Below average — CMS composite of the measures below.
A standard survey is most likely before 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 Aurora Valley Care during CMS and state inspections, most recent first.
A resident with dysphagia and aspiration risk returned from the hospital with instructions for aspiration precautions and to remain upright for all oral intake, but the chart had no related orders or care plan interventions. The resident and family reported staff were not consistently aware of the swallow precautions, and an RN and the DON both confirmed they could not find documentation for the needed precautions.
The facility failed to maintain clean and sanitary resident rooms and shared bathrooms, resulting in dirty, sticky, and debris-covered floors, dried urine and foul odors in shared bathrooms, and damaged flooring in resident rooms. A nonverbal resident with a leg fracture had a persistently sticky and dirty floor despite concerns raised by a collateral support person, while two cognitively intact residents reported chronically dirty, urine-stained, and malodorous shared bathrooms and damaged, dirty room floors. Observations confirmed extensive dried urine, dirt, hair, and debris under bariatric commodes, foul odors extending into rooms, peeling duct tape over a floor hole, and cracked flooring embedded with dirt. Staff reported confusion between housekeeping and nursing regarding responsibility for cleaning urine spills, and the Administrator stated an expectation that rooms and bathrooms be cleaned at least daily or as needed.
A resident admitted with a repaired mid-spine fracture, ankylosing spondylitis, and chronic respiratory failure reported that provider-ordered medications were not available for several days after admission. Review of the MAR showed multiple missed doses of enoxaparin, mirtazapine, cyclobenzaprine, pregabalin, sildenafil, and a Butrans patch. The DON reported the facility was using a new pharmacy and was unsure why the medications were missed, while stating the expectation that resident-specific medications be available for administration on the day of admission.
Insufficient staffing delayed resident care and call light response. Residents reported long waits for incontinence care, help getting back to bed, and bathroom assistance, and one resident council meeting included multiple residents agreeing there was not enough staff. Observations showed call lights left on for 15 to 40 minutes before being answered, and staff, including a nursing assistant, an LPN, and the DON, acknowledged staffing shortages made it difficult to complete cares timely.
Facility administration failed to maintain an adequate supply of clean bed and bath linens in good repair. Residents and staff reported frequent shortages, with some residents using slightly soiled linens or going without them, while laundry was often returned stained, wet, malodorous, or otherwise in poor condition. Staff described the laundry problem as long-standing and ongoing, with repeated complaints documented to corporate about the quality of the laundry service.
Missing Hospital Transfer Agreement: The facility failed to provide a written transfer agreement with one or more local hospitals after it was requested from the Administrator. No documentation was produced, and the Administrator stated the facility was expected to have the required agreement with local hospitals.
Laundry handling and hand hygiene failures were observed. Staff used a household washer and dryer in a therapy gym to process resident clothing and linens, while clean and soiled items were stored and handled in shared or non-designated areas, including a dirty linen room with a clean clothing rack and an office used for sorting that also contained chemicals and other stored items. In a separate observation, an LPN did not perform hand hygiene between medication-related tasks for one resident or before gloving for another resident, and the DON acknowledged the missed hand hygiene.
A facility failed to maintain adequate linens, gowns, towels, and washcloths, leaving residents with soiled or missing bedding, missing clothing, and delayed bathing supplies. Residents and family members reported ongoing shortages, and staff acknowledged the problem. The facility also exposed residents in several rooms to very hot conditions during bed bug heat treatment, and two residents’ wheelchairs were repeatedly observed with food debris and other soilage.
Resident rights were not periodically reviewed or consistently made accessible to residents. During a Resident Council meeting, several residents said they had not been offered information on their rights or did not remember any discussion of them, and one resident stated they could not exercise rights they did not know about. Council minutes showed copies of the Resident [NAME] of Rights were sometimes given to new residents or a few residents, but there was no documentation that rights were discussed with all attendees. A Know Your Rights poster, binder, and laminated sheets were posted too high on the wall to be readable or accessible for residents using wheelchairs.
Resident rights notice and State contact information were not posted in a readable, accessible location for residents who used wheelchairs. During Resident Council, several residents said they had not been informed how to contact the State Agency, and a poster with the agency and advocacy group contact information was mounted high on the wall near the dining room rather than at eye level.
A facility failed to ensure residents and visitors knew where the State Recertification Survey results binder was located. During Resident Council, several residents said they had never seen the binder or did not know its location, and although the binder was later observed in the former lobby/main entrance area, no notice was seen in the lobby to direct people to it.
Failure to Notify Ombudsman of Transfers and Discharges: The facility did not provide written discharge/transfer notices or send required copies to the LTC Ombudsman for two residents. One resident left AMA, and another resident with failure to thrive and ESRD on dialysis was sent to the ER for low BP. Records also showed multiple hospital transfers without documentation of Ombudsman notification.
Failure to hold required care conferences and include resident participation. The facility did not complete quarterly IDT care planning conferences for multiple residents, and records showed missing documentation of resident and representative invitations, absent nutrition services participation in some meetings, and no evidence of ongoing care plan reviews. Several residents stated they had never had a care conference or were not kept informed about their plan of care, and the Social Service Director and DON acknowledged the conferences were not being held quarterly.
A facility failed to oversee restorative ROM and walking programs for three residents with significant mobility needs. One resident with stroke-related weakness and a hand contracture had repeated PROM documentation showing the program was not completed as planned, another resident with a brain injury had inconsistent walking maintenance documentation, and a third resident with dementia and ROM limitations had PROM documented as not occurring. Staff interviews showed confusion about who was responsible for carrying out and monitoring the restorative programs, and an observation found the resident’s knee ROM did not match the care plan target.
Medication administration was not consistent with provider orders for three residents. One resident with dementia, HTN, and HF received Losartan when SBP was below the hold parameter and had doses held when BP was within range. Another resident with HF and HTN had Amlodipine and Metoprolol given without required BP/pulse checks and at times when vital signs were below ordered hold parameters, while other doses were held when parameters were met. A third resident with a stroke and HTN received Amlodipine and Hydralazine despite BP or pulse being below hold parameters, and Lidocaine patch documentation also showed NA entries.
The facility failed to show that the Medical Director received and reviewed QAPI content when absent or otherwise participated in the QAPI process as required. The Administrator stated the QAA/QAPI team met quarterly and that QAPI data was uploaded to a cloud platform, but no evidence showed the Medical Director reviewed it. The Medical Director did not attend multiple QAA meetings, sign-in sheets did not show participation, and the facility could not provide further documentation of involvement.
The facility failed to ensure direct care staff received effective communication training. Although 89 direct care staff were employed, only 8 had completed the training. An NA and an LPN stated training would be documented in the electronic records if received, and the Administrator acknowledged the training had not yet been provided and was not scheduled to begin until later in the year.
Failure to train all staff on the facility’s QAPI program. Record review showed the facility employed 109 staff, but no QAPI training documentation was provided when requested. Interviews with a NA, receptionist, maintenance assistant, housekeeping manager, and LPN showed inconsistent understanding of QAPI, and the Administrator acknowledged that all staff had not received the required training.
Facility staff failed to consistently assist dependent residents with ADLs, including bathing, nail care, and eating. Residents with needs for hygiene and meal assistance were repeatedly observed with long or dirty nails, missed or inconsistent showers, and meals where staff did not help despite obvious need. Care plans and task records showed gaps in bathing and nail care documentation, and staff interviews confirmed inconsistent completion and documentation of these cares.
Delayed informed consent for psychotropic medications. Two residents receiving psychotropic meds for depression, anxiety, restlessness, and agitation had consents completed only after the meds were already being administered. The record showed one resident’s SSRI consent was signed weeks late, and another resident’s consent for an SNRI and antipsychotic was also obtained after first doses, with no additional documentation of education about the reason for the meds or their risks and benefits.
A resident with PTSD and psychotropic medication use did not have a new Level I PASARR completed after an exempted hospital stay ended. The hospital had completed the initial PASARR before admission, but the facility did not complete the required PASARR until months later. The Administrator acknowledged the PASARR was not completed timely.
A resident with DM, neuropathy, PVD, and a hx of stroke had very dry, scaly feet observed on multiple occasions. Although weekly diabetic foot checks and nail care were documented as completed, the resident stated staff did not apply lotion to the feet, and staff interviews confirmed lotion should be used when skin is dry or calloused. The podiatry consult had recommended keeping the skin soft with moisturizer to avoid cracks and fissures.
A resident with nicotine dependence and a history of smoking was admitted as cognitively intact and was initially given nicotine patches, which the resident often refused. Later, the resident stated they planned to keep smoking, and staff observed the resident smoking off the facility property. The record had no documented smoking assessment after staff became aware the resident was smoking, and the care plan had no smoking-related interventions or information.
Failure to Address Bowel and Bladder Incontinence: A resident with a stroke, hemiplegia, and spasticity was always incontinent of bowel and bladder and required total staff assistance for toileting. Although the care plan directed staff to provide care after each incontinent episode and use briefs, the record did not show an evaluated, resident-centered toileting program. The resident said staff had not discussed improving incontinence and preferred the toilet or a bed pan, while staff said the resident usually used a brief and had never been placed on a toileting program.
A resident with diabetes and osteomyelitis had an IV access in the chest with an intact transparent dressing, but the record lacked orders and documentation for routine saline flushes and IV dressing changes. Staff stated IVs were flushed every shift and dressings changed weekly, yet they could not find MAR documentation, and the DON acknowledged the missed orders and documentation.
Respiratory care was not provided as ordered for two residents. One resident with OSA had CPAP use documented on some nights, but the resident reported needing staff help, not being reminded, and not having a strap for the mask; observations showed the CPAP stored at the bedside without a strap, and the DON later acknowledged the device could not have been used as charted. Another resident dependent on oxygen had tubing dated well beyond the weekly change interval and an oxygen concentrator with white splatter and dust debris on repeated observations, despite staff stating tubing was changed weekly and concentrators were cleaned routinely.
