Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Arlington Health And Rehabilitation during CMS and state inspections, most recent first.
The facility failed to provide required transfer/discharge notices to a resident who was discharged and to two residents who were transferred to the hospital, and failed to notify the LTC Ombudsman for the two transferred residents as soon as reasonably able. Staff interviews showed the RN and LPN/RCM were unfamiliar with the notice process, and the Administrator could not produce copies of the notices at the time of review.
PASRR Level I screenings for three residents with mental health diagnoses were not timely submitted for Level II evaluation after they remained in the facility beyond the 30-day exempted hospital discharge period. The records showed no documentation in the EHR that the referrals were followed up, and staff stated they used a separate tracking system instead of documenting the process in the clinical record.
Oxygen tubing was not consistently dated, cleaned, changed, or stored properly for three residents receiving oxygen. Two residents with emphysema and COPD had nasal cannulas with whitish debris, and one also had tubing lying on the bed without being dated or initialed. Another resident with multiple respiratory and cardiac diagnoses had oxygen tubing with debris, not dated, and not stored in a bag, and staff noted there was no active MAR/TAR order for weekly tubing changes.
A resident on hospice had a PRN Lorazepam order received by the facility but it was not entered on the MAR until several days later, with staff noting they were waiting for POA consent. Two residents with type 2 DM also lacked documented monitoring for hypo/hyperglycemia: one resident’s care plan did not include a diabetes focus area, and another resident’s care plan and MARs did not include symptom monitoring despite DM-related medication orders.
Failure to Provide Ordered Heel Offloading and PU Care: A resident with DM2, a fracture, and existing pressure ulcers to the sacrum, R heel, and L foot was repeatedly observed without ordered heel protectors or heel offloading. The care plan and wound care note included interventions such as q2h repositioning, a low-air-loss mattress, and heel offloading boots, but the resident was seen in a wheelchair and in bed with the boots off and heels not floated. The RN stated the resident was to wear heel protector boots when up and have heels floated when in bed.
Failure to Obtain Order and Consent for Bed Placement Against Wall: A resident with Guillain-Barre Syndrome, Parkinson's disease, prostate cancer, and moderate cognitive impairment had a bed placed against the wall without documentation of an order, consent, or care plan. The resident also had multiple falls, and staff stated the bed against the wall was considered a restraint requiring a provider order, resident/POA notification, discussion of risks and benefits, and consent before placement.
Medication timing was not followed for 2 of 25 med pass observations, creating an 8.33% error rate. An LPN gave a resident Sucralfate and Pantoprazole after breakfast even though both meds were ordered before meals and were scheduled for 7:00 AM on the MAR. The LPN stated they knew the meds were to be given before meals.
Medication storage and security deficiencies were identified in the LTC facility. An open bottle of Aplisol in the med fridge had no open date, an expired bottle of Pure Bone Health remained in storage, and the fridge temperature log showed multiple out-of-range and missing readings while influenza vaccines were stored inside. An expired bottle of Melatonin was also found in the rehab med room, and the 200-hall treatment cart was observed unlocked and unattended with wound supplies and prescription creams inside.
A resident with no natural teeth had upper and lower dentures that were loose and ill-fitting, could not be worn, and interfered with chewing and speech. Although a consulting dentist recommended relining both dentures, the record showed no documented arrangement for denture fixation, and staff interviewed were not aware the dentures were loose or that the resident wanted them fixed.
Improper Storage of Resident Food Items in Nourishment Refrigerator: A nourishment refrigerator in the conference room/dining room contained an undated plate of resident food, rice pudding past its expiration date, and pizza dated beyond the posted 3-day limit. Staff M stated they checked temps and logged them, but initially did not inspect the left drawer where the undated food item was stored.
A facility failed to keep resident records complete and organized for two residents. One resident with chronic pain syndrome and anxiety had repeated PRN pain and anxiety medication use documented, but the chart lacked consistent documentation of required non-pharmacological interventions before PRN administration. Another resident with ESRD on scheduled dialysis had dialysis communication sheets that were not consistently managed in the record system, and Medical Records staff stated they were unaware the sheets were also kept in a binder at the nurse's station.
The facility failed to adhere to professional food safety standards, with observations revealing undated and unlabeled food items in the kitchen and nourishment refrigerators. Spoiled cucumbers and improper labeling practices were noted, posing risks of food contamination and foodborne illnesses. Staff interviews confirmed that open food items should be dated and discarded if not compliant.
The facility failed to complete comprehensive Resident Assessment Instruments (RAIs) and Care Area Assessments (CAAs) for several residents, including those with psychotropic drug use, stroke, diabetes, dementia, and severe cognitive impairment. The assessments lacked necessary summaries and analyses of residents' goals, preferences, strengths, or needs, crucial for updating care plans. Staff interviews revealed confusion over responsibilities and incomplete documentation, impacting the quality of care provided.
The facility failed to implement comprehensive care plans for residents, leading to deficiencies in individualized care. A resident with dementia was at risk for wandering, yet their care plan lacked interventions. Another resident used a positioning wedge not reflected in their care plan. A resident with chronic conditions reported not having a shower, and their care plan lacked person-centered interventions. A resident with severe cognitive impairment struggled to eat independently, and their care plan did not reflect the need for feeding assistance. Another resident's care plan did not accurately reflect their activity preferences or the need for heel floating.
The facility failed to provide adequate care and communication for several residents, including a resident with CHF who experienced significant weight gain without provider notification, leading to hospitalization. Another resident with swallowing difficulties did not receive a full evaluation, and a resident with insomnia was not given prescribed medication due to a pharmacy issue. Additionally, a resident with ongoing diarrhea continued to receive a stool softener, and a resident did not have timely follow-up with an infectious disease doctor.
Two residents in a facility were administered psychotropic medications without appropriate diagnoses or documentation of non-pharmacological interventions. One resident received Seroquel without a valid diagnosis, and the facility failed to limit PRN use to 14 days. Another resident was given Lorazepam and Seroquel for reasons not aligned with the orders, and non-pharmacological interventions were not documented. Staff interviews revealed confusion and lack of documentation regarding medication use and interventions.
