrator, Maintenance Director, and LPN/Infection Preventionist all stated there was no formal program or documentation, and the facility provided only a policy rather than an actual plan.
Advance Directives Not Obtained or Documented for Four Residents
Penalty
Summary
The facility failed to ensure advance directives were obtained and completed for 4 of 21 sampled residents reviewed for advance directives: Residents 3, 4, 22, and 82. The facility policy stated the social services director or designee would ask residents or family/legal representatives about any written advance directives, display that information in the medical record, offer assistance if none had been established, and ensure the care plan matched documented treatment preferences and/or advance directives. Resident 3 was admitted to the facility and had a quarterly MDS showing moderate cognitive impairment. Review of the EHR showed no advance directive documentation and no documentation that assistance had been provided to formulate an advance directive. The care plan also had no focus area addressing an advance directive. Resident 4 was readmitted and had a quarterly MDS showing the resident was cognitively intact. The EHR contained no advance directive documentation and no documentation that the resident had been provided assistance to formulate one, and the care plan had no focus area addressing an advance directive. Resident 22 was readmitted and had an admission MDS showing moderate cognitive impairment. The EHR showed no advance directive documentation and no documentation that advance directives had been discussed. Staff G stated they would check for POA documentation and ask the resident who the contact person would be if none was found, and acknowledged there was no advance directive or documentation of discussion for Resident 22. Resident 82 was admitted for hospice care with cancer diagnoses; the hospital record showed the resident elected no CPR and had an advance directive, but the facility’s advance directives tab showed only a POLST and no advance directive. The care conference note contained no discussion of an advance directive, and Staff A stated the facility had not located the resident’s advance directive and was checking with the hospital.
Unnecessary Psychotropic Medication Review Deficiency
Penalty
Summary
The facility failed to ensure two residents were reviewed for unnecessary psychotropic medications. For one resident with diagnoses including generalized anxiety disorder and PTSD, the record showed Seroquel was ordered twice daily for behaviors and insomnia even though the admission MDS indicated no psychosis, the clinical record showed no signs of psychosis or insomnia, and there was no consent for the medication in the record. A progress note documented the resident denied trouble sleeping, and the MAR directed staff to monitor for anxiety-related behaviors, but the documentation showed no signs of anxiety on all shifts and no sleep monitor was in place. For the second resident, who also had diagnoses including generalized anxiety disorder, PTSD, and major depressive disorder, the physician ordered Hydroxyzine for anxiety and insomnia at bedtime. The August MAR did not show non-pharmacological interventions or monitoring of hours of sleep. Staff interviews stated that non-pharmacological interventions should be attempted before psychotropic medication and documented on the MAR, and that sleep hours should be monitored for sedative/hypnotic medications, but staff acknowledged these items were not on the physician orders or documented on the MAR for this resident.
PASRR Level II Not Submitted After Hospital Exemption Ended
Penalty
Summary
The facility failed to ensure the recommendation of the Level II Preadmission Screening and Resident Review (PASRR) evaluation was submitted after a hospital exemption was no longer valid for one resident. Resident 72 was admitted with diagnoses including Major Depressive Disorder, severe with psychotic symptoms, and anxiety. The resident’s PASRR Level I documented serious mental illness with mood disorders and noted evidence of serious functional limitations during the past six months related to the mental illness. The Level I also indicated that a Level II must be completed if the scheduled discharge did not occur. In the resident’s progress notes, a hospital-exempt PASRR was documented by Social Services, with the note that if the stay at the facility exceeded 30 days, a Level II had to be completed. Two days later, it was documented that the resident would be staying at the facility as a long-term care resident. During interview, the Social Services staff member stated that when a PASRR comes from the hospital with an exemption but indicates a Level II, the process is to send in a Level II for validation, and confirmed that no Level II PASRR was sent in for Resident 72. This was identified as a repeat deficiency from a prior survey.
Unmarked Courtyard Step Led to Resident Fall
Penalty
Summary
The facility failed to provide an environment free from accident hazards over which it had control for 1 of 3 residents reviewed for falls, involving a resident admitted after orthopedic surgery who was alert, oriented, and wheelchair bound. During an interview, the resident stated they fell about a week earlier while outside in the courtyard after backing their wheelchair toward what they believed was a paved ramp, then falling back off a step onto the cement ground. The resident reported hitting their head and scraping both elbows, and said the step blended in with the cement and was not obvious. The resident was observed with several scratched areas on their arms covered with band aids. An observation of the first-floor courtyard showed a cement pathway with a ramp, a left turn, and then a straight section leading to a cement step. The step area had metal railings on both sides but no gate or barrier at the top and no identifying paint or other markings to indicate that it was a step. Orange flag tape had been tied across the hand railings at the top of the step. The Administrator stated the courtyard was intentionally configured as a therapy courtyard with changes in elevation and the step, and stated the facility had previously not provided supervision when residents were in the courtyard and had not identified the step as a potential hazard.