A resident with ESRD on dialysis had a newly created left arm fistula, but the room had no signage or orders warning staff not to use that arm for BP checks or lab draws. Staff gave inconsistent responses about fistula precautions, and the resident reported that staff sometimes checked BP on the left arm; an LPN stated the arm used did not matter because the facility used a wrist cuff, while the DON acknowledged the fistula arm should not be used for BP measurements.
A resident with anxiety, depression, and chronic pain had a Level II PASRR that identified the need for further psychiatric assessment, but no behavioral health provider notes, assessments, or referrals were documented. The resident was observed in a dark room, reporting constant pain, poor sleep, and depression, and became tearful and agitated when discussing their condition. Staff confirmed the resident had mood instability and that no counseling or behavioral health services had been offered.
A resident with stroke, restlessness, and agitation was receiving daily Seroquel. The pharmacist’s MRR recommended orthostatic BP checks and behavior monitoring, but the MAR/TAR showed these were not carried out and the record had no explanation for not following the recommendation. The DON stated orthostatic BP checks were not considered because the resident could not stand, though the resident could move from lying to sitting and behavior monitoring was needed to assess for changes from baseline.
Medication storage and monitoring were not maintained in the North med cart/room and TCU med room. An LPN found insulin lispro pens past the discard date and another with no open date, plus a discontinued lorazepam bottle for a resident stored in an unlocked cabinet instead of the locked med refrigerator and narcotic count. In the TCU med room, the refrigerator and room temp log was incomplete, with missed readings and several out-of-range room temps left unexplained; the DON confirmed the insulin, lorazepam, and temperature log expectations.
The facility failed to ensure timely dental follow-up for two residents after in-house dental care. One resident reported a broken dental bridge that had not been repaired, and another resident had mouth/facial pain, difficulty chewing, and needed a referral for extractions. Records showed the dental provider had requested follow-up care, but there was no documentation that the appointments or referral were completed, and staff interviews showed confusion about who was responsible for arranging the dental visits.
Failure to Perform Hand Hygiene During Meal Service: A Cook and a Dietary Aide were observed handling food, meal tickets, and kitchen equipment during tray line service without performing hand hygiene when indicated. The Cook repeatedly touched meat, vegetables, rolls, the oven warmer, and the steamer with gloved hands while continuing to serve meals, and the Dietary Aide scratched their head with a bare hand before continuing to place food on trays. The Dietary Mgr and RD acknowledged hand hygiene should have been performed during these tasks.
The governing body failed to ensure an adequate supply of clean linens for residents and did not timely respond to repeated staff concerns about poor laundry service and insufficient linen quantities. Residents and staff reported frequent shortages of bed linens and towels, and the Administrator stated the laundry problem had been ongoing, with items returned stained, wet, or missing, and repeated requests for help or a vendor change were documented through corporate communications.
A resident with dementia and pancreatic cancer was on hospice for end-of-life care, but the facility did not identify a designated interdisciplinary team member to serve as the hospice liaison. The hospice agreement required the facility to name a staff member to coordinate care and communication with hospice, yet the agreement and facility policy did not identify who that person was. Staff gave inconsistent answers about whether the liaison was the DON, RCM, resident's nurse, or the Social Services Director.
A resident who required extensive assistance with toileting was found in a urine-soaked bed after returning from the emergency room. The resident did not use the call light for help, and a Nursing Assistant did not provide care, assuming no assistance was needed. The LPN responsible did not ensure the resident's needs were met, and the Director of Nursing stated that residents should be checked every two hours.
A resident with right-sided hemiplegia and hemiparesis required assistance with eating, particularly when in bed, due to severe osteoarthritis and a torn rotator cuff. Despite this, the care plan inaccurately stated they could eat independently, leading to inadequate care. Staff communication about the resident's needs was not documented in the care plan, resulting in a lack of guidance for proper care.
A resident with a history of anxiety, mild dementia, and stroke was identified with moderate depression symptoms, but the facility failed to seek timely mental health services. The resident exhibited refusals of care, including medication and repositioning, leading to deteriorating health and worsening wounds. Despite an order for a behavioral health evaluation, the facility did not follow through, and staff were unaware of the need for such an evaluation. The resident's family expressed concerns about the decline, resulting in a hospital evaluation request.
A resident with ill-fitting dentures causing an open sore did not receive timely follow-up for necessary dental services. Despite a dental exam indicating the need for a denture adjustment, no further action was documented. Staff interviews confirmed the lack of follow-up, and the resident was later discharged to the hospital.
The facility failed to address substance use disorders in the care plans of two residents, leading to potential accident hazards. One resident was hospitalized after being found intoxicated following a fall, while another resident with opioid dependence had no safety interventions in place. The administrator acknowledged the need for care planning and monitoring, but this was not implemented.
A resident with Wernicke's Encephalopathy and adult failure to thrive was neglected in terms of incontinence and hygiene care, leading to their removal from the facility AMA. Family members repeatedly found the resident in unsanitary conditions, but staff failed to document or address these concerns adequately. The facility's management was unaware of the situation, highlighting a communication breakdown.
A facility failed to report allegations of potential neglect to the State Agency. A resident left the facility AMA after their family raised concerns about neglect, including the resident being undressed and having urine everywhere. Despite being aware of these concerns, the Social Services Director and Resident Care Manager did not report them to the Administrator or the State Agency, and no report was submitted.
During a COVID-19 outbreak, the facility failed to follow quarantine and isolation precautions, affecting several residents and involving improper PPE use by a staff member. Residents with COVID-19 had open doors against CDC guidelines, and a staff member did not wear the required PPE in a quarantine room. Interviews revealed a lack of documentation and communication regarding precautions.
A resident with end-stage renal disease, diabetes, and seizures experienced vomiting and missed seizure medication doses, but the medical provider was not notified. Staff interviews revealed a lack of communication and documentation regarding the resident's condition changes, leading to a seizure and hospital transport.
The facility failed to implement effective discharge planning for three residents, resulting in unsafe discharges and unmet care needs. One resident was discharged without proper documentation of their urinary status, another left AMA multiple times due to inadequate monitoring of behaviors, and a third resident discharged AMA without proper education on risks. The facility's discharge planning process was insufficient, leading to these deficiencies.
The facility failed to adequately address the risks of elopement and substance use for residents with substance use disorders. A resident with severe cognitive impairment and a history of substance abuse frequently left the facility without staff knowledge and was found with drug paraphernalia. Another resident, initially unresponsive, had an incomplete care plan that did not address elopement or substance use risks. A third resident, with moderate cognitive impairment and alcohol abuse history, had a care plan that failed to address substance use disorder. Staff were unsure of processes for dealing with substance use emergencies.
A resident with an indwelling urinary catheter due to acute urinary retention was not properly assessed or managed by the facility. The facility failed to follow its policy requiring comprehensive assessment and medical justification for catheter use. Despite hospital orders for continued catheter use and a urologist follow-up, the facility did not schedule the appointment and canceled the consult without proper documentation. Staff interviews revealed a lack of clarity and communication regarding catheter management, leading to the resident's discharge with the catheter still in place.
A resident experienced ongoing mouth pain due to the facility's failure to schedule a dental appointment for necessary extractions. Despite being cognitively intact and requesting the appointment, the resident's pain persisted, reaching severe levels. Staff responsible for scheduling acknowledged the oversight, and the DON confirmed the need for the appointment.
The facility failed to ensure timely physician visits for several residents, with gaps exceeding the required intervals. This deficiency was identified through interviews and record reviews, revealing that residents with various diagnoses, including depression, stroke, and diabetes, did not have documented physician visits within the mandated timeframes. The facility's recent switch to a new provider group contributed to the lack of proper tracking and documentation.
A LTC facility failed to administer medications as ordered for three residents, leading to significant medication errors. One resident missed multiple doses due to unavailability and dialysis scheduling conflicts. Another resident missed doses while at dialysis, and a third experienced a delay in receiving a post-surgery antibiotic due to communication issues with an oral surgeon's office.
The facility failed to ensure proper hand hygiene and PPE use during medication administration and wound care, and did not implement Enhanced Barrier Precautions for residents at risk of infection. A resident with MRSA was not placed on EBP, and another resident on EBP did not receive care in accordance with these precautions. Additionally, the facility's water management plan was outdated and inadequately maintained.
Failure to Document and Implement Swallow Precautions
Penalty
Summary
The facility failed to ensure swallow interventions were developed and implemented for one resident who had a history of dysphagia and aspiration risk. The resident was first admitted from a local hospital, then re-admitted after another hospital stay with new discharge instructions dated 04/19/2026 that included aspiration precautions and a recommendation to establish gastroenterology care for further workup of dysphagia. A facility provider note written on 04/24/2026 documented that the resident required dysphagia precautions and dysphagia management for severe esophageal dysmotility with aspiration risk, and stated the resident must be upright for all oral intake. Despite those documented needs, the resident’s order summary for 04/01/2026 through 05/31/2026 did not show any orders related to aspiration, swallowing, or dysphagia precautions. The resident’s care plan, dated 04/02/2026 and updated on 04/22/2026, also did not show any focus or interventions related to swallowing difficulty, dysphagia, or aspiration precautions. The resident’s medical record later listed chronic respiratory failure, disease of the esophagus, and mild cognitive impairment. During observation and interview on 05/27/2026, the resident was seen lying in bed with the head of the bed at about 45 degrees while a partially finished lunch tray was at the bedside. The resident stated they had increasing difficulty swallowing, had returned from the hospital on swallow precautions, and needed to take small bites and only 1-2 pills at a time because food or pills could feel stuck and come back up into the throat and mouth. The resident’s family member stated staff did not seem aware of the swallow precautions on at least two occasions. Staff D stated they knew the resident needed to be upright for meals and pills but could not find any orders for aspiration or swallow precautions, and the DON also stated there were no orders, care plan focus, interventions, or corresponding diagnosis documented for aspiration precautions.