The facility failed to comply with Infection Prevention and Control Guidelines, with staff not adhering to Enhanced Barrier Precautions, proper hand hygiene, and catheter care protocols. A resident with a cholecystostomy tube did not receive appropriate peri-care, and a resident with multi-drug resistant bacteria had improper wound care. Miscommunication about precautionary measures and inadequate signage further contributed to the risk of infection transmission.
Two residents were found self-administering medications without proper assessment or documentation. One resident had eye drops without a physician's order or a self-medication program in their care plan, while another had an inhaler at their bedside without a safety evaluation or documentation. Staff were unaware of these medications, contrary to facility policy requiring an interdisciplinary assessment and prescriber's order for self-administration.
The facility failed to provide the correct beneficiary notices for two residents regarding Medicaid/Medicare coverage. One resident received an incorrect form for the SNF ABN, while another received the NOMNC only 24 hours before the last covered day, instead of the required 48 hours. The Social Service Director was unaware of the updated form requirement and could not explain the timing error.
The facility failed to promptly address grievances for two residents, leading to unresolved issues. A resident reported missing clothing, but no grievance was logged, and the issue remained unaddressed. Another resident reported broken blinds, which were acknowledged but not documented or repaired. These deficiencies highlight a breakdown in the grievance process.
A facility failed to report alleged financial exploitation of a resident, who believed they had paid their child's mortgage, to the state agency and law enforcement. Despite being aware of the concerns, the Social Service Director did not ensure a report was made or documented conversations with APS. This deficiency was a repeat issue.
A resident with a left hip fracture requiring assistance for transfers did not receive scheduled showers since admission, despite being on a shower schedule. Staff interviews revealed a lack of documentation and follow-up on bathing tasks, leading to a deficiency in providing necessary ADL care.
A facility failed to provide proper respiratory care for a resident with COPD, as the oxygen concentrator was set incorrectly at 2.5 lpm instead of the ordered 2 lpm. The resident's nasal cannula was improperly positioned or not in use during observations. The LPN did not verify the concentrator settings, and the DON confirmed the expectation to ensure settings matched physician orders.
A facility failed to develop a comprehensive dementia care plan for a resident, lacking specific interventions and personalized goals to address their physical, mental, and psychosocial needs. The resident exhibited anxiety and wandering behaviors, but the care plan did not include strategies to manage these issues. Staff interventions, such as encouraging phone calls to the resident's daughter and engaging in music, were not documented in the care plan, placing the resident at risk for unmet needs.
The facility failed to properly store and dispose of medications, with expired lorazepam found in the medication room and an open bottle of Acidophilus requiring refrigeration left unrefrigerated in a medication cart. An LPN noted that the night shift was responsible for these tasks, but inconsistencies in adherence to protocols were evident.
The facility failed to serve meals in a timely manner and at appropriate temperatures, impacting food palatability and safety. Meal trays were observed sitting in the hallway of South Hall, with oatmeal found at 124°F, below the recommended 165°F. The Resident Council reported consistent issues with cold and late food, especially on weekends.
A facility failed to coordinate effectively with a hospice provider for a resident, resulting in the absence of a hospice care plan in the resident's EHR. The resident, with a terminal prognosis, showed signs of confusion and agitation, and the lack of a coordinated care plan placed them at risk of unmet care needs. Facility staff were unaware of the missing care plan until prompted by surveyors.
The facility failed to update care plans for two residents, leading to potential risks. One resident experienced multiple falls without adequate care plan revisions, while another had incorrect medication categorization and outdated interventions. Staff acknowledged errors but had not addressed them, risking residents' health and quality of life.
A resident with a history of atrial fibrillation and other conditions experienced ongoing abdominal pain and discomfort, which was not adequately assessed or communicated to the physician by the LTC facility staff. Despite the resident's worsening condition, including vomiting and restlessness, the staff failed to conduct timely assessments or notify the physician appropriately, leading to the resident's hospitalization and subsequent death.
A resident with a history of atrial fibrillation, anticoagulant use, diabetes, and stroke experienced increased abdominal pain, but staff failed to conduct thorough assessments or notify the physician promptly. The resident was left in pain during the night shift, and vital signs were not checked. Despite the resident's distress, staff did not perform additional assessments or notify the physician until hours later. The resident was found in distress and later passed away in the hospital. Interviews revealed staff awareness of the resident's condition but inadequate actions were taken.
The facility failed to conduct thorough investigations into incidents involving residents, including an unexpected death and allegations of abuse by a nursing assistant. Investigations were delayed, lacked key witness interviews, and did not notify physicians or families. Care plans did not address potential psychosocial harm, indicating significant lapses in the facility's response to these serious incidents.
A resident with intact cognition was sent to the hospital after a change in condition and passed away unexpectedly. The LTC facility failed to report the death to the state agency as required by the Purple Book guidelines. The DNS and Administrator were unaware of the reporting requirements, and the investigation summary indicated the resident did not receive timely care.
Failure to Provide Transfer/Discharge Notices and Ombudsman Notification
Penalty
Summary
The facility failed to provide 3 of 3 sampled residents with a notice of transfer/discharge that outlined their specific rights related to transfer or discharge. Resident 3 was discharged from the facility on 01/13/2026, and review of the electronic record showed no documentation that a notice of transfer/discharge was provided before discharge. During interview, a Registered Nurse stated that when a resident discharges, a packet of information is filled out and provided, but also stated they had not provided a notice of transfer/discharge and were not familiar with the form. Resident 58 and Resident 63 were both transferred to the hospital, and record review showed no written notice of transfer or discharge was provided to either resident or to the Ombudsman. Staff interviews showed that the LPN/Resident Care Manager did not know what a written notice of transfer or discharge was and did not provide one when residents were transferred to the hospital. The Administrator stated Social Services was the primary person who completed the notice, with the Administrator as backup, but the notices were not scanned into the EHR and were kept in a binder; the Administrator was unable to provide copies at the time of interview. In follow-up, notices for Resident 58 and Resident 63 were dated 01/26/2026, and the Administrator stated they would be sent to the Ombudsman, with one notice sent 30 days after discharge and the other 5 days after discharge.