Inadequate weight monitoring and nutrition/hydration management
Penalty
Summary
The facility failed to ensure adequate weight monitoring and effective nutrition and hydration interventions for two residents reviewed for nutrition. The deficiency was cited under WAC 388-97-1060(3)(h) and was identified through observation, interview, and record review. The report states this was a repeat deficiency from a prior statement of deficiencies dated 11/15/2024. Resident 81 was admitted with diagnoses including severe protein-calorie malnutrition, GERD, electrolyte disturbances, and chronic lung disease. Hospital transfer orders directed staff to weigh the resident daily and provide a pureed diet with berry nutritional supplements. The record showed the resident was underweight at 62 pounds with an ideal body weight of 120 pounds, but the initial nutritional risk assessment was incomplete and listed a regular texture diet instead of the ordered pureed diet. The care plan included only an RD consult and did not address the resident’s goals, food preferences, missing dentures, or other interventions. The record showed only a few weights, all at 62 pounds, and no further weights after 08/14/2025. A progress note documented the resident had lost dentures and could not tolerate a regular texture diet, and the diet was later downgraded to mechanical soft. Resident 3 had repeated observations of untouched meal trays, poor appetite, dental pain, and limited intake. The resident stated they had not eaten for months, had broken teeth and toothache, felt weak, and wanted their appetite back. The resident also reported inadequate fluid intake and stated there was no water pitcher or cup in the room at one point. The diet order remained regular texture, despite the resident’s inability to chew, and the care plan did not include a nutrition care area. The record showed significant weight loss from 271.5 pounds to 215.4 pounds, but there were no routine weights documented between 03/25/2025 and 08/01/2025. The record also lacked documentation of fluid intake amounts and did not show how much nutritional shake the resident consumed after it was ordered.
Inaccurate Dialysis Care Planning and Monitoring
Penalty
Summary
Safe, appropriate dialysis care/services were not provided for a resident with end stage renal disease who received hemodialysis three days a week and had an indwelling tunneled IJ catheter in the right upper chest as the dialysis access. The resident stated the staff at the facility were not doing anything with the catheter and that the kidney center handled it. The resident’s care plan dated 02/03/2025 contained generic dialysis interventions that were not individualized to the resident’s IJ catheter and instead included monitoring for an AV fistula, including bruit and thrill checks that did not apply to the resident. The TAR also contained inaccurate and conflicting directions, including an instruction to remove a dressing four hours after return from dialysis if the resident had a fistula, and staff were signing this as completed even though the resident did not have a fistula. The TAR directed staff to check the right upper chest for lack of bruit/thrill, infection, swelling, or bleeding, but the documentation used only “y,” “n,” “0,” and blanks without clarification. Staff confirmed they were confused about what the entries meant and stated they intended to indicate no complications. The dialysis communication process was also inconsistent, with the facility sending pre-dialysis information with the resident, receiving post-dialysis information by fax for scanning, and separately completing electronic pre- and post-dialysis assessments. The unit manager stated the care plan had not been completed accurately for the resident’s dialysis access and that the facility had not been auditing whether all sections of the dialysis assessments were completed in the electronic record. This was identified as a repeat deficiency from 11/15/2024.
Failure to Provide Non-Pharmacological Interventions Before PRN Pain Medication
Penalty
Summary
Ensure each resident's drug regimen must be free from unnecessary drugs was not met for Resident 26. The resident was admitted with diagnoses including arthritis and pain in the right hip and had physician orders for PRN pain medication. Review of the MAR showed the resident received PRN pain medication 38 times from 07/21/2023 through 07/31/2025 and 43 times from 08/01/2023 through 08/17/2025. During interviews, an RN stated non-pharmacological interventions would be attempted before PRN pain medication was given. An LPN nurse manager confirmed that non-pharmacological interventions should be attempted before PRN pain medication administration and would be documented on the MAR, but acknowledged they were not being provided for Resident 26. The DON also acknowledged that non-pharmacological interventions should be attempted prior to administering PRN pain medication but would not be documented on the MAR.