Failure to Maintain Clean and Sanitary Resident Rooms and Shared Bathrooms
Penalty
Summary
The facility failed to maintain a clean and sanitary, safe, and comfortable environment for multiple residents, resulting in dirty and malodorous resident rooms and shared bathrooms. One resident with a developmental disability and nonverbal status was observed to have a room with a sticky floor, black scuff marks, droplets of a clear red liquid, and scattered paper towel pieces, hair, and dust, after a collateral contact reported that the resident’s floor had been sticky and dirty on an almost daily basis despite notifying nursing staff. The resident’s electronic medical record showed they had been admitted after a right upper leg fracture and required support from a collateral contact due to being nonverbal. Two cognitively intact residents reported that their shared bathrooms were often dirty with dried urine and foul odors, and that their room floors were damaged and dirty. Observations confirmed that the shared bathrooms contained bariatric commodes covering the toilets, with dried yellow urine, dirt, hair, and other debris extending from wall to wall under and around the toilets, along with a strong foul odor that extended into the residents’ rooms. One resident’s room had a floor hole patched with duct tape that was peeling and dirty, and another resident’s room had cracked flooring with dirt embedded in the cracks, along with scuff marks and general debris on the floors. Nursing assistants reported that the housekeeping supervisor had been sick and that there was a language barrier with some housekeeping staff, leading to a misunderstanding about whether housekeeping or nursing staff were responsible for cleaning urine spills in the bathrooms, while the Administrator stated the expectation that resident rooms and bathrooms be cleaned at least daily or as needed to maintain a sanitary environment.
Missed Ordered Medications Due to Unavailable Pharmacy Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident by not ensuring ordered medications were available and administered as prescribed. The resident, who was cognitively intact, had been admitted with diagnoses including surgical repair of a mid-spine fracture, ankylosing spondylitis, and chronic respiratory failure. In a telephone interview, the resident reported that provider-ordered medications were not available for several days after admission. Review of the resident’s electronic medical record and MAR showed multiple missed doses of several medications during the admission period. Record review on specific dates in February showed missed doses of enoxaparin on two evenings, mirtazapine on one evening, cyclobenzaprine on one evening and the following morning, pregabalin on one evening and the following morning, and sildenafil at multiple scheduled times over two days. Additionally, a Butrans patch ordered for pain control was missed at a scheduled noon administration later in the month. In an interview, the DON stated the facility had a new pharmacy and that they were unsure why the resident’s medications were missed when the resident first admitted, and further stated the expectation that resident-specific, provider-ordered medications should be available for administration the same day of admission.
Insufficient Staffing Delayed Resident Care and Call Light Response
Penalty
Summary
The facility failed to ensure sufficient staff were available to meet the care needs of 7 of 9 sampled residents reviewed for ADLs and 3 of 3 sampled residents reviewed for restorative nursing. Residents reported delays in receiving assistance with incontinence care, getting out of bed, and call light response. One resident stated they had to wait 30 minutes for incontinence care, another said they sometimes waited an hour, and another reported waiting 45 minutes for a call light to be answered. A resident council meeting also included multiple residents agreeing that there was not enough staff and that assistance was not provided timely. Observations and interviews showed call lights remaining on for extended periods before being answered, including one for 20 minutes, another for 15 minutes and 30 seconds, and others for 40 minutes, 39 minutes, 30 minutes, 27 minutes, and 19 minutes. Staff interviews confirmed staffing concerns, with a nursing assistant stating there was not enough staff to provide care timely and that having only three nursing assistants made it difficult to get cares done. A LPN stated it was sometimes a challenge to get all tasks done when staffing was short, and the DON stated staffing was based on resident acuity and care needs, but should not be so bad that cares were not provided.
Insufficient Clean Linen Supply and Poor Laundry Service
Penalty
Summary
Facility administration failed to effectively use its resources to maintain compliance with federal regulatory requirements for clean bed and bath linens in good repair. Multiple residents and staff members reported that bed linens and towels were frequently not available in sufficient quantities, and residents sometimes had to use slightly soiled linens or go without them. The report states that bed linens were often returned from the laundry provider soiled, stained, wet, and malodorous, and that the facility had an insufficient supply of linens for resident needs. Interviews with staff showed the laundry service had been a long-standing problem and that the issue had been ongoing for years. Staff A stated the facility had used a sister facility for laundry for about 25 years and was aware of the poor service and lack of linen, describing it as a consistent issue and a pattern rather than a one-time event. Staff A also stated that the Quality Assurance and Performance Improvement committee had completed a performance improvement plan about the laundry and linen issue in December 2024, and that correspondence to corporate documented repeated problems with stained clothing and tablecloths, resident clothing returned bagged instead of hung, linens returned wet, and towels smelling of feces. The correspondence reviewed did not show short-term interventions taken before the survey to address the immediate lack of clean linens.
Missing Hospital Transfer Agreement
Penalty
Summary
The facility failed to have a written transfer agreement with one or more local hospitals as required. Hospital transfer agreements were requested from Staff A, the Administrator, on 09/15/2025 at 8:53 AM and again at 12:11 PM, but no documentation was provided. In an interview on 09/15/2025 at 1:51 PM, Staff A stated they expected the facility to have a transfer agreement with the local hospitals as required.
Laundry handling and hand hygiene failures
Penalty
Summary
The facility failed to provide laundry services in a manner that prevented the spread of infection. The facility assessment stated the average daily census was 75 and that residents had a variety of diagnoses and infectious diseases, but there was no documentation showing how laundry services were provided. A facility policy required soiled linens to be handled with tear-resistant reusable rubber gloves, washed in hot water at 158-176 degrees Fahrenheit for 10 minutes or otherwise manually reprocessed, and clean linens to be sorted, packaged, transported, and stored in a designated area separated from dirty items. During observation and interview, staff described a newly implemented laundry process that used the household washer and dryer in the therapy gym. The therapy gym contained a simulated home environment with a washer, dryer, kitchen area, and bathroom. Clean hanging clothing and walkers were stored in the same closet space as a rolling hamper containing wet and soiled towels, and protective gowns were not readily available. Staff also stated soiled linen was stored in covered barrels on units, transported to the dirty linen room, then moved in covered bins to the therapy gym for washing. The dirty linen room contained a hanging rack used to transport clean laundry, and staff acknowledged that the clean clothing rack should not have been stored in the same room as soiled linens. Clean linen was then placed in a clean bag and taken to an office for sorting and folding, but the office had no designated sorting or folding area and contained stored chemicals, blankets on the floor, a bag of boots on the floor, and clothing and curtains hanging on the door. The facility’s maintenance director stated they were unaware the household washer and dryer in the therapy gym had been used to wash all resident clothing and had not assessed the equipment or water temperature before the process began. The infection preventionist stated they had not been informed of the new laundry process and was unsure whether the washer reached the required temperature or whether cold wash chemicals were used. The administrator later stated the facility had implemented the new laundry system at the beginning of the month and recently realized the machines did not reach the required temperatures. In a separate deficiency, an LPN was observed administering medications to two residents without performing hand hygiene between tasks, including after handling one resident’s medication and before returning to continue care, and before putting on gloves for another resident. The LPN stated hand hygiene should have been performed between residents’ care and before and after glove use, and the DON acknowledged the missed hand hygiene.
Linen shortages, overheated rooms, and unclean wheelchairs
Penalty
Summary
The facility failed to provide an adequate supply of bed linens, gowns, towels, and washcloths for 15 of 15 sampled residents reviewed for a safe, clean, homelike environment. During Resident Council, residents stated the linen shortage and missing clothing continued, with reports that clothes did not come back from laundry, pillows and blankets were feared lost if sent out, and clean sheets were not consistently available. Staff also acknowledged ongoing linen shortages, including a recent change in laundry service and continued difficulty obtaining enough supplies. Multiple residents were directly affected by the lack of linens and clothing. One resident reported having to use slightly soiled sheets and, at one point, three pillowcases instead of a top sheet. Another resident remained in bed because staff could not find a sling needed to get them up, and staff confirmed the sling could not be located. A resident representative reported that towels were not available after bathing and that bath towels had to be brought from home. Another resident stated the facility frequently ran out of linens and gowns, had no clothes, and was kept in briefs because no gowns, sheets, or pillowcase were available. Other residents were observed with stained sheets, no top sheet, or bedding that was not their own. The facility also failed to maintain safe and comfortable room temperatures for rooms 29 through 39 on the Southeast unit during bed bug heat treatment. Rooms and hallways were observed to be very hot, with temperatures measured as high as 96 degrees in the hallway and 94.2 degrees inside a room. Residents reported the rooms were too hot and difficult to sleep in, and fans were placed in the hallways. The administrator stated there was room on the Northeast unit to move residents, but no discussion occurred because the treatment was short in duration and hydration rounds and fans were used. In addition, Resident 19 and Resident 43’s wheelchairs were repeatedly observed to be unclean. Resident 19’s wheelchair had food debris on the legs, foot pedals, and cushion, and later had food debris and blue foam padding attached with cloth tape. Resident 43’s wheelchair had debris on the legs and wheels, and the cushion had white splatter and later brown matter. Staff stated nursing assistants were responsible for cleaning wheelchairs, and the administrator stated they should be cleaned nightly for dignity and infection control. The report also noted other environmental concerns, including a room with damaged drywall and a persistent urine or sour musty odor in parts of the facility.