PASRR Level II Evaluations Not Timely Submitted After Exempted Hospital Discharges
Penalty
Summary
The facility failed to ensure PASRR Level I screening forms for exempted hospital discharges were submitted for Level II evaluation when residents remained in the facility beyond the 30-day exemption period for 3 of 6 residents reviewed. Resident 1 was admitted with anxiety disorder, and the Level I PASRR documented that no Level II evaluation was indicated at that time because of the exempted hospital discharge; however, Staff C stated the PASRR was not sent for Level II evaluation until after the resident had stayed past 30 days. Resident 18 was admitted with depression and anxiety, and the Level I PASRR also indicated no Level II evaluation was needed due to the exempted hospital discharge, but the record contained no other PASRR forms and no documentation that the facility followed up after the resident remained in the facility past 30 days. Resident 6 was admitted with anxiety, major depressive disorder, and social exclusion and rejection. The Level I PASRR for this resident likewise documented fewer than 30 days of nursing facility services and no Level II evaluation due to the exempted hospital discharge, but the EHR contained no documentation showing referral for a Level II evaluation after the resident stayed beyond 30 days. During interview, Staff C stated the facility’s PASRR process was to ensure a Level I was completed prior to admission and that, for exempted hospital discharges, the Level I would be sent to the PASRR evaluator for a Level II; Staff C also stated the facility used a separate tracking system rather than documenting this in the clinical record, and acknowledged the referrals for these residents were past the 30-day exemption timeline.
Oxygen tubing not dated, cleaned, or changed as required
Penalty
Summary
The facility failed to ensure respiratory equipment and tubing were regularly cleaned, changed, dated, and/or stored properly for 3 of 3 sampled residents receiving oxygen therapy. The facility policy titled, Oxygen Administration, dated 11/15/2023, documented that oxygen tubing was to be changed weekly and stored in plastic bags when not in use. However, Resident 8, who had diagnoses of emphysema and COPD, was observed on multiple occasions receiving oxygen by nasal cannula that was not dated or initialed, and whitish debris was seen in the cannula. The cannula was also observed lying on the resident’s bed without being dated or initialed. Resident 8’s MAR/TAR documented oxygen at 2 liters per minute as needed for shortness of breath, but there was no order to change the oxygen cannula/tubing, and the care plan did not include interventions related to changing the tubing. Resident 9, who also had emphysema and COPD, was observed receiving oxygen by nasal cannula with tubing dated 01/06/2026, and whitish debris was observed on the nasal cannula. Resident 9’s MAR/TAR documented oxygen at 2 liters per minute as needed for shortness of breath, but there was no order to change the oxygen cannula/tubing, and the care plan did not include interventions related to changing the tubing. Resident 2, with diagnoses including pulmonary edema, asthma, atelectasis, pleural effusion, CHF, and pulmonary hypertension, was observed with oxygen tubing connected to a concentrator by the bed; the tubing had white debris on the nasal piece, was not dated, and was not stored properly in a bag. Resident 2’s door did not have an oxygen-in-use sign posted. Resident 2’s care plan included a respiratory focus but did not include oxygen care such as changing the tubing, and staff stated the tubing was supposed to be changed weekly with a date, but there was no active order in the MAR/TAR for that change.
Delayed hospice medication implementation and missing diabetes monitoring
Penalty
Summary
The facility failed to ensure Resident 15 received hospice-related treatment in accordance with physician orders. Resident 15 was admitted with diagnoses including history of falling, dementia, psychotic mood disturbance, and anxiety, and later admitted to hospice services. Hospice visit notes received by the facility documented an order for Lorazepam 0.5 mg, one tablet every two hours as needed for anxiety/dyspnea, dated 12/31/2025. The medication administration record did not show the Lorazepam order until 01/13/2026, five days after the hospice orders were received, and the resident’s record documented consent from the POA for Lorazepam on 01/13/2026. No other progress note documentation was found regarding the Lorazepam order before that date. Staff stated hospice orders were to be updated in the clinical record and MAR, and that orders were processed within 24 hours, but also stated they were awaiting POA consent. The facility also failed to ensure diabetic monitoring was in place for two residents with type 2 diabetes. Resident 1 had orders for Lantus 14 units in the morning, to hold for blood sugar less than 100, glucagon 0.5 mg every 15 minutes as needed for hypoglycemia or blood sugar less than 60, and blood sugar checks once daily in the morning, but the physician orders did not include monitoring for signs and symptoms of hypo/hyperglycemia. Resident 1’s care plan did not include a diabetes focus area, goals, interventions, or monitoring. Resident 27 had orders for Metformin 500 mg twice daily, but physician orders did not include blood sugar checks or monitoring for signs and symptoms of hypo/hyperglycemia. Although diabetes was listed in Resident 27’s care plan focus, monitoring for signs and symptoms of hypo/hyperglycemia was not included, and the MARs reviewed for November and December 2025 and January 2026 did not contain such monitoring.
Failure to Provide Ordered Heel Offloading and Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure Resident 17 received recommended and physician-ordered interventions for pressure ulcer prevention and treatment. Resident 17 was admitted with diagnoses including a fracture of the left upper leg, diabetes mellitus type two, and pressure ulcers of the sacral region and right heel. The care plan dated 01/07/2026 documented multiple skin conditions, including diabetic foot ulcers, surgical incisions, and shearing to the coccyx, and the wound care note dated 01/13/2026 documented pressure ulcers to the coccyx, right heel, and multiple pressure ulcers to the left foot. Interventions listed in the wound care note included repositioning every two hours, a low air loss mattress, and heel offloading boots. Observations showed Resident 17 repeatedly without the ordered heel protection and without heels offloaded. On 01/21/2026, the resident was observed sitting upright in a wheelchair with a heel protector boot on the left foot only, while the other boot was on a chair across from them. The resident stated they had pressure ulcers on both heels. On 01/23/2026, the resident was observed in therapy in a wheelchair with no heel protectors and feet on the footrests, and later that day lying in bed with feet hanging over the foot of the bed, heels not offloaded, and no heel protectors on either foot. On 01/26/2026, the resident was again observed lying in bed with feet hanging over the foot of the bed, heels not offloaded, and not wearing heel protectors. The Kardex dated 01/23/2026 only directed staff to encourage the resident to utilize protective skin measures, and the MAR documented an order to offer to offload the heels when in bed each shift. An RN stated the resident was to wear heel protector boots when up in the wheelchair and have heels floated when in bed.