Expired insulin prepared for administration
Penalty
Summary
The facility failed to ensure a resident with Type 2 DM remained free from a significant medication error during insulin administration. Resident 44 was readmitted with diagnoses including Type 2 DM, and the physician order dated 11/06/2024 directed Humalog Solution to be administered subcutaneously three times daily for diabetes. During a medication administration observation on 08/14/2025, an RN withdrew an insulin vial that had been opened on 07/10/2025 and was preparing to administer it to Resident 44. The RN stated the vial could be used until the end of August, while the unit manager stated the insulin was only good for 28 days after opening and was already expired. The RN stated they would have injected the medication if they had not been stopped. The DON later stated nurses were expected to check medication expiration dates and not administer expired insulin. The report also states this was a repeat deficiency from the prior statement of deficiencies dated 11/15/2024.
Missed Weekly CBC/CMP Labs
Penalty
Summary
The facility failed to ensure laboratory tests were completed as ordered and failed to provide timely laboratory results for Resident 33, who was re-admitted with diagnoses including iron deficiency anemia secondary to blood loss, a left hip pressure ulcer, cellulitis of the right leg, and an open wound to the left lower leg. A physician's order dated 06/13/2025 directed weekly CBC with differential and CMP testing. Review of the MAR showed staff signed that labs had been obtained on multiple dates in June, July, and August 2025, but the clinical record did not contain corresponding results for some of the expected weekly tests, including the weeks of 06/27/2025, 07/21/2025, and 08/12/2025. The clinical record showed CBC/CMP results for some dates, but not for every week the tests were ordered. In interview, the PA stated they wanted the resident to have weekly CBC and CMP labs and said that if they noticed missing results, they would complete another lab slip and ensure there was a current order. A LPN/unit manager stated they had heard the resident had missed some weekly labs, and the DON stated they were not aware of any lab concerns and described the missed labs as an isolated event. The report also cited the facility policy requiring notification and follow-up of practitioner recommendations regarding labs.
Food trays did not match resident meal orders or tray cards
Penalty
Summary
The facility failed to ensure food services met the individual food plans, nutritional needs, and preferences for one resident who was cognitively intact and had a documented need for large protein portions. The resident stated on multiple occasions that the food served did not match the tray card or what had been ordered from the menu. On one lunch tray, the tray card documented a large protein serving with meatballs/beef, mixed vegetables, and oven roasted potatoes, but the tray observed contained a slice of pizza instead of the listed items. The resident stated the pizza was not considered a large protein serving. On another lunch tray, the tray card documented vegetable stuffed peppers, yellow rice, and asparagus spears, but the tray observed contained a fruit plate, biscuits, cottage cheese, sherbet, and cranberry juice; the resident stated the ordered items were not present and noted dislike of cottage cheese. At breakfast, the tray card documented homestyle pancakes, but the tray observed contained two pieces of bread and no pancake. On another breakfast tray, the tray card documented four slices of bacon and two ounces of sausage links, but the tray observed contained only two slices of bacon and no sausage links. Staff acknowledged that the tray card and food served sometimes did not match, and the administrator stated the expectation was that they should match.
Failure to Provide Ordered Rehab Services
Penalty
Summary
The facility failed to provide required specialized rehabilitative services for one resident who was admitted with a history of stroke affecting the left side, muscle weakness, limited activity due to disability, and depression. The admission MDS showed the resident had no cognitive impairment, no refusal of care, and was dependent for toileting care and required substantial to maximum assistance for transfers. Hospital transfer orders and facility physician orders included evaluation and treatment for PT, OT, and ST, and the care plan identified the resident as admitted for rehabilitation with interventions for skilled PT, OT, and ST. Therapy evaluations were completed shortly after admission. The PT evaluation recommended treatment five days a week and documented fair rehabilitation potential with goals focused on restoration and adaptation. The OT evaluation also recommended treatment five days a week and documented good rehabilitation potential, with the resident able to follow directions, make needs known, and actively participate in skilled treatment. The ST evaluation recommended treatment three days a week and documented excellent rehabilitation potential. A provider note later documented that the resident was admitted for ongoing PT and OT treatment to improve weakness and ongoing rehabilitation. The resident stated they came to the facility from the hospital because they needed more PT so they could walk again, and reported they had only been seen by therapy when they first admitted and had not received treatments since then. Staff stated therapy was not treating the resident because there was no insurance coverage or authorization for the services, and that the resident had been admitted under Medicaid with no Medicare days available. Staff also stated the authorization request for therapy reimbursement was forwarded after the evaluation, and approval for a few PT and ST visits was not obtained until 17 days after admission. The administrator stated the facility would not have admitted the resident if they had skilled therapy orders and no payor source, and confirmed therapy would not be provided without a payor source.