Resident Rights Not Periodically Reviewed or Readily Accessible
Penalty
Summary
The facility failed to periodically review resident rights with residents during their stay for 4 of 5 sampled residents interviewed during a Resident Council meeting. During the meeting, Resident 38 stated residents were only given a copy of their rights if they asked for them, while Residents 21 and 46 said they did not remember ever being offered information on resident rights or having discussions about their rights. Resident 34 stated they were unable to exercise their rights if they did not know what their rights were, and the residents confirmed they had not seen posted information related to resident rights. Review of Resident Council minutes showed that on 06/23/2025, nine residents attended and copies of the Resident [NAME] of Rights were given to new residents, but the minutes did not identify which residents received them and did not document that the rights were discussed with all residents. On 07/28/2025, five residents attended and there was no documentation that resident rights were discussed or copies were provided. On 08/25/2025, six residents attended and three residents received a copy of the Resident [NAME] of Rights, but there was no documentation that the rights were discussed or reviewed with all residents. A poster titled, Know Your Rights, with an attached binder and laminated sheets was observed posted high on the wall next to the dining room, and it was not at a level readable or accessible for residents using wheelchairs. Staff stated residents were notified of their rights on admission and that resident rights should be reviewed and discussed periodically with all residents.
Resident Rights Notice Not Readily Accessible
Penalty
Summary
The facility failed to ensure that contact information for all pertinent State regulatory and advocacy groups was provided and posted in a format and at a level that residents could read and access. During a Resident Council meeting, Residents 21, 34, 38, and 46 stated they had not been informed or did not remember being informed how to contact the State Agency if they had concerns about their care. Residents 21, 38, and 46 used wheelchairs, and the poster with the contact information was observed mounted high on the wall next to the main dining room rather than at a readable or accessible level for residents in wheelchairs. The poster, titled "We Care about Your Concerns," included contact information for the State regulatory agency and advocacy groups, but it was not positioned at eye level for wheelchair users. During the same observation, Residents 21 and 46 were shown the poster and given an information sheet with the contact details, while Residents 38 and 34 were asleep in their rooms and the information sheet was left on their bedside tables. The Administrator later acknowledged that the poster was not at eye level for residents who used wheelchairs and stated it would be moved.
Survey Results Binder Not Clearly Posted or Known
Penalty
Summary
The facility failed to ensure residents and visitors were informed of the location of the State Recertification Survey results binder, and 4 of 5 sampled residents (Residents 21, 34, 38, and 46) stated during a Resident Council meeting that they had never seen the binder and did not know where it was located. A binder containing the State Recertification Survey results was later observed in a plastic holder on the wall beneath framed facility license documents in the area that had previously served as the lobby and main entrance. During interviews, the Life Enrichment Director stated the binder was discussed sometimes during Resident Council meetings, and the Administrator stated there was a notice at the facility entrance indicating the survey binder was in the administrative lobby; however, no such notice was observed in the lobby area after the interview.
Failure to Notify Ombudsman of Resident Transfers and Discharges
Penalty
Summary
The facility failed to provide residents and/or their representatives with written notice that included the reason for transfer or discharge and failed to send a copy of the notice to the Office of the State Long-Term Care Ombudsman for 2 of 3 sampled residents reviewed for discharges. For Resident 2, the discharge assessment documented discharge from the facility to the community with return not anticipated, and nursing progress notes documented that the resident left the facility against medical advice. There was no documentation that the Ombudsman was notified of the discharge, and both the Social Service Director and the Administrator were unable to find documentation showing that the required notification had been sent. For Resident 86, the admission assessment documented diagnoses including failure to thrive and end-stage kidney disease dependent on dialysis, and the resident was cognitively intact. Nursing progress notes documented that the resident was sent to the hospital emergency room from the dialysis provider related to low blood pressure. There was no documentation that the Ombudsman was notified of the hospital transfer. Review of hospitalizations over the previous four months showed 43 resident transfers to the hospital, and no documentation was provided to show the Ombudsman was notified of those transfers. Staff interviews showed uncertainty about who was responsible for the notifications, and the Ombudsman stated they were not notified of hospital transfers.
Failure to Hold Required Care Conferences and Include Resident Participation
Penalty
Summary
The facility failed to complete interdisciplinary team care planning conferences within the required timeframes and failed to ensure resident and/or resident representative participation in development, review, and revision of the plan of care for 9 of 9 sampled residents reviewed for care conferences. The facility policy titled, Care Conferences, stated care conferences were to be scheduled upon admission, quarterly, with significant changes of condition, and as requested, and that the resident and resident representative were to be notified and the meeting documented in the medical record. The cited regulation was WAC 388-97-1020 (2)(f), (4)(b). Resident 9 had dementia with psychotic disturbance and a guardian for medical decisions. The resident stated staff did what they wanted and did not tell them anything about their plan of care. The record showed a care conference note from 07/19/2024 documenting the resident did not participate but the guardian did, and there was no documentation that quarterly care conferences occurred after that date. No additional care conference documentation was provided when requested. Resident 27 had diabetes and depression and stated they had never had a care conference. The record showed a care conference evaluation note from 07/09/2024 documenting attendance, but no documentation of quarterly care conferences after that. Resident 44 was cognitively intact and had a 06/18/2024 care conference evaluation showing the resident representative, social services, and nurse manager attended, but nutrition services was not documented as present and no quarterly care conferences were documented afterward. Resident 43, Resident 41, Resident 48, Resident 5, Resident 7, and Resident 63 also had records showing either only an initial or prior care conference, blank invitation fields on quarterly social service evaluations, or no documentation that quarterly care conferences or care planning meetings occurred, and several residents stated they had not been informed or had never had a care conference. Staff C, Social Service Director, and Staff B, DON, acknowledged care conferences were not being held quarterly.
Restorative ROM and Walking Programs Not Consistently Implemented
Penalty
Summary
The facility failed to implement and oversee a comprehensive restorative nursing program for three residents who had documented range of motion and mobility needs. The deficiency involved Resident 44, who had a stroke with weakness on one side of the body, a left-hand contracture, and functional ROM limitations in one arm and leg; Resident 43, who had a non-traumatic brain injury and was on a walking maintenance program after discharge from skilled therapy; and Resident 19, who had dementia, failure to thrive, malnutrition, and functional ROM limitations in all extremities. For Resident 44, the care plan required gentle PROM stretching to the joints in the left arm and leg with participation documented, but the restorative documentation repeatedly showed entries of response not required, not applicable, or zero across many months. Quarterly restorative evaluations also showed that PROM was seldomly conducted due to staffing, that the program was reassigned to a nursing assistant, and later that PROM was again seldomly conducted with recent functional decline and increased falls. Therapy was then requested, and a restorative walking maintenance program was implemented after physical therapy. For Resident 43, the care plan required walking to and from the shower room up to 150 feet two to three times weekly with participation documented, but the monthly documentation showed multiple entries of response not required or not applicable and inconsistent completion of the walking program. For Resident 19, the care plan required gentle PROM stretching to the knees with each lower-extremity dressing or toileting need, but the documentation showed the program did not occur and was marked not applicable many times. Staff interviews showed confusion about who was responsible for the restorative programs, with some staff stating restorative aides did the programs, others stating nursing assistants on the floor did them, and the restorative RN stating the programs should have been conducted as written and documentation should never show that the program did not occur. An observation of Resident 19 showed knee ROM measured at 78 degrees on the right knee, not the 80 degrees specified in the care plan.
Medication Administration Not Consistent With Provider Orders
Penalty
Summary
The facility failed to administer medications according to provider orders for 3 residents reviewed for unnecessary medications. The deficiency involved blood pressure medications and, for one resident, lidocaine patches. The record review and staff interviews showed multiple instances where medications were given when hold parameters were met, held when they should have been administered, or administered without required vital signs being obtained first. For one resident with dementia, high blood pressure, and heart failure, the record showed an order for Losartan 100 mg each morning with instructions to hold the medication if systolic blood pressure was below 110. The MAR documented that Losartan was given when the blood pressure was 108/61, and it was held on other occasions when the blood pressure readings were 116/79 and 113/53. Staff stated that medication parameters were displayed on the MAR and that the medication should not be given outside those parameters. The DON reviewed the MAR and stated the medication was not given according to the provider order and staff needed to follow the parameters closely. For another resident with heart failure and high blood pressure, the orders included Amlodipine 5 mg twice daily and Metoprolol Succinate 25 mg daily, both with hold parameters for systolic blood pressure below 110 and heart rate below 60. The MAR showed multiple administrations of these medications without blood pressure and pulse being obtained, as well as administrations when the documented blood pressure or pulse was below the ordered parameters. The record also showed several instances where the medications were not given when the documented vital signs were within the ordered parameters. Staff interviews reflected that blood pressure medications should be held when parameters were not met and that the medications should have been given as ordered. For the third resident, who had a stroke and high blood pressure, the orders included Amlodipine 10 mg daily and Hydralazine 50 mg three times daily with hold parameters for systolic blood pressure below 120 and heart rate below 60, along with Lidocaine patches for pain. The MAR showed blood pressure medications given when the pulse was 54, when systolic blood pressure was 112, 109, 117, 118, 101, and 55, and several doses were also documented with X or NA entries and no vital signs found. The MAR also showed Lidocaine patch documentation entries marked NA on multiple dates. Staff stated the blood pressure medications should have been held when parameters were not met and that the Lidocaine patches should have been administered as ordered.