Failure to Obtain Order and Consent for Bed Placement Against Wall
Penalty
Summary
A nursing home failed to ensure safety assessment and monitoring were completed and failed to obtain consent and/or a physician order before placing one resident's bed against the wall. Resident 38 was admitted with diagnoses including Guillain-Barre Syndrome, Parkinson's Disease, and Prostate Cancer, and the admission MDS dated 12/17/2025 indicated moderate cognitive impairment. During observation on 1/21/2026, the resident's bed was positioned against the wall, and the electronic health record contained no documentation of an order, consent, or care plan for that bed placement. The State reporting log showed the resident had multiple falls, including on 12/13/25, 12/17/25, 12/21/25, 12/23/25, 01/06/26, and 01/13/26. Review of the fall investigations did not document the bed against the wall as an intervention to prevent falls. Staff stated the bed against the wall was considered a restraint and required a provider order, notification of the resident or POA, discussion of risks and benefits, consent, and care plan updates before placement. On 01/23/2026, staff stated the bed was moved away from the wall because there was no order to have it against the wall.
Medication Timing Error
Penalty
Summary
Medication administration timing was not provided as ordered for 2 of 25 medication observations, resulting in an 8.33% medication error rate. During an observation on 01/21/2026 at 8:14 AM, Staff D, an LPN, gave Resident 6 morning medications including Sucralfate and Pantoprazole while the resident had a meal tray at the bedside and stated they had finished breakfast. The resident’s order summary showed Sucralfate 1 gram by mouth before meals and at bedtime and Pantoprazole 40 mg twice a day before meals, and the January 2026 MAR showed both medications scheduled for 7:00 AM before meals. During an interview immediately afterward, Staff D stated they were aware the order was to give the medications before meals.
Medication Storage, Labeling, and Treatment Cart Security Deficiencies
Penalty
Summary
Drugs and biologicals were not properly labeled and stored in the medication rooms reviewed. In the long-term care medication room, an open bottle of Aplisol solution was found in the refrigerator without an open date, even though the label stated it should be discarded 30 days after opening. The same refrigerator also contained a bottle of Pure Bone Health with an expiration date of 10/2025 and a resident’s name written on it. The medication refrigerator was also storing influenza vaccines, and the temperature log showed multiple temperatures below the accepted 36 degrees in January 2026, December 2025, and November 2025, along with missing temperature documentation on several occasions. In the rehabilitation medication room, stocked medications included a bottle of Melatonin with an expiration date of 12/2025. In addition, the 200-hall treatment cart was observed unlocked and unattended while containing wound supplies, prescription skin creams, hemorrhoid cream, antifungal cream, and Nystatin powder. Staff confirmed the treatment cart should have been locked when not in use.
Failure to Arrange Prompt Dental Services for Loose Dentures
Penalty
Summary
The facility failed to ensure prompt dental services were provided for a resident who had no natural teeth and whose upper and lower dentures were loose and ill-fitting. The resident was cognitively intact, stated the dentures were too loose to wear, and reported they could not chew certain vegetables or meat without them. The resident also stated they wanted the dentures fixed and would eat better if they worked, and later stated they could not even talk with the loose dentures on. When the resident put on both dentures, the upper dentures dropped and could not remain in place, and the lower dentures moved while talking and caused slurred speech. Record review showed the resident’s admission assessment documented no natural teeth, but the care area assessment did not document whether the resident had or used dentures or why they were not used. A care conference form noted dentures or other dental needs, but the follow-up section was blank. The care plan documented upper and lower dentures that the resident did not wear, without documenting the reason. A consulting dentist report identified loose and ill-fitting dentures and recommended relining the upper and lower dentures, but progress notes from that date through the end of the review period contained no documentation of denture fixation arrangements. Staff interviewed stated they were not aware the dentures were loose or that the resident wanted them fixed, and medical records staff confirmed the resident’s name was not on the next dentist visit list.
Improper Storage of Resident Food Items in Nourishment Refrigerator
Penalty
Summary
The facility failed to ensure resident meals were stored in accordance with professional standards of food safety in 1 of 3 nourishment refrigerators. On 01/20/2026, the refrigerator/freezer unit in the conference room/dining room was observed to contain a plate covered with foil in the bottom left drawer that was not dated and had a resident name and room number; the plate contained turkey with dried edges, potatoes, stuffing, and gravy. The same drawer also contained rice pudding with a resident name and room number and an expiration date of 01/17/2026, as well as a plastic bag with pizza dated 01/18/2026. A printed sign on the freezer door stated that items needed to be labeled with date and resident name and thrown out after 3 days. In interview, Staff M, Food Preparation Worker, stated they checked temperatures and documented them on a paper log taped to the side of the refrigerator, and that they removed expired items such as sandwiches, nutritional shakes, and juice. On 01/21/2026, Staff M entered the conference room/dining room, checked temperatures, and filled out the temperature log, but stated they had not found anything else to throw away and initially said they never looked in the left drawer because no one was supposed to put anything there. Staff M then located the undated plate in the bottom left drawer and discarded it, and stated they would inform the dietary manager of food being placed in the left drawer.
Incomplete resident records for PRN medication documentation and dialysis communication sheets
Penalty
Summary
The facility failed to ensure resident records were complete, accurate, accessible, and systematically organized for Resident 5 and Resident 17. For Resident 5, who had diagnoses including chronic pain syndrome and generalized anxiety syndrome, physician orders included PRN Methadone, PRN Acetaminophen, and PRN Hydroxyzine, along with non-pharmacological interventions to be used before PRN pain and anxiety medications. Review of the MAR showed repeated administrations of PRN Acetaminophen and Hydroxyzine across January 2026, but the record contained no documentation of non-pharmacological interventions on the days the PRN pain medication was given, and only one documented non-pharmacological intervention for anxiety medication use. Resident 5 stated staff had offered non-pharmacological interventions before giving the medications, while an LPN could not locate documentation of those interventions and the DNS stated only one documented intervention was found during the review period. Resident 17, who had end stage renal disease and was dependent on dialysis, had dialysis scheduled three times weekly. The dialysis communication sheets directed staff to document resident status changes, medications given for pain or anxiety, vital signs, bleeding at the access site, and bruit and thrill findings, and to complete the top portion for dialysis staff. The EMR contained dialysis communication sheets, and during interview Medical Records staff stated the dialysis communications were uploaded into the EMR after nursing staff placed them in a box, but staff were not aware the sheets were also kept in a binder at the nurse's station. The report cited WAC 388-97-1720(1)(a)(i)(ii).