Insufficient Nursing Staff Resulting in Delayed Care and Medication Administration
Penalty
Summary
The facility failed to provide sufficient nursing staff on both the first and second floors, resulting in delays in medication administration, untimely responses to residents' call lights, and inadequate supervision of nursing assistants. Observations and interviews revealed that nurses were responsible for covering multiple medication carts and had more residents assigned than they could manage, leading to late medication passes. The electronic Medication Administration Record (eMAR) frequently showed residents' medications as late, and staff reported being unable to complete their duties on time due to being short-staffed. Multiple staff members stated that when only two nurses were present on a unit, they could not provide timely care, supervise aides, or monitor residents' conditions adequately. Residents reported consistently receiving their medications late and experiencing long wait times for assistance after activating their call lights. Some residents stated they had to wait up to an hour or more for help, and in some cases, had to walk to the nurses' station themselves. Grievance forms and interviews with residents and family members corroborated these issues, with reports of residents having to yell for help, waiting extended periods for pain medication, and staff acknowledging the ongoing staffing shortages. Review of facility assignment sheets over a one-month period confirmed that numerous shifts on both floors operated with only two nurses, and nurses were often required to share medication carts. The staffing coordinator indicated that nurse shifts were being cut due to a lower census, but the remaining residents, particularly those in rehab, required more assistance. Despite staff raising concerns to management and the staffing coordinator, no additional support was provided, and the staffing shortages persisted, directly impacting the timeliness and quality of resident care.
Failure to Provide Patient-Centered Discharge Planning and Communication
Penalty
Summary
The facility failed to ensure that discharge planning was patient-centered and involved both the resident and their representatives, as required by policy. For two residents reviewed, there was no evidence that the interdisciplinary team developed or documented a discharge plan that addressed the residents' goals, needs, or referrals to local agencies. Additionally, there was a lack of direct communication with the residents and their families regarding the discharge process, timeline, and preparation, despite facility policy requiring such involvement and documentation at least twenty-four hours prior to discharge. One resident, who was cognitively intact, and their family reported not receiving any information about discharge planning throughout the stay. The resident repeatedly asked staff for updates but was only informed of the discharge on the day it was to occur, leaving insufficient time to arrange transportation. Documentation in the electronic health record did not show any follow-up or involvement of the resident or family in the discharge planning process after an initial note, nor did it reflect any multidisciplinary team discussions or communication about the discharge timeline. Another resident, who was moderately cognitively impaired, also lacked documented discharge planning or communication with the family. The care plan indicated a need for 24/7 care at home, but there was no evidence that the discharge plan was reviewed or updated as the resident's cognitive status declined. Staff interviews confirmed that there was no documentation of communication with the resident or family, no record of team discussions, and no evidence that the family was prepared or received caregiver training prior to discharge.
Medication Error Rate Exceeds Regulatory Threshold Due to Late Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, resulting in a 27 percent error rate. This was identified through observation, interview, and record review, where 8 medication errors were found out of 29 opportunities. The errors occurred because two nurses administered medications outside of the scheduled administration times. Specifically, medications scheduled for administration at 7:00 AM or 8:00 AM were given significantly later, with times ranging from 9:04 AM to 9:58 AM. The medications involved included Levothyroxine, Acetaminophen, Diclofenac gel, Diamox, Dorzolamide-timolol, Protonix, and Hydrocortisone cream. The report details that the facility did not have a policy specifying the acceptable window for medication administration when medications were ordered at a specific time. Staff interviews confirmed that the expected practice was to administer medications within one hour before or after the scheduled time, but this was not consistently followed. The lack of adherence to scheduled medication times led to the identified errors for multiple residents, as observed and documented by surveyors.
Failure to Timely Log and Report Incidents
Penalty
Summary
The facility failed to maintain a completed state reporting log for two of the three months reviewed, specifically April and May 2025. Incidents that occurred during these months were not logged within the required five days of discovery, as all incidents for April were entered on the last day of the month and all incidents for May were entered at the end of the month. The dates of the incidents ranged over several days in each month, indicating a delay in timely reporting. During an interview, the administrator stated that the April log was not updated on time due to a new Director of Nursing Services (DNS) and was unaware that the May log was also not updated timely, especially during the DNS's vacation. This failure to log incidents promptly was identified through record review and staff interview.