QAPI Committee Lacked Evidence of Medical Director Participation
Penalty
Summary
The facility failed to provide evidence that the Medical Director received and reviewed the content of QAPI meetings when not present, and failed to show that the Medical Director communicated with and participated in the QAPI process as required. Facility policy stated the QAA/QAPI committee was to coordinate and evaluate activities under the QAPI program and review multiple sources of data, including QAPI minutes, incident reports, grievance logs, survey results, staff turnover, satisfaction data, infection control, and quality measure triggers. The QAPI plan also stated QAA members were responsible for reviewing data and input from residents, staff, family members, and other stakeholders, and for determining PIPs, correcting issues, monitoring progress, and providing input. During interviews, the Administrator stated the QAPI team included the QAA team and department heads, including the Medical Director, and met quarterly. The Administrator later stated QAPI data had been uploaded to a cloud platform since May 2025 and committee members had access to it, but no evidence was provided that members reviewed the uploaded data. The Administrator acknowledged the Medical Director did not attend QAA meetings in December 2024, February 2025, May 2025, or August 2025, and stated it was important for the Medical Director to attend to provide input and be aware of failed practices. Sign-in sheets provided for 08/29/2024 and 12/04/2024 did not show the Medical Director’s signature, and the facility reported the sheets for February or March 2025 were misplaced. When asked about the Medical Director’s last involvement with QAPI by any method, the Administrator acknowledged Staff PP attended the February 2025 meeting, approximately 7 months earlier, and no further documentation was provided.
Incomplete Effective Communication Training for Direct Care Staff
Penalty
Summary
The facility failed to ensure direct care staff received training on effective communication, as required. Review of the staff list showed the facility employed 89 direct care staff, but documentation provided after the training request showed only 8 of the 89 direct care staff had completed effective communication training. In interviews, a Nursing Assistant and an LPN stated that if they had received this training, it would be documented in the electronic training records. The Administrator stated that effective communication training was new to the facility this year, was scheduled to begin in November 2025, and acknowledged that staff had not received the training, while also stating the facility expected staff to receive it as required.
Failure to Train All Staff on QAPI Program
Penalty
Summary
Mandatory training on the facility’s Quality Assurance and Performance Improvement (QAPI) program was not provided to all staff. During record review, the staff list given to surveyors on 09/03/2025 showed the facility employed 109 staff, and when QAPI training records were requested from the Administrator on 09/15/2025, no documentation was provided. In interviews, a Nursing Assistant, Receptionist, Maintenance Assistant, Housekeeping Manager, and LPN gave inconsistent responses about QAPI training or stated they would expect it to be documented in electronic training records, while the Receptionist stated, "I don't know what QAPI is. Should I know what that is?" The Administrator acknowledged that all staff had not received QAPI training and stated they expected staff to receive the training as required.
Failure to Provide Consistent ADL Assistance for Bathing, Nail Care, and Eating
Penalty
Summary
The facility failed to consistently provide assistance with bathing, nail care, and eating for dependent residents. Surveyors observed multiple residents with long, dirty, or untrimmed fingernails, missed or inconsistent bathing, and residents who were not assisted during meals despite needing help with eating and hygiene. The report identified failures for Residents 5, 7, 17, 19, 29, 43, and 48, all of whom had care plans or assessments showing they needed staff assistance with ADLs. Resident 29 was cognitively intact and had diagnoses including stroke and diabetes. The quarterly assessment documented that the resident needed nursing assistance with personal hygiene, including nail care, and the care plan stated the resident’s nails were to be cleaned as needed and trimmed by the nurse. Surveyors repeatedly observed the resident with long fingernails and black debris underneath them while the resident was in bed eating snacks. The nail care record showed diabetic nail care was documented weekly, but all nail care during the reviewed period was charted as refused. The resident told surveyors they did not refuse nail care and said they liked their nails short, though long enough to open soda cans. Staff stated the resident consistently refused nail care and that refusals were communicated in the book, but the communication book contained only two entries related to nail care refusal during the review period. Resident 48 was cognitively intact, had a stroke diagnosis, and required moderate assistance with personal hygiene. Surveyors observed the resident eating with their hands while lying in bed, with long fingernails and brown matter underneath them on multiple occasions. The care plan addressed bathing, oral care, and dressing, but did not include nail care interventions. The nail care record showed no nail care was provided during the reviewed period and no refusals were documented. Resident 17 had stroke-related paralysis and contractures, was cognitively intact, and required partial assistance with personal hygiene and substantial assistance with bathing. The resident was observed with long, jagged fingernails and dark material under them on several occasions, and the nail care task record showed no nail care was provided and no refusals were documented. Resident 5 required total assistance for bathing and stated they were not getting showers twice weekly, while Resident 43 required assistance with bathing and extensive assistance with nail care and was observed with soiled clothing, body odor, and long nails on multiple occasions. Resident 7 required substantial to maximum assistance for bathing and stated they had gone a long time without a shower and had body odor, while Resident 19, who had severe cognitive impairment and needed assistance with eating, was repeatedly observed eating without staff assistance and with nasal drainage over the meal area.
Delayed Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consents for psychotropic medications before administration for 2 of 5 sampled residents reviewed for unnecessary medications. Resident 27 had diagnoses including depression and was receiving escitalopram daily as ordered after it was prescribed on 04/12/2025, but the informed consent for escitalopram was not completed until 08/27/2025, 45 days after the medication had been prescribed and administered. Staff stated that informed consents for psychotropic medications needed to be obtained when the medication was prescribed and prior to administration, and the Social Services Director confirmed the consent had not been obtained timely. Resident 63 had diagnoses including restlessness and agitation and was receiving daily psychotropic medications. The record showed duloxetine was prescribed to treat depression and quetiapine was prescribed to treat anxiety and restlessness, with the first doses given on 08/08/2025 for duloxetine and 05/30/2025 for quetiapine. The psychoactive medication informed consent was signed after both medications had already been administered, including 12 days after duloxetine was first given and 47 days after quetiapine was first given, and the record did not show additional verbal or written documentation that the resident had been educated about the reason for the medications or their risks and benefits.
Delayed PASARR Completion After Exempted Hospital Stay
Penalty
Summary
The facility failed to ensure a PASARR was completed after an exempted hospital stay ended for Resident 43, who had diagnoses of PTSD and was receiving psychotropic medication. The resident’s Level I PASARR had been completed and signed by the hospital before admission, but a new Level I PASARR was not completed by the facility until four months and thirteen days after the exempted hospital stay ended. During an interview, the Administrator stated the PASARR needed to be completed after the 30-day stay ended and acknowledged it was not completed timely.
Failure to Provide Proper Foot Care for a High-Risk Resident
Penalty
Summary
The facility failed to ensure proper foot care for Resident 27, who had diabetes and a history of stroke affecting the left side and was fully dependent on staff for bathing, lower-body dressing, and transfers with a mechanical lift. The resident was alert, oriented, and able to make needs known. A podiatry consult documented additional high-risk conditions, including peripheral neuropathy and peripheral vascular disease, and recommended keeping the skin soft with moisturizer to avoid cracks and fissures, with follow-up in two to three months or sooner if needed. The record did not contain other podiatry progress notes or additional podiatry referrals. Surveyors observed Resident 27 on multiple occasions with both feet uncovered and very dry, scaly, and flaky on the bottoms. The resident stated staff did not put anything on their feet, such as lotion. Staff interviews indicated that lotion should be applied when skin was dry or calloused during diabetic foot checks, and the DON stated the resident's feet should have lotion applied regularly. The resident also stated lotion was sometimes applied after showers, but showers occurred only every 12 days or so, and lotion was not applied at other times. The TAR showed weekly diabetic foot checks and diabetic nail care were completed with no omissions, but the resident's feet remained extremely dry and scaly during the observations.
Failure to Assess Safe Smoking Ability
Penalty
Summary
The facility failed to evaluate and assess a resident for safe smoking abilities after becoming aware the resident was smoking, and no smoking assessment was documented in the record. Resident 54 was admitted on 07/17/2025 and was documented as cognitively intact, with diagnoses including nicotine dependence. The admission evaluation form noted the resident had recently quit smoking and had previously smoked a pack of cigarettes a day. The July 2025 MAR showed the physician ordered nicotine patches daily for 15 days beginning 07/12/2025 to help manage nicotine cravings, but the resident refused the patches eight of the 15 days and the order was discontinued on 07/27/2025. Progress notes documented that on 07/25/2025, during a provider visit, the resident stated they planned to go outside and smoke a cigarette, refused nicotine patches, and would continue to smoke. A 09/02/2025 provider note documented the nicotine patches were discontinued because the resident routinely went outside to smoke. On 09/09/2025, the resident was observed smoking a cigarette while being walked on the sidewalk across the street from the facility. The record contained no documentation that a smoking assessment was completed when staff became aware the resident was smoking, and the safety care plan had no interventions or information related to smoking. Staff R stated that if a resident later decided to smoke, a smoking assessment needed to be done, and Staff B confirmed the resident smoked and acknowledged the assessment and care plan update had not been done.
Failure to Address Bowel and Bladder Incontinence
Penalty
Summary
The facility failed to provide care and services necessary to improve bowel and bladder functions for one resident who was reviewed for incontinence care. The resident had diagnoses including back fractures and a stroke with hemiplegia, was able to make needs known, and required total staff assistance for toileting. The quarterly assessment documented that the resident was always incontinent of bowel and bladder and was not on a toileting program. The care plan stated the resident was incontinent of bowel and bladder related to a stroke and directed staff to provide care after each incontinent episode and use incontinence briefs. The bowel and bladder evaluation documented that the resident was not appropriate for a toileting program because of spasticity and inability to sit on the toilet or commode. Flow sheets showed bowel incontinence, care as needed, and use of a bed pan on two occasions, but the medical record did not show that the facility evaluated and developed effective, resident-centered interventions to address the resident's bowel and bladder incontinence. The resident stated staff could transfer them to the toilet with a hoyer lift, that no one had spoken with them about improving incontinence, and that they would be okay with a bed pan but would rather be put on the toilet. Staff stated the resident usually used a brief, was changed after incontinence, and had never been placed on a toileting program; the DON acknowledged the resident should have been placed on a toileting program using the bed pan.