Deficiency in Food Safety Practices
Penalty
Summary
The facility failed to ensure that resident meals were prepared and stored in accordance with professional standards of food safety. During an observation, it was noted that the facility kitchen refrigerator contained undated and unlabeled food items, including applesauce, cottage cheese, and freezer jam. Additionally, a cabinet labeled as a Fruit Bar contained trays of salad dressings without preparation dates. Furthermore, a refrigerator located outside the building contained cucumbers that were visibly spoiled, with black circles and a mushy texture. Staff interviews revealed that all open food items should be dated, and undated items should be discarded. In another observation, a refrigerator/freezer in a small dining room/conference room contained snacks and sandwiches for residents, which were also undated and unlabeled. Items included a fast-food bag with a roast beef sandwich, opened egg nog, a gallon of milk, a med pass supplement, and a coconut drink, all without open dates. The freezer had a note indicating no ice packs, yet contained one. Staff interviews indicated that nourishment refrigerators were checked weekly, and opened items should be discarded after three days. These lapses in food safety practices left residents at risk for food contamination and foodborne illnesses.
Incomplete Resident Assessments and Care Area Analyses
Penalty
Summary
The facility failed to ensure that the Resident Assessment Instrument (RAI) and Care Area Assessments (CAAs) were comprehensively completed for several residents, which is necessary to holistically analyze and update the plan of care based on each resident's individualized needs. This deficiency was identified for five residents, including those with conditions such as psychotropic drug use, stroke, diabetes, dementia, and severe cognitive impairment. The assessments lacked comprehensive summaries or analyses that included the residents' current goals, preferences, strengths, or needs, which are crucial for determining if updates to the care plans were needed. For Resident 1, the psychotropic drug use CAA was incomplete, lacking necessary summaries and analyses. Staff interviews revealed confusion over responsibility for completing the psychotropic medication reviews, with the Licensed Practical Nurse (LPN)/MDS Coordinator and Social Service Director both indicating that the other was responsible. Similarly, for Resident 16, the pressure ulcer/injury CAA was not comprehensive, and the LPN/MDS Coordinator admitted to relying solely on medical records for information, with some sections left for social services to complete. Resident 22's cognition/dementia and communication CAA also lacked comprehensive summaries, and the same issue was noted for Resident 32, who had severe cognitive impairment and communication issues. Staff interviews indicated that the LPN/MDS Coordinator was only completing parts of the CAA worksheets, unaware that other areas needed addressing. For Resident 12, the pressure ulcer/injury CAA was incomplete, despite the resident being at high risk for pressure ulcers, as indicated by the Brayden Scale. The LPN/MDS Coordinator admitted to copying and pasting information without addressing all necessary areas.
Deficiencies in Care Plan Implementation and Individualized Care
Penalty
Summary
The facility failed to review, revise, and implement comprehensive care plans for several residents, leading to deficiencies in individualized care. Resident 22, diagnosed with dementia, was at risk for wandering, yet their care plan lacked documented interventions for a wandering incident. Observations showed Resident 22 entering rooms other than their own, and staff were unaware of the need for updated interventions. Additionally, the care plan did not include person-centered information or goals related to their dementia, despite significant cognitive changes noted in assessments. Resident 16, with a history of stroke and diabetes, had a care plan that did not include the use of a green positioning wedge, which the resident used to relieve pressure. The resident was resistant to repositioning, preferring to lie on their back, yet this behavior and the use of wedges were not reflected in the care plan. Staff were unaware of these omissions, indicating a lack of communication and updates to the care plan. Resident 40, with multiple chronic conditions, reported not having a shower since breaking their leg, and their care plan lacked person-centered interventions for bathing preferences. Additionally, the care plan did not address the use of antibiotics or insulin, nor did it include non-pharmacological interventions for pain management. Resident 33, with severe cognitive impairment, was observed struggling to eat independently, yet their care plan did not reflect the need for feeding assistance. The resident experienced significant weight loss, and staff were unaware of the need for one-to-one feeding, as it was not documented in the care plan. Resident 34, also with severe cognitive impairment, had a care plan that did not accurately reflect their activity preferences or the need for heel floating, leading to inconsistencies in care delivery.
Inadequate Care and Communication in Resident Treatment
Penalty
Summary
The facility failed to ensure that several residents received care and treatment in accordance with professional standards of practice, leading to unmet care needs and potential medical complications. Resident 13, who was admitted with conditions including congestive heart failure and peripheral artery disease, had orders for daily weight monitoring with specific instructions to notify the provider of significant weight gains. However, there were multiple instances where weight gains were not communicated to the physician, resulting in the resident experiencing severe respiratory distress and requiring hospitalization for possible pneumonia and fluid overload. Additionally, Resident 13 was observed not wearing prescribed heel boots, and there was a lack of documentation regarding the resident's refusal to wear them. Resident 19, diagnosed with vascular dementia and heart failure, experienced a change in condition requiring additional assistance with meals. Despite a request for a speech-language pathology evaluation due to concerns about swallowing, only a screening was conducted, which did not identify any issues. The resident continued to exhibit signs of difficulty, such as pocketing food, but no further evaluation was pursued. This oversight in addressing the resident's swallowing difficulties could have led to further complications. Resident 260, who had a history of insomnia, was not provided with their prescribed sleep medication, Ambien, due to a pharmacy issue. The lack of medication availability was not communicated to the provider, and the resident reported poor sleep as a result. Similarly, Resident 40, who had ongoing diarrhea, continued to receive a stool softener without the administration of Imodium, despite family requests to stop the medication. Lastly, Resident 20 did not have timely follow-up with an infectious disease doctor as required, and there was a significant delay in obtaining necessary documentation from the clinic. These deficiencies highlight a pattern of inadequate communication and follow-up on medical orders and resident needs.