Lack of Qualified Infection Preventionist During Outbreak
Penalty
Summary
The facility failed to ensure the designation of a qualified Infection Preventionist (IP) responsible for the infection control program, which is crucial for early detection, analysis, and management of healthcare-associated infections. During a viral respiratory disease outbreak, it was found that Staff B, who was acting as the IP, had not received the necessary training or certification for the role. Interviews with Staff C, the Unit Manager, and Staff A, the Administrator, confirmed that Staff B was hired for the IP/Staff Development Coordinator role but had not been enrolled in a certification program. A review of the facility's key personnel list revealed no staff was officially designated as the IP, placing residents and staff at risk for transmission of infectious diseases.
Failure to Notify Emergency Contact of Resident Hospitalization
Penalty
Summary
The facility failed to notify the responsible party for a resident who was hospitalized, which was a requirement according to the facility's policy. The policy stated that a nurse should inform the resident's representative when the resident is transferred to a hospital. In this case, the resident was admitted to the facility with a son listed as the primary emergency contact and a significant other as the secondary contact. However, when the resident was sent to the hospital due to unclear speech and changes in neurological function, there was no documentation that any family or responsible party was notified. Interviews and record reviews revealed that the family was unaware of the resident's hospitalization. A family member stated that they were not informed and discovered the resident's absence when visiting the facility the day after the transfer. The facility's visitor log confirmed that the significant other visited the facility after the resident had been hospitalized. The administrator acknowledged that the primary emergency contact should have been notified, but there was no documentation to confirm that this was done.
Director of Nursing Lacked Active License
Penalty
Summary
The facility failed to ensure that the Director of Nursing (DON), identified as Staff B, had an active professional license, which placed all residents at risk of substandard quality of care. Staff B was hired as the new DON and was responsible for supervising the nursing department and overseeing resident care. Multiple staff members, including an LPN and a unit manager, confirmed that Staff B was the current DON and that they would seek guidance from Staff B for nursing concerns. However, a review of the Washington State Provider Credential Search website revealed that Staff B's Registered Nurse license was suspended and expired. The facility's administrator, Staff A, was aware of the suspension of Staff B's license, yet Staff B continued to serve in the role of DON.
Incomplete Background Check for DON
Penalty
Summary
The facility failed to complete a background check prior to the employment of a staff member, identified as Staff B, who was hired as the Director of Nursing. This oversight was discovered during a review of the facility's policy on abuse, which mandates screening potential employees for a history of abuse, neglect, or mistreatment by completing a background check. Staff B's employment file indicated a hire date, but the background check was incomplete due to missing information. Despite this, Staff B was observed interacting with surveyors and moving unaccompanied in resident areas. The facility's administrator, Staff A, acknowledged the incomplete background check and confirmed that there was no evidence of Staff B being supervised or accompanied by another staff member since their hiring. This failure placed residents at risk of interactions with unqualified staff, potentially leading to abuse, neglect, and exploitation.
Failure to Verify DNS Credentials and Background
Penalty
Summary
The facility's governing body failed to ensure compliance with its abuse policy by not verifying that the Director of Nursing (DNS) had a completed background check and an active professional license before employment. The employment records showed that the DNS was hired without these verifications. During an interview, the Human Resources staff revealed that the background check for the DNS was incomplete, requiring additional information, and that the DNS's Registered Nurse license was suspended. Despite being aware of these issues, the Administrator stated that the decision to hire the DNS was made by the governing body.
Ineffective Administration and Unaddressed Resident Concerns
Penalty
Summary
The facility failed to administer services effectively and efficiently, impacting residents' optimal physical, mental, and psychosocial well-being. The administration did not ensure thorough investigations of all allegations, nor did they maintain systems to prevent repeat citations. This included issues documented in Resident Council meeting minutes regarding long call light wait times, which were not addressed. The administrator was responsible for the day-to-day functions and implementing operational policies but failed to put corrective actions in place to sustain these systems. The facility's last annual recertification Statement of Deficiencies showed repeat deficiencies in several areas, including resident rights, grievances, and abuse prevention. The administration did not implement an Abuse Prohibition policy effectively, leading to delayed investigations and failure to protect residents. The administrator acknowledged that the Director of Nursing Services completed investigations for abuse allegations, but they were responsible for reviewing them. Despite receiving monthly Resident Council Minutes, the administrator did not address the repeated concerns about call light wait times.