IV Access Maintenance Orders Not Documented or Implemented
Penalty
Summary
Provide for the safe, appropriate administration of IV fluids when needed was not maintained for Resident 35, who had diagnoses of diabetes and osteomyelitis of the spine and was alert, oriented, and able to make needs known. During observation, an IV access was present in the resident’s right chest with an intact transparent dressing over the insertion site, and the dressing was labeled with a smudged date that appeared to be 09/01. The insertion site was without signs of complications at the time of observation. Record review showed the resident received IV antibiotics three times a week since 07/19/2025, with the final ordered dose given on 09/02/2025. The record did not contain documentation of orders for IV site dressing changes or routine saline flushes, and these orders were not implemented until after surveyor inquiry. Staff interviews indicated IV lines were flushed every shift and before and after IV medication, and dressing changes were done weekly, but staff could not locate documentation in the MAR when asked. The DON acknowledged that weekly dressing changes and saline flushes should have been entered as orders and documented when completed, and stated this was missed and was failed practice.
Respiratory equipment not implemented as ordered and not maintained clean
Penalty
Summary
Safe and appropriate respiratory care was not provided for two residents when respiratory equipment was not implemented as ordered and was not maintained in a clean and functional manner. The facility’s oxygen management policy required oxygen to be administered by physician order, oxygen tubing to be changed weekly or when soiled or damaged, and concentrator filters to be cleaned weekly or per manufacturer recommendations. No documentation was found describing how CPAP machines were to be maintained. Resident 27 had diagnoses including diabetes and obstructive sleep apnea and was fully dependent on staff for bathing, repositioning, and transfers. The medical record included an order for CPAP use every night shift, but the MAR showed the CPAP was used on some nights and not used on others. The resident stated multiple times that they did not wear the CPAP every night because they forgot to ask staff, needed staff help to put it on, and staff did not offer or remind them. Observations showed the CPAP lying in the resident’s nightstand drawer and later on the nightstand with no strap on the mask; the resident stated the strap was missing and that they had not used the CPAP because they still did not have a strap to hold the mask in place. Staff B later acknowledged that the CPAP could not have been used as documented because all parts were not available. Resident 43 had diagnoses including heart failure, diabetes, and stroke and was cognitively intact and dependent on supplemental oxygen. The provider ordered oxygen tubing to be changed weekly, and the care plan directed staff to monitor for signs and symptoms of infection. Observations showed the oxygen tubing was dated 17 days earlier than the observation date, and the oxygen concentrator was unclean with white splatter and thick dust debris in the filter area. Similar observations of the dated tubing and unclean concentrator were made repeatedly over multiple days. Staff D stated tubing was changed weekly and concentrators were wiped down nightly and when dirty, and Staff B stated oxygen tubing was changed weekly.
Dialysis Fistula Arm Used for Blood Pressure Checks
Penalty
Summary
Safe, appropriate dialysis care/services were not provided for a resident with a newly created left arm fistula. The resident had diagnoses of diabetes, hypertension, and dialysis-dependent end stage kidney disease, was alert and oriented, and stated they received dialysis three times per week. During observation, an intact incision was seen on the resident’s left arm in the bend of the elbow, and there was no signage in the room indicating that the left arm should not be used for blood draws or blood pressure checks. The record also contained no orders or warnings directing staff not to use the left arm for blood pressure measurements. Staff interviews showed inconsistent understanding of fistula precautions. A nursing assistant stated residents told CNAs which arm to use for blood pressures. The resident stated staff sometimes checked blood pressure on the left arm and that they were unaware it should not be used, only that the right arm gave better readings. An LPN stated it did not matter which arm was used because the facility used a wrist cuff. The DON acknowledged that when a dialysis resident had a fistula, that arm should not be used to obtain blood pressures.
Failure to Provide Behavioral Health Services for Resident with Depression and Pain
Penalty
Summary
The facility failed to ensure that a psychological evaluation was completed and that behavioral health services were offered as recommended for a resident with anxiety, depression, chronic pain, and cognitive intactness. The resident’s admission assessment documented nearly constant pain that interfered with daily activities and sleep, along with a mood score indicating moderate depression symptoms. A Level I PASRR completed in March 2025 identified anxiety and mood disorders and required a Level II evaluation. The Level II behavioral health evaluator documented that the resident had a long history of pain, became verbally aggressive and agitated, and that failure to acknowledge the resident’s pain increased those behaviors. The evaluator determined the resident needed further psychiatric assessment based on behaviors and mood lability and noted the resident was not connected with mental health services. A provider later ordered referral to Behavioral Health Solutions for psychiatric and psychological evaluation and treatment as indicated, and the care plan was updated to include psychiatric consultation and follow-up, but no behavioral health provider progress notes, assessments, or referrals were documented in the resident’s record. During interviews and observations, the resident was repeatedly found lying in a dark room with the window shade closed, reporting constant pain, poor sleep, depression, and frustration about not progressing without hip surgery. The resident became fretful, agitated, tearful, and raised their voice when discussing their condition, and stated that no counseling or services had been offered to help them cope with their pain and emotions. Staff interviews confirmed the resident’s mood fluctuated, they became agitated easily, and the Director of Social Work had not sent a behavioral health referral.
Failure to Follow Pharmacist Medication Review Recommendations
Penalty
Summary
The facility failed to timely act on the pharmacist’s monthly medication regimen review recommendations for one sampled resident who was reviewed for unnecessary medications. The resident had diagnoses including stroke, restlessness, and agitation, and was receiving Seroquel daily under a provider order dated 05/30/2025. The facility policy required the licensed pharmacist to review the medication regimen and report irregularities, with non-urgent recommendations to be completed by the next monthly review. The May 2025 pharmacy medication review noted that the resident was taking Seroquel and recommended orthostatic blood pressures and behavior monitoring. Review of the June and July 2025 medication and treatment administration records showed that orthostatic blood pressures and behavior monitoring were not obtained or implemented as recommended. The resident record contained no documentation explaining why the pharmacy recommendation was not followed. During interview, the DON stated they had not considered orthostatic blood pressures because the resident could not stand, but acknowledged the resident could move from lying to sitting and that behavior monitoring was important to identify changes from baseline.
Medication Storage, Labeling, and Temperature Monitoring Deficiencies
Penalty
Summary
Medication storage and labeling were not maintained in accordance with accepted professional principles in the North medication cart and room. During observation, an insulin lispro pen for one resident was found with an opened date of 08/05/2025, 38 days earlier, despite a note indicating insulin pens should be discarded 30 days after opening. A second lispro insulin pen for another resident had been used, but the opened date was left blank. Staff stated insulin pens should be discarded one month after opening and that, because the open date was unknown on one pen, both observed pens should be discarded. In the North medication storage room, a full bottle of lorazepam 2 mg/ml labeled for Resident 24 was found in an unlocked upper cabinet with discontinued medications. The medication had been discontinued on 02/27/2025, and staff stated it should have been refrigerated and included in the narcotic count, but it was not logged in the current medication book or stored in the locked medication refrigerator. In the TCU medication room, the refrigerator and room temperature log showed the last entry was 09/08/2025, with no readings on 09/07/2024 and only an evening reading on 09/08/2025. Four evening room temperature readings were outside the listed parameters without any explanation in the comments section. The DON stated the temperature logs should be accurate, insulin pens should be discarded 28 days after opening, liquid lorazepam should be stored in the refrigerator and included in the narcotic count, and the discontinued lorazepam should have been destroyed.
Missed Dental Follow-Up Appointments for Two Residents
Penalty
Summary
The facility failed to ensure timely follow-up dental appointments for 2 of 3 sampled residents, Residents 41 and 29, after dental services were provided in the facility. Resident 41’s quarterly assessment documented that the resident was independent with eating and performed oral hygiene with set-up assistance, and was moderately cognitively impaired but able to make needs known. On observation, Resident 41 stated that a dental bridge was broken and that nobody was doing anything to get it repaired, and showed the area where the bridge would be worn. Review of the dental provider’s notes showed Resident 41’s teeth were cleaned and a follow-up appointment was to be scheduled in three months, but the record contained no documentation that the facility had been informed of the broken bridge or that the follow-up appointment had been scheduled. Resident 29’s quarterly assessment documented diagnoses including stroke and diabetes, and that the resident was cognitively intact. The assessment also documented mouth and/or facial pain and difficulty chewing. Resident 29 stated that a referral was supposed to have been made for dental care, but that it had been at least two months ago. The dental provider’s notes for Resident 29 showed teeth were cleaned, no emergent dental needs were identified, a follow-up appointment was to be scheduled in three months, and the facility was asked to refer the resident to a dentist for extraction of tooth root tips. The record contained no documentation that the referral for extractions or the follow-up dental cleaning appointment had been made. Staff interviews showed inconsistent understanding of who was responsible for arranging in-house dental follow-up and outside dental appointments, and Staff C confirmed that neither resident had been highlighted for follow-up on the provider’s census sheet.
Failure to Perform Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to perform hand hygiene when indicated during meal service. During observation on 09/10/2025, Staff HH, a Cook, repeatedly handled meat, vegetables, rolls, oven warmer doors, steamer equipment, and meal tickets with gloved hands while continuing to serve food without performing hand hygiene. Staff HH was observed touching food items and meal tickets multiple times, including sorting meal tickets, handling meat and vegetables, opening the oven warmer and steamer, and serving plates without washing or sanitizing hands between tasks. Staff KK, a Dietary Aide, was also observed placing cold items on meal trays, scratching their head with a bare hand, and then continuing to place plates of food on trays without hand hygiene being performed. In interview, Staff II, Dietary Manager, stated Staff KK should have performed hand hygiene after scratching their head. Staff JJ, Registered Dietician, stated staff needed to use utensils to handle food rather than their hands, and both Staff II and Staff JJ agreed hand hygiene should have been performed after Staff HH touched the oven warmer, steamer, and meal tickets and before serving food. The report states this failure placed residents at risk for foodborne illnesses.