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary psychotropic medications, which placed them at risk for adverse events and diminished quality of care. For Resident 22, the facility did not have appropriate diagnoses for the use of Seroquel, an anti-psychotic medication, and failed to implement non-medication interventions before administering the medication. The resident's care plan did not address the PRN use of anti-psychotics, and there was no documentation of non-medication interventions prior to giving the PRN dose of Seroquel. Additionally, the facility did not limit the PRN use of psychotropic medications to 14 days as required, and there was confusion between the hospice agency and the facility regarding the management of these medications. Resident 1 was administered Lorazepam and Seroquel without appropriate diagnoses or documentation of non-pharmacological interventions. The resident's care plan indicated the use of Lorazepam for terminal agitation, but the medication was administered for reasons not aligned with the order, such as inability to sleep and pain. The facility also failed to document non-pharmacological interventions before administering these medications, and the PRN order for Seroquel exceeded the 14-day limitation. Staff interviews revealed a lack of understanding and documentation regarding the use of these medications and the required interventions. The facility's policy on psychotropic medications was not followed, as evidenced by the lack of appropriate diagnoses, failure to implement non-medication interventions, and inadequate monitoring and updating of care plans. The facility's staff, including the Director of Nursing and Director of Operation, acknowledged the deficiencies and the confusion between the hospice agency and the facility regarding the management of psychotropic medications. These failures highlight significant gaps in the facility's medication management practices, particularly concerning the use of psychotropic medications for residents in hospice care.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure compliance with Infection Prevention and Control Guidelines, leading to multiple deficiencies across various areas. Staff did not adhere to Enhanced Barrier Precautions (EBP) in three out of four hallways, and there were lapses in personal care and wound care procedures. For instance, a Nursing Assistant Certified (NAC) did not use a gown during high-contact peri-care for a resident with a cholecystostomy tube and failed to perform hand hygiene between glove changes, citing the time it takes for hands to dry. Similarly, a Licensed Practical Nurse (LPN) conducted wound care for a resident with multi-drug resistant bacteria without changing gloves between different wound sites, potentially contaminating supplies and surfaces. The facility also demonstrated a lack of proper signage and understanding of EBP requirements. A resident with a history of respiratory MRSA was not placed under EBP, and there was confusion among staff regarding the meaning of door jamb indicators. Additionally, a resident with a gastrostomy tube was not recognized as needing precautions, leading to staff entering the room without performing hand hygiene or using PPE. This miscommunication and lack of adherence to protocols increased the risk of infection transmission. Further deficiencies were observed in catheter care and hand hygiene practices. A resident's catheter bag was repeatedly found touching the floor or garbage, contrary to CDC guidelines, and staff were unaware of the correct procedures. Housekeeping staff also failed to perform hand hygiene between glove changes, which was against the facility's policy. These failures, combined with improper handling of enteric contact precautions, such as not washing hands with soap and water, contributed to the overall risk of infection spread within the facility.
Failure to Assess Residents for Safe Self-Medication Administration
Penalty
Summary
The facility failed to ensure that two residents, Resident 5 and Resident 263, were properly assessed for the safety of self-medication administration. Resident 263, who was alert and oriented, was observed with an eye drop container labeled Pataday Ophthalmic Solution on their overbed table and stated they self-administered the eye drops daily. However, there was no physician order for the eye drops, and the resident's care plan did not include a self-medication program. Staff members were unaware of the eye drops in the resident's room, and the facility's policy required an interdisciplinary team assessment and a prescriber's order for self-administration, which was not followed. Similarly, Resident 5, a long-term resident with no cognitive issues, was observed with an inhaler at their bedside after returning from a doctor's appointment. The resident stated they used the inhaler as needed, but there was no self-medication assessment or documentation in the care plan for keeping the inhaler at the bedside. Staff interviews revealed a lack of awareness and adherence to the facility's policy, which required a doctor's order and a safety evaluation for residents to have medications at the bedside. The Director of Nursing Services acknowledged the oversight and indicated that the medication should be removed until proper procedures were followed.
Failure to Provide Correct Beneficiary Notices
Penalty
Summary
The facility failed to provide the required beneficiary notice for two residents regarding Medicaid/Medicare coverage and potential liability for services not covered. For Resident 47, the facility used an incorrect form, CMS form R-131, instead of the required CMS-10055 form for Skilled Nursing Facilities (SNF) Advance Beneficiary Notice of Non-coverage (ABN). This discrepancy was acknowledged by the Social Service Director, who was unaware of the updated form requirement. For Resident 265, the Notice of Medicare Non-Coverage (NOMNC) was provided only 24 hours before the last covered day of Medicare Part A services, instead of the required 48 hours, as per guidelines. The Social Service Director, responsible for issuing these notices, could not explain the timing error.
Failure to Address Resident Grievances Promptly
Penalty
Summary
The facility failed to promptly initiate, resolve, and document resident grievances for two residents, leading to delays in addressing their concerns. Resident 45, who was cognitively intact, reported missing clothing items, including two pairs of socks and one pair of pants, since September. Despite informing nurses and laundry staff, no grievance was logged, and the resident had not received any communication or resolution regarding the missing items. Interviews with staff revealed a lack of awareness and uncertainty about whether a grievance form was filled out, indicating a breakdown in the grievance process. Resident 25, who was alert but forgetful, reported during a Resident Council meeting that the blinds in their room had holes. Although the Maintenance Manager acknowledged the issue and promised to order replacements, the maintenance log did not reflect this concern, and the blinds remained unrepaired. The facility's grievance log also did not document this issue, highlighting a failure to properly record and address the resident's grievance. These deficiencies in handling grievances resulted in unresolved issues and potential frustration for the residents involved.
Failure to Report Financial Exploitation Concerns
Penalty
Summary
The facility failed to adhere to its policies and procedures for timely reporting of alleged financial exploitation concerning a resident. Specifically, the facility did not report to the state agency and law enforcement when a resident expressed concerns about their financial affairs. The resident, who had a history of hypertension, stroke, and type two diabetes mellitus, believed they had paid their child's mortgage, which raised concerns about potential financial exploitation. Despite these concerns, there was no documentation of a report being made to the appropriate authorities, as required by the facility's policy and the Nursing Home Guidelines, The Purple Book. Interviews with facility staff revealed that the Social Service Director was aware of the concerns regarding the resident's funds being used by their child but did not ensure a report was made to the department. The Social Service Director also failed to document conversations with the Adult Protective Services (APS) investigator about these concerns. The facility administrator acknowledged that new or additional information about a resident should prompt a report, but this was not done in this case. This deficiency was noted as a repeat issue from a previous survey.