Governing Body's Lack of Oversight Leads to Repeated Deficiencies
Penalty
Summary
The governing body of the facility failed to provide adequate oversight and monitoring of the appointed Administrator, resulting in a lack of clinical systems related to various critical areas such as Abuse/Neglect, Resident Rights, Grievances, Pressure Ulcers, Infection Control and Prevention, Social Services, Nutrition, Care Planning, Accidents and Supervision, Transfer and Discharge, Staffing, Medication Safety, Range of Motion program, and Infection Control Practices. This lack of oversight led to repeated deficiencies in these areas, as noted in the facility's last annual recertification Statement of Deficiencies. The governing body also failed to ensure the Administrator had sufficient staff to meet the residents' needs, including personal care, grooming, restorative care, and an effective call light system. Interviews and record reviews revealed that the governing body did not actively participate in the Quality Assurance Performance Improvement (QAPI) program, as evidenced by their absence from QAPI meetings and lack of communication with the Administrator. The Administrator reported that the governing body, consisting of the Chief Nursing Operator, Chief Operating Officer, Regional Director of Operations, and Regional Director of Clinical Services, did not engage in the facility's operations or provide necessary support. The facility's assessment and QAPI minutes lacked signatures or reviews from the governing body, indicating a disconnect between the governing body and the facility's management. This failure to engage and support the facility's operations placed residents at risk for suboptimal care and services.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to adequately respond to and resolve concerns raised by the Resident Council over several months, leading to unmet care needs and diminished quality of life for residents. The administration did not investigate or address issues reported during Resident Council meetings from May to August 2024. These issues included slow response times to call lights during the night shift, incorrect food orders, and a lack of staff presence at nursing stations. Despite these concerns being documented in various forms and logs, there was no evidence of follow-up or resolution. Interviews with Resident Council representatives revealed ongoing issues with night shift staffing and call light response times, as well as problems with food service accuracy. Resident 50 reported that overnight call light response times were excessively long, and there was a shortage of night shift staff. Resident 19 noted that residents were not receiving the food they requested, and the facility was not adhering to the menu. These concerns were echoed in the Resident Council meeting minutes, yet there was no documentation of any actions taken to address them. The facility's grievance and concern reporting logs did not reflect the issues raised by the Resident Council, and there was a lack of documentation regarding the investigation or resolution of these grievances. Staff interviews confirmed that the concerns were known to the administration, but no steps were taken to address them. This systemic failure to act on resident grievances placed all residents at risk for unmet care needs and a diminished quality of life.
Failure to Address and Document Resident Grievances
Penalty
Summary
The facility failed to recognize, record, and promptly resolve grievances for five residents, which placed them at risk for anxiety, undue stress, and a diminished quality of life. Resident 98 experienced multiple unresolved issues, including a malfunctioning air mattress, a non-working call light, and missing medications. Despite reporting these issues to staff and leaving messages for maintenance, no grievances were logged, and the maintenance director was unaware of the mattress issue. Resident 98 also faced delays in room relocation and was not informed about the grievance process. Resident 2 reported missing bed pads, and Resident 37 reported a missing tee shirt, both of which were not logged as grievances. Resident 43's favorite pajamas went missing, and they were not informed about the grievance process. Resident 255 reported missing ice packs and covers, but these concerns were also not documented in the grievance log. Interviews with staff revealed a lack of awareness and understanding of the grievance process, with some staff unaware of how to report or track missing items. The facility's grievance policy encourages staff to guide residents on filing grievances, but this was not effectively implemented. The administrator and director of nursing were unsure why grievances were not created for Resident 98's concerns. The facility's grievance log showed no entries for the missing belongings of Residents 2, 37, 43, and 255, indicating a systemic failure to address and document resident grievances as required by the facility's policy and regulatory standards.
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 975 citations issued within 25 miles in the last 12 months — including the 2 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 Lynnwood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lynnwood Post Acute Rehabilitation Center | 1.4 mi | ★★★★★ | 1 | 0 |
| Edmonds Post Acute | 2.8 mi | ★★★★★ | 60 | 0 |
| Pine Ridge Post Acute | 3.1 mi | ★★★★★ | 18 | 0 |
| Bothell Health Care | 3.1 mi | ★★★★★ | 2 | 0 |
| Fircrest Nursing Facility | 4.5 mi | ★★★★★ | 25 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.