Insufficient Linen Supply and Delayed Response to Laundry Concerns
Penalty
Summary
The governing body failed to ensure the facility had resources to provide residents with an adequate supply of clean linens. Interviews with multiple residents and staff on 09/03/2025, 09/04/2025, 09/08/2025, 09/09/2025, 09/10/2025, 09/12/2025, and 09/15/2025, along with the resident council meeting on 09/05/2025, showed that not having enough bed linens and towels was a frequent issue at the facility. The deficiency affected all residents and was identified during observations, interviews, and record review. The Administrator stated that linen service had already been identified as a problem through the facility's QAPI process and that housekeeping had completed a PIP on the issue. The Administrator also stated that the laundry service had been an ongoing concern since before they became administrator in 2023, with linens and clothing not always returned, items returned stained or wet, and towels smelling of feces. Record review showed repeated communications to the corporate office from 09/14/2024 through 09/03/2025 about these laundry problems, including stained items, clothing returned bagged instead of hung, and requests for assistance or a change in vendor. The Administrator stated that budget-related issues went through the President of Operations and that the response to changing the linen supply process was limited by financial barriers.
Missing Designated Hospice Liaison
Penalty
Summary
The facility failed to identify a designated interdisciplinary team member to serve as the liaison for coordinating care and communication with the hospice provider for 1 of 1 sampled residents receiving hospice services. The 03/30/2022 agreement between the hospice provider and the facility stated that the facility would designate an interdisciplinary team member to work with hospice staff to coordinate care for hospice residents, but the agreement did not identify the staff member, their title, or the department where they worked. The facility policy titled Hospice-Admission, Discharge, Care and Treatment, dated December 2024, also did not document who the designated facility liaison was responsible for collaborating in the development and care of the resident. Resident 61 had diagnoses including dementia and cancer of the pancreas, and the 07/17/2025 comprehensive assessment showed severe cognitive impairment and that the resident was placed on hospice services for end-of-life care. The medical record showed the resident had received hospice services since 07/10/2025. During interviews, nursing assistants stated they were unsure who the hospice liaison was and thought it might be the DON, the Resident Care Manager, or the resident's nurse. The Administrator stated that the Social Services Director handled coordination with hospice providers and acknowledged that the facility policy did not list a team member as a hospice liaison, as required.
Failure to Assist Resident with Toileting Needs
Penalty
Summary
The facility failed to provide necessary care and services to a dependent resident who required assistance with toileting. Resident 1, who was cognitively intact and required extensive assistance for bathroom use, was found by Staff C, an LPN, lying in a urine-soaked bed and clothing. This occurred after the resident returned from the emergency room and was transferred back into bed with a transfer sheet still under them. The resident did not use their call light to request assistance during the night shift, and Staff E, a Nursing Assistant, did not provide any care, assuming the resident did not need help. The facility investigation revealed that Staff D, another LPN assigned to the resident, was not interviewed or followed up with regarding the incident. Staff D's medication administration record showed a code indicating that tasks were not completed. Interviews with the resident and staff indicated that the resident typically received assistance before midnight and in the early morning but did not on this occasion. The Director of Nursing stated that residents should be checked every two hours during the night, and it was the responsibility of the night shift nurse to ensure all ADL tasks were completed by the nursing assistant.
Failure to Update Care Plan for Resident's Eating Assistance Needs
Penalty
Summary
The facility failed to revise and implement a comprehensive care plan for a resident who had specific needs related to their ability to eat. The resident, who was admitted with right-sided hemiplegia and hemiparesis following a stroke, malnutrition, and wounds on their left foot, was documented in the care plan as being able to eat independently. However, progress notes from nursing staff indicated that the resident required assistance with eating, particularly when in bed, due to their inability to raise their left arm high enough and lower their head without pain. This discrepancy between the care plan and the resident's actual needs placed the resident at risk of receiving inappropriate and inadequate care. Interviews with staff revealed that the occupational therapist had verbally communicated the resident's need for assistance when eating in bed to the Resident Care Manager, but this information was not documented in the resident's care plan. Additionally, the care plan did not include the resident's diagnoses of severe osteoarthritis and a torn rotator cuff in the left shoulder, which contributed to their difficulty in feeding themselves while in bed. The lack of updated and accurate information in the care plan failed to provide staff with the necessary guidance to meet the resident's individualized needs and preferences.
Failure to Address Behavioral Health Needs
Penalty
Summary
The facility failed to meet the behavioral health needs of a resident who was identified as having symptoms of moderate depression. Despite a depression screening indicating moderately severe depression symptoms, the facility did not seek mental health services in a timely manner. The resident's medical record showed a history of anxiety, mild dementia, and a stroke, with additional diagnoses including malnutrition and osteomyelitis. The resident exhibited refusals of care, including medication and repositioning, which were documented in nursing progress notes. These refusals were not addressed with person-centered interventions by the interdisciplinary team. The resident's condition deteriorated, with documented weight loss, poor food intake, and worsening wounds. Despite an order for a behavioral health evaluation due to labile behaviors, the facility did not follow through with the evaluation or referral. The resident's care plan was updated to reflect resistive behaviors but lacked interventions for the diagnosed mild dementia, positive depression screen, or the ordered mental health evaluation. Interviews with staff revealed a lack of awareness and communication regarding the need for a behavioral health evaluation. The resident's family expressed concerns about the resident's physical and mental decline, leading to a request for hospital evaluation. The facility's failure to address the resident's behavioral health needs and implement appropriate interventions contributed to the resident's declining condition and quality of life. The lack of timely mental health services and communication among staff and with the resident's family were significant factors in the deficiency.
Failure to Follow Up on Dental Services for Resident
Penalty
Summary
The facility failed to follow up on necessary dental services for a resident who had ill-fitting dentures causing an open sore. The resident, who was admitted with conditions including right-sided weakness and paralysis after a stroke, severe malnutrition, dysphagia, and chronic ulcers, complained of mouth pain and refused to remove their upper denture. A dental appointment was initially scheduled but was canceled and rescheduled. A dental exam revealed an open sore and the need for a denture adjustment, but no further documentation was found regarding the adjustment or monitoring of the sore. Interviews with staff revealed that a request for a denturist appointment was made, but there was no follow-up on the request. The Director of Nursing confirmed the lack of follow-up, and the Administrator acknowledged that the appointment was not pursued further. The resident was eventually discharged to the hospital, and the staff member responsible for the follow-up was no longer employed at the facility.
Failure to Address Substance Use Disorders in Resident Care Plans
Penalty
Summary
The facility failed to identify, evaluate, and implement safety interventions for residents with substance use disorders, leading to potential accident hazards. Resident 1 was admitted with a diagnosis of COVID-19 and an unspecified alcohol-induced disorder, yet their care plan did not include interventions for substance use disorder. This oversight resulted in an incident where Resident 1 was found intoxicated after a fall, with a blood alcohol level of 297 mg/dL, necessitating hospitalization for observation. Similarly, Resident 2, admitted with ankylosing spondylitis and opioid dependence, did not have a care plan addressing their substance use disorder. The facility did not identify or analyze risks associated with their condition, nor were any safety interventions implemented. During an interview, the facility's administrator acknowledged the need for care planning and monitoring for residents with substance use disorders, but this was not reflected in the care plans of the affected residents.
Neglect of Resident's Incontinence and Hygiene Needs
Penalty
Summary
The facility failed to protect a resident from neglect, specifically in addressing concerns related to incontinence and personal hygiene. The resident, who was admitted with diagnoses of Wernicke's Encephalopathy and adult failure to thrive, was found by family members to be frequently naked, wet with urine, and surrounded by urine-soaked bedding and floors. Despite these observations, the facility did not document or address these issues adequately, leading to the resident's removal from the facility against medical advice. Interviews with staff revealed that the concerns were known but not properly communicated or documented. Staff C, the Resident Care Manager, and Staff D, the Social Services Director, were aware of the family's complaints but failed to escalate the issue to the facility Administrator or discuss it in the Interdisciplinary Team meetings. Staff C admitted to witnessing the unsanitary conditions but did not create any documentation or implement effective interventions. The facility's lack of response to the family's repeated concerns and the absence of a documented care plan to address the resident's incontinence and hygiene needs contributed to the neglect. The Administrator was unaware of the situation until after the resident's removal, indicating a breakdown in communication and oversight within the facility's management structure.
Failure to Report Allegations of Neglect
Penalty
Summary
The facility failed to report allegations of potential neglect to the State Agency immediately as required, concerning a resident who left the facility Against Medical Advice (AMA). The resident's family had raised concerns during a care conference that the resident was always naked, not dressed, and had urine everywhere. Despite being aware of these concerns on several occasions, including during a care conference, the Social Services Director and the Resident Care Manager did not report the concerns to the Administrator or the State Agency. The Director of Nursing was informed, but no report was made to the State Agency. A record review confirmed that no report of possible neglect was submitted by the facility regarding the care of the resident.
Failure to Follow COVID-19 Precautions and PPE Protocols
Penalty
Summary
The facility failed to adhere to quarantine and isolation precautions during a COVID-19 outbreak, affecting four out of five residents and involving improper use of personal protective equipment (PPE) by one staff member. Observations revealed that residents with current COVID-19 infections had their room doors open, contrary to CDC guidelines that require doors to be closed if safe. Specifically, two residents with Aerosol Precaution signs had their doors wide open, with no documented safety reasons for this. Additionally, a staff member was observed in a quarantine room wearing only a surgical mask instead of the required N95 respirator, eye protection, gown, and gloves, while interacting with a resident who was not wearing any PPE. Interviews with staff members highlighted a lack of communication and documentation regarding quarantine precautions. A physical therapy assistant was unaware of the need for PPE when working with a resident in a quarantine room, and a registered nurse confirmed the absence of precaution orders in the electronic medical records for the involved residents. The facility's administrator and director of nursing acknowledged the need for closed doors for COVID-19 positive residents and confirmed that quarantine precautions should be documented in the residents' care plans and electronic health records.