Failure to Provide Scheduled Bathing for Resident
Penalty
Summary
The facility failed to provide necessary activities of daily living care for Resident 263, specifically in the area of bathing. Resident 263, who was admitted with a left hip fracture and required two-person maximum assistance for transfers, reported not having received a shower since admission. Despite being alert and able to verbalize needs, the resident's requests for a shower were not fulfilled, and there was no documentation of bathing or refusal in the clinical records for the past 14 days. Interviews with staff revealed that the resident was placed on a shower schedule for Tuesdays and Thursdays, but there was no follow-up to ensure the showers were provided. Staff members admitted to not auditing or checking if residents received their showers and acknowledged the lack of a system to document refusals. The oversight in providing showers and the absence of documentation contributed to the deficiency, as observed by the surveyors.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for a resident, identified as Resident 40, who was reviewed for respiratory care. The deficiency was observed when Resident 40, who had a physician order for oxygen therapy at two liters per minute (lpm) as needed to maintain oxygen saturation above 90%, was found with the oxygen concentrator set incorrectly at 2.5 lpm. Additionally, the nasal cannula was not properly positioned in the resident's nostrils during an observation, and on another occasion, the nasal cannula was found on the floor, not in use, while the concentrator remained set at 2.5 lpm. Resident 40 had a medical history that included diabetes type two, chronic obstructive pulmonary disease, and high blood pressure. Despite the physician's order for oxygen therapy, the nursing staff, including a Licensed Practical Nurse (LPN) identified as Staff DD, did not verify the settings on the oxygen concentrator, which was a part of their responsibility. The Director of Nursing Services, identified as Staff B, confirmed that the nursing staff was expected to ensure the oxygen settings matched the physician's orders. This oversight placed Resident 40 at risk for unmet needs and potential negative outcomes.
Inadequate Dementia Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive dementia care plan for Resident 22, who was diagnosed with dementia and admitted to the facility. The care plan did not adequately address the resident's physical, mental, and psychosocial needs, nor did it establish personalized and achievable goals or identify specific interventions to promote a person-centered environment. The care plan lacked detailed information on how Resident 22's dementia manifested, what situations increased or decreased their stress and anxiety, and the role of family support in their overall cognition. Observations and interviews revealed that Resident 22 exhibited behaviors such as anxiety, self-propelling in the hallways, and calling out for their daughter. Despite these behaviors, the care plan did not include specific strategies to address them. Staff interventions included encouraging phone calls to the resident's daughter and engaging in storytelling and music, but these were not documented in the care plan. Additionally, the resident was noted to be essentially blind, making music an important aspect of their care, yet this was not reflected in the care plan. The lack of a detailed and personalized care plan placed Resident 22 at risk for unmet needs and decreased quality of life.
Improper Storage and Disposal of Medications
Penalty
Summary
The facility failed to ensure proper storage and timely disposal of drugs and biologicals, as observed in two medication carts and one medication room. Specifically, three vials of lorazepam with an expiration date of October 2024 were found in the medication room refrigerator, and a bag labeled Promethegan had its expiration date altered from 2023 to April 2025 by hand. Additionally, an open bottle of Acidophilus, which required refrigeration after opening, was found in the medication cart on the Medicare Hall, indicating a lack of adherence to storage instructions. Staff interviews revealed that the night shift was responsible for removing and destroying or returning expired medications, but this process was not effectively implemented. Staff U, an LPN, acknowledged the expired lorazepam and the altered expiration date on the Promethegan, stating that the latter came from the emergency kit. Furthermore, Staff U noted that the night shift was also responsible for ensuring proper storage of medications, but the Acidophilus found in the North Hall cart was replaced with a new brand that did not require refrigeration, indicating a lack of consistent oversight and adherence to medication storage protocols.
Failure to Serve Meals Timely and at Safe Temperatures
Penalty
Summary
The facility failed to ensure that meals were served in a timely manner and at appropriate temperatures, impacting the palatability and safety of the food provided to residents. On the morning of January 31, 2025, a full cart of meal trays was observed in the hallway of South Hall, with none of the trays having been served. Staff I, an LPN, mentioned that the carts had arrived a few minutes prior, and there were two nursing aides working on the South Hall, with another aide expected to arrive. Staff D, a Nursing Aide Certified, began distributing the meal trays at 8:52 AM, indicating that the trays had been sitting for a few minutes. However, the dietary manager, Staff HH, noted that the trays were sent out at around 8:15 AM, and upon checking, found the oatmeal on one of the trays to be at 124 degrees Fahrenheit, which was below the recommended temperature of 165 degrees Fahrenheit for hot foods. The Resident Council reported that the food was consistently cold and late, particularly on weekends when the dietary manager was absent. The facility's policy outlined the recommended temperature ranges for safe food holding, storage, and serving, which were not met in this instance. The dining times indicated that meals should be provided between 7:45 AM and 8:45 AM, but the delay in serving and the inadequate temperature of the food suggest a failure to adhere to these guidelines, potentially affecting the residents' nutritional status and meal acceptance.
Failure to Coordinate Hospice Care Plan
Penalty
Summary
The facility failed to ensure effective communication and coordination of care between the facility and the hospice provider for a resident receiving hospice services. The facility did not obtain or maintain a copy of the resident's current hospice coordinated plan of care, nor was it integrated into the facility's care plan. This oversight placed the resident at risk of not receiving necessary care and services. The facility's contract with hospice required coordination regarding the plan of care, but this was not adhered to, as evidenced by the absence of the hospice care plan in the resident's electronic health record (EHR). The resident, who had a terminal prognosis related to an end-stage disease process, was admitted to hospice care, but the hospice plan of care was missing from their EHR. Despite multiple hospice notes being present, there was no indication that they were reviewed by facility staff. The resident exhibited confusion and agitation, with behaviors such as self-propelling up and down halls and calling out for their daughter. Interviews with facility staff revealed a lack of awareness regarding the missing hospice care plan, which was only located and provided after the surveyor's inquiry.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to adequately review and revise care plans for two residents, leading to potential risks for unmet care needs. Resident 40, who was admitted with conditions including diabetes, COPD, and high blood pressure, experienced multiple falls. Despite having a care plan that identified them as a fall risk, the plan was not updated to reflect the resident's recent falls and was inconsistent with the Care Area Assessment. The care plan included interventions such as using a fall mat and ensuring the call light was within reach, but these measures were not effectively preventing falls, as evidenced by the incident reports. Resident 1, who was under palliative care with severe cognitive impairment, was receiving both antidepressant and antipsychotic medications. However, their care plan incorrectly combined these two categories of psychotropic medications, leading to confusion in monitoring and interventions. Additionally, the resident's care plan included a wander guard intervention, but there was no recent wandering risk assessment, and the wander guard was found not in use, indicating a lack of proper review and revision of the care plan. Interviews with staff revealed that there were errors in the care planning process, such as incorrect categorization of medications and outdated interventions. Staff acknowledged the need for updates and corrections in the care plans, but these deficiencies had not been addressed at the time of the survey, placing residents at risk for adverse health effects and diminished quality of life.
Failure to Provide Timely Assessment and Treatment Leads to Resident's Death
Penalty
Summary
The facility failed to provide timely assessments and treatment for a resident experiencing ongoing abdominal pain and discomfort, leading to an unexpected hospitalization and subsequent death. The resident, who had a history of atrial fibrillation, long-term anticoagulant use, diabetes, and a previous stroke, was admitted with intact cognition and was dependent on staff for personal care. Despite the resident's POLST form indicating a preference for selective treatment and hospital transfer if necessary, the facility did not adequately respond to the resident's acute change in condition. Over the course of several days, the resident experienced persistent abdominal discomfort, which was documented in nursing progress notes. However, there was a lack of thorough assessment and communication with the physician. The resident's condition worsened, with symptoms including restlessness, crying out in pain, and vomiting a dark coffee-colored substance. Despite these alarming signs, the nursing staff failed to conduct a comprehensive assessment or notify the physician in a timely manner, resulting in a delay in treatment. Interviews with staff revealed a lack of adherence to the facility's notification policy and inadequate monitoring of the resident's condition. The resident's vital signs were not assessed regularly, and the physician was only notified by fax, which is not appropriate for urgent situations. The failure to recognize the severity of the resident's condition and take prompt action constituted an immediate jeopardy, ultimately leading to the resident's hospitalization and death.
Neglect in Resident Care Due to Inadequate Assessment and Communication
Penalty
Summary
The facility failed to provide necessary care and services to prevent neglect for a resident who experienced a significant change in condition. The resident, who had a history of atrial fibrillation, long-term use of anticoagulants, diabetes, and a history of stroke, was admitted to the facility and was dependent on staff for toileting and personal care. The resident experienced increased abdominal pain over several days, but the licensed staff did not conduct a thorough assessment or consult with the physician in a timely manner. This lack of action resulted in the resident being left alone in their room in pain during the night shift. The medical records indicated that the resident's vital signs were not checked during the night shift, and the resident continued to experience abdominal discomfort without relief from antacids. Despite the resident's persistent calls for assistance and visible distress, the staff did not perform additional assessments or notify the physician until hours later. The resident was eventually found covered in dark brown vomit with right lower abdominal pain and decreased breath sounds, leading to their transfer to the hospital where they later passed away. Interviews with staff revealed that the Nursing Assistant Certified (NAC) and Licensed Practical Nurse (LPN) were aware of the resident's discomfort but failed to take appropriate actions. The NAC reported the resident's distress but did not re-enter the room after being told by the LPN that they would handle the situation. The LPN admitted to not assessing the resident's vitals or notifying the physician promptly, instead sending a fax about the resident's condition. The Director of Nursing Services (DNS) confirmed that the staff did not meet the facility's expectations for assessing and communicating changes in the resident's condition.
Inadequate Investigations into Resident Incidents
Penalty
Summary
The facility failed to conduct thorough investigations into several serious incidents involving residents, leading to deficiencies in care and oversight. Resident 1 experienced a significant change in condition and was sent to the hospital, where they passed away shortly after. The investigation into this unexpected death was inadequate, lacking crucial details about the nurse's delayed response and inappropriate communication method with the physician. The investigation did not address whether abuse or neglect contributed to the resident's death, despite evidence of the resident's distress and pain prior to hospitalization. In another incident, Resident 2 alleged abuse by a nursing assistant who refused to assist them with incontinence care. The investigation was delayed and incomplete, failing to interview a key witness, Resident 4, who overheard the interaction. The investigation also did not notify the resident's physician or family and lacked documentation of monitoring for potential psychosocial harm. The care plan for Resident 2 did not reflect the incident or address potential harm, indicating a lack of comprehensive follow-up. Similarly, Resident 3 reported rough handling by the same nursing assistant during care. The investigation was again insufficient, with no interviews conducted with other staff or witnesses, and no notification to the resident's physician or family. The care plan did not address potential psychosocial harm, and the investigation relied on a generic questionnaire rather than specific inquiries into the nursing assistant's conduct. These failures in investigation and documentation highlight significant lapses in the facility's response to allegations of abuse and neglect.
Failure to Report Unexpected Death
Penalty
Summary
The facility failed to ensure timely reporting of an unexpected death of a resident, which is a requirement under their policies and procedures for abuse and neglect. The resident, who had intact cognition and no refusals of care, experienced a change in condition and was sent to the hospital, where they passed away hours later. Despite the unexpected nature of the death, the facility did not report the incident to the state agency, as required by the Nursing Home Guidelines, The Purple Book. The Director of Nursing Services (DNS) and the Administrator were unaware of the reporting requirements outlined in the Purple Book, which mandates reporting unexpected deaths to the Department of Social and Health Services (DSHS) hotline, logging the incident on the state reporting log, and notifying law enforcement and the coroner. The facility's investigation summary indicated that the resident did not receive timely or thorough care and services, contributing to the deficiency in reporting the unexpected death.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 203 citations issued within 25 miles in the last 12 months — including the 1 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Arlington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Marysville Care Center | 8.9 mi | ★★★★★ | 23 | 0 |
| Mountain View Rehabilitation And Care Center | 9.6 mi | ★★★★★ | 9 | 0 |
| Josephine Caring Community | 11.7 mi | ★★★★★ | 28 | 0 |
| Bethany At Pacific | 14.1 mi | ★★★★★ | 0 | 0 |
| Everett Transitional Care Services | 15.1 mi | ★★★★★ | 8 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.