Failure to Notify Medical Provider of Resident's Condition Change
Penalty
Summary
The facility failed to assess and respond to a change in condition for a resident, leading to a deficiency in quality of care. The resident, who had diagnoses of end-stage renal disease, diabetes, and seizures, was admitted to the facility and was on a medication regimen to prevent seizure activity. The resident tested positive for COVID-19 and experienced vomiting and a seizure, but the medical provider was not notified in a timely manner. Staff interviews revealed that the resident had vomited and missed doses of seizure medication, but this information was not communicated to the medical provider or documented in the provider medical book. Staff E, a Resident Care Manager, noted that they were unaware of the resident's vomiting and missed medication until after the resident had a seizure and was transported to the hospital. Staff D, another Resident Care Manager, also stated they were not informed of the resident's condition changes and missed medication doses. The Nurse Practitioner confirmed they were not notified of the resident's vomiting and missed medication, which should have prompted a notification to the medical provider. This lack of communication and documentation placed the resident at risk for medical complications and unmet care needs.
Inadequate Discharge Planning Leads to Unsafe Discharges
Penalty
Summary
The facility failed to implement an effective discharge planning process for three residents, leading to unsafe discharges and unmet care needs. Resident 4 was admitted with urinary retention and an indwelling catheter, requiring a urologist appointment for further management. Despite the resident's condition and the need for follow-up, the facility discharged Resident 4 without proper documentation of their urinary status or a provider order for discharge. Additionally, the resident's report of feeling feverish on the day of discharge was not communicated to the receiving facility. Resident 1, who had severe cognitive impairment and a history of substance abuse, left the facility against medical advice (AMA) multiple times. The facility failed to adequately monitor and manage the resident's behaviors, including drug use and elopement. The AMA discharge form was not properly completed, lacking the resident's signature and documentation of the risks associated with leaving the facility. Resident 5, who was cognitively intact and independent with activities of daily living, chose to discharge AMA due to boredom and restlessness. The facility did not document any discharge barriers or provide adequate education on the risks of leaving AMA. The AMA form was incomplete, missing information on potential complications and the facility's release from liability. The facility's failure to properly assess and document discharge needs and plans resulted in unsafe discharges for all three residents.
Failure to Address Substance Use and Elopement Risks
Penalty
Summary
The facility failed to identify, evaluate, and implement safety interventions for residents with substance use disorders, leading to potential risks of elopement and substance use within the facility. Resident 1, with severe cognitive impairment and a history of substance abuse, was admitted with a desire to leave the facility and exhibited exit-seeking behavior. Despite being identified as at risk for elopement, the baseline care plan did not address these risks adequately. Resident 1 frequently left the facility without staff knowledge, was found with drug paraphernalia, and exhibited signs of substance use, yet interventions were not effectively implemented to mitigate these risks. Resident 2, admitted with a history of psychoactive substance abuse and other medical conditions, was initially unresponsive and dependent on staff for activities of daily living. However, as Resident 2's condition improved, the care plan failed to address the risk of elopement or substance use within the facility. The assessments and care plans were incomplete, lacking critical information on substance use disorder and elopement risk, leaving Resident 2 vulnerable to potential hazards. Resident 3, with moderate cognitive impairment and a history of alcohol abuse, was identified as at risk for elopement and had a wanderguard bracelet placed. However, the care plan did not address the substance use disorder or the risk of substance use while in the facility. The facility's staff, including nursing assistants and social service directors, were unsure of the processes for dealing with substance use emergencies and were not adequately trained to recognize signs of substance use, contributing to the facility's failure to provide a safe environment for residents with substance use disorders.
Deficiency in Urinary Catheter Management
Penalty
Summary
The facility failed to accurately assess and manage the urinary status of a resident, identified as Resident 4, who was admitted with an indwelling urinary catheter due to acute urinary retention. The facility's policy required a comprehensive assessment and medical justification for the continued use of an indwelling catheter, which was not adequately followed. Resident 4's medical records showed inconsistencies in catheter care documentation, with omissions noted on specific dates, and a lack of a urinary toileting program attempt despite the resident's ability to perform most activities of daily living independently. Resident 4 was admitted to the facility with a history of urinary tract infections and acute cystitis, and had a urinary catheter placed in the hospital due to urinary retention. Despite the hospital's discharge orders for continued catheter use until a urologist could evaluate the situation, the facility did not ensure a follow-up appointment with a urologist was scheduled. Furthermore, the facility's nursing staff canceled the urologist consult without proper documentation or provider orders, and Resident 4 was discharged back to their previous living setting with the catheter still in place. Interviews with facility staff revealed a lack of clarity and communication regarding Resident 4's catheter management. Staff members were unable to locate provider orders for catheter discontinuation or urologist consultation, and there was no documentation of monitoring for urinary retention or routine catheter care. The Director of Nursing acknowledged the oversight in monitoring and follow-up, and the facility's failure to adhere to its own policies and procedures for catheter management and resident assessment.
Failure to Schedule Dental Appointment for Resident
Penalty
Summary
The facility failed to schedule a necessary dental appointment for a resident, identified as Resident 59, who was experiencing ongoing mouth pain. The resident was cognitively intact and capable of making decisions regarding their care, with a diagnosis that included cavities. A dental care plan dated January 2, 2024, indicated that Resident 59 had broken teeth and required nursing staff to coordinate dental care arrangements. A dental visit on May 15, 2024, documented that the resident requested to have all their teeth extracted due to pain, and several teeth were extracted during that visit. However, a referral for the extraction of the remaining teeth was not documented, nor was there any evidence that the remaining teeth had been extracted. Interviews with the resident and staff revealed that the resident had communicated their need for a dental appointment to have their teeth extracted, but the appointment was not scheduled. The resident reported severe pain, rating it a 10 on a scale of 1-10, and continued to experience significant discomfort. Staff J, responsible for making appointments and arranging transportation, acknowledged that the appointment request had been missed. Staff I and the Director of Nursing confirmed that an appointment should have been made for the resident, indicating a lapse in the facility's coordination of necessary dental services.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility failed to ensure that physician visits were conducted every 30 days for the first three months after admission and then every 60 days as required for eight of the fourteen sampled residents. This deficiency was identified through interviews and record reviews, revealing that several residents did not have documented physician visits within the required timeframes. For instance, Resident 12, who was admitted with depression and stroke, had no physician visits documented in their Electronic Medical Record (EMR). Similarly, Resident 21, with diagnoses including diabetes and depression, had no physician visit notes during their five months in the facility. Other residents, such as Resident 15, Resident 24, and Resident 42, also experienced significant gaps between physician visits, exceeding the mandated intervals. The facility's Executive Director and Medical Records staff acknowledged the issue, noting that the facility had recently switched to a new provider group, which may have contributed to the lack of proper tracking and documentation of physician visits. The staff were unsure of the follow-up procedures if a resident was not seen, indicating a lapse in the system to ensure compliance with the required visit schedule.
Medication Administration Failures in LTC Facility
Penalty
Summary
The facility failed to ensure that residents received their medications as ordered, leading to significant medication errors for three residents. Resident 42, who had diagnoses including end-stage kidney disease, seizures, and diabetes, missed multiple doses of medications such as levetiracetam, Advair, erythromycin, and others due to unavailability or absence during dialysis appointments. The staff did not coordinate medication administration times with dialysis schedules, resulting in missed doses when the resident was out of the facility. Resident 36, also requiring dialysis, missed doses of several medications including acetaminophen, atorvastatin, apixaban, and others. These omissions occurred on days when the resident was at dialysis, and the facility did not send medications with the resident or adjust administration times to accommodate the dialysis schedule. This lack of coordination and planning led to repeated medication omissions. Resident 80, who had recently undergone oral surgery, experienced a delay in receiving an antibiotic prescribed to prevent infection. The facility did not obtain the medication until three days after the surgery due to communication issues with the oral surgeon's office. Staff failed to promptly secure the necessary orders and medication, which could have been addressed by contacting the facility's provider for immediate assistance.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to ensure proper hand hygiene and use of personal protective equipment (PPE) during medication administration and wound care, as well as failed to implement Enhanced Barrier Precautions (EBP) for residents at risk of infection. During a medication pass observation, Staff F, an Infection Preventionist/Registered Nurse, did not perform hand hygiene or wear gloves while administering insulin to Resident 78, who required assistance with activities of daily living due to diabetes. This oversight was contrary to the facility's hand hygiene policy, which mandates handwashing before handling medications and after contact with a resident's skin. Resident 12, who was colonized with MRSA and had weeping leg wounds, was not placed on EBP, despite the risk of infection transmission. The resident expressed concerns about their MRSA status and the lack of precautions taken. Observations revealed that Resident 12's room lacked signage and PPE supplies necessary for EBP, and the resident's soiled stockings indicated inadequate infection control measures. Staff interviews confirmed that Resident 12 should have been on EBP due to their draining wounds, but this was not implemented. Resident 17, who had pressure sores and was on EBP, did not receive care in accordance with these precautions. Staff EE and Staff FF provided personal and wound care without wearing the required PPE, despite the presence of an EBP sign outside the resident's room. Staff interviews revealed a lack of awareness and understanding of EBP requirements, leading to non-compliance with infection control protocols. Additionally, the facility's water management plan was outdated and inadequately maintained, with missing test results and unclear procedures, further compromising resident safety.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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 Spokane
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sunshine Health & Rehab | 0.6 mi | ★★★★★ | 13 | 0 |
| Sullivan Park Care Center | 2.3 mi | ★★★★★ | 0 | 0 |
| Alderwood Manor | 4.7 mi | ★★★★★ | 24 | 0 |
| Spokane Valley Health And Rehabilitation Of Cascad | 5.2 mi | ★★★★★ | 26 | 0 |
| Touchmark On South Hill Nursing | 5.9 mi | — | 0 | 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.