Above average — CMS composite of the measures below.
The next survey window likely opens around October 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 Avalon Care Center Federal Way, L.l.c. during CMS and state inspections, most recent first.
Failure to follow and clarify physician orders affected multiple residents. A resident on hospice continued to receive an antianxiety medication after hospice ended, another resident had unclear BP and behavior monitoring orders, and a third resident had overlapping pain medication parameters. Staff also applied pain patches to the wrong site, gave pain medication when pain was documented as zero, and administered pain and BP medications outside ordered parameters. DON and unit staff stated the orders should have been followed or clarified.
Medication administration errors exceeded the allowed rate after surveyors observed 6 errors in 32 medications for 3 residents. An RN gave the wrong Vitamin D3 dose and failed to administer a prescribed pain patch, another RN applied too few pain patches and placed them in the wrong location, and an LPN gave eye drops to both eyes instead of one, administered the wrong supplement dose, and applied a pain patch without clarifying an incomplete order.
Staff failed to follow posted TBP and EBP instructions and did not consistently perform hand hygiene during medication administration. A CNA entered a resident’s contact precaution room multiple times without PPE, staff entered other contact precaution rooms without gowns and gloves, an RN provided IV and feeding tube care without following the posted gown/glove directions, and an RN preparing medications did not perform hand hygiene before, during, or after resident care activities as expected by the DON.
A resident with multiple complex diagnoses and SMI was identified through PASRR as needing a Level II eval, and the eval was completed with recommendations for the resident’s plan of care. However, the resident’s comprehensive care plan did not include the Level II recommendations months later, and the Social Services Director confirmed they were not incorporated as expected.
Care plans were not kept current for three residents. One resident’s plan still listed mobility bars, wheelchair-related needs, and pressure-ulcer prevention items that no longer matched the resident’s condition, another resident’s falls and dental care plans did not reflect documented interventions or broken teeth, and a third resident’s digestive disorder plan called for small frequent meals even though staff continued serving regular meals.
Failure to support resident communication needs: Two residents had documented language and hearing barriers, but staff did not consistently provide interpreter services or hearing assistance. One resident preferred Spanish and had difficulty understanding staff, while another resident had broken hearing aids, no hearing devices in the room, and repeatedly asked staff to repeat themselves. Staff reported relying on gestures, pointing, speaking louder, or figuring out what the resident needed without consistent use of the available communication supports.
Staff failed to provide needed ADL assistance with bathing, nail care, shaving, and personal hygiene for multiple dependent residents. Observations showed long fingernails with debris and long facial hair, while records and staff interviews confirmed that residents required assistance and that refusals were not consistently documented when care was not completed.
Activity programming did not meet the individual needs of two residents. One resident with mood disorder, respiratory failure, and weakness had documented interests in books, newspapers, religious services, music, and going outside, but activity documentation was minimal and observations showed the resident in bed with the TV off and no leisure items in use. Another resident with no memory impairment had care plan directions for posted schedules, invitations to activities, and leisure materials, yet was observed with no reading materials or music, and activity participation and refusals were inconsistently documented.
The facility failed to provide restorative and functional maintenance services for two residents with limited ROM and mobility. One resident with slight memory impairment, muscle weakness, and limited ROM to both legs had a care plan for daily gentle ROM, but there was no documentation that ROM was provided and the resident said staff had not discussed exercises in over a month. Another resident with generalized muscle weakness, paralysis, and dependence for mobility had a care plan for daily active ROM during care, but no documentation showed it was completed; the DON stated the facility did not have designated restorative staff and expected CNAs to provide and document the ROM.
Failure to follow feeding tube orders was identified for a resident with dysphagia who depended on a GT for most calories. An RN gave more water than ordered, did not check tube placement or residuals, did not assess for intolerance, and delayed the scheduled enteral formula by several hours instead of giving it at the ordered time.
Failure to implement pharmacy recommendations for two residents. One resident with recent orthopedic surgery continued receiving Vitamin D3 50,000 units daily even after a pharmacist review, lab result, and signed MD order indicated the dose should change based on the vitamin D level. Another resident with fractures and brittle bones had a pharmacist review recommending calcium and iron be separated from other meds for absorption, but the completed report was not in the chart and the supplements remained scheduled with other meds.
Surveyors found expired and improperly labeled medications in the West Station med room and West 2 med cart. An expired medication for itching and nine expired IV meds were present in storage, and several opened multi-dose injectable meds used to treat a blood sugar disorder lacked open dates or had an illegible open date. Staff confirmed the expired meds should have been discarded and that open dates were needed to determine when multi-dose meds should be discarded.
The facility failed to assess and obtain consent for bed rail use for two residents, leading to one resident sustaining an injury. Despite expectations for assessments and consents, these were not completed, placing residents at risk.
The facility failed to implement an effective Antibiotic Stewardship Program, resulting in inappropriate antibiotic use for six residents. The facility did not maintain accurate documentation or assessments using McGeer's and Loeb's criteria, and specific deficiencies were noted for each resident. The Infection Preventionist acknowledged the lack of up-to-date documentation and assessments due to workload challenges.
The facility failed to provide required written notices to residents and their representatives at the time of transfer or discharge to an acute care hospital. This deficiency was identified for several residents who were transferred to hospitals on various dates. The facility's administrator acknowledged the absence of a process for written transfer notifications, resulting in the failure to provide these notifications.
The facility failed to update care plans for several residents, leading to discrepancies between documented care and actual resident needs. One resident's care plan inaccurately listed a pressure ulcer location, while another's included unnecessary IV monitoring instructions. A third resident's plan contained conflicting information about their transfer abilities. Additionally, a resident receiving hospice care had no related goals or interventions in their care plan, and another resident's preference for bed positioning was not reflected in their plan.
The facility failed to provide restorative nursing programs (RNP) for several residents with limited range of motion (ROM) and mobility, as required by their care plans. Residents, including those with functional limitations and medical conditions such as amputations and strokes, did not receive necessary exercises and assistance to maintain or improve their functioning. The facility lacked dedicated staff for RNPs, expecting CNAs to incorporate these duties into their ADL care, leading to inadequate documentation and implementation of RNPs.
The facility failed to ensure sanitary conditions in food handling and storage. Staff did not perform proper hand hygiene while preparing meals, and the dishwasher machine was not maintained correctly, with ineffective chlorine tests and incorrect temperature documentation. Additionally, unit refrigerators contained unlabeled and expired food items, contrary to facility policy.
The facility failed to maintain an effective infection prevention and control program, with staff not consistently performing hand hygiene or using PPE as required. There was also a lack of interventions to prevent Legionnaires' disease, and no documentation of infection surveillance using McGeer's or Loeb's criteria for residents on antibiotics. These deficiencies placed residents and staff at risk for infections and antibiotic resistance.
The facility failed to inform two residents or their representatives about the risks and benefits of psychotropic medications and did not obtain consent before administration. One resident with schizophrenia, anxiety, and depression received medications without documented consent, while another with dementia received antipsychotic medication without documented discussion of risks and benefits with their guardian.
The facility failed to ensure two residents had appropriate Advanced Directives (AD) and guardianship documentation. One resident had no AD or guardianship despite impaired memory, and another had expired guardianship paperwork with no current documentation. Staff interviews confirmed the lack of necessary records, risking residents' rights to have their medical treatment preferences honored.
The facility failed to initiate a grievance process for two residents who reported issues. One resident reported missing personal items after a hospital stay, but no grievance form was completed, and the administrator was unaware of the issue. Another resident reported long call light response times during the night shift, but no grievance form was filled out, and the administrator was not informed. This lack of action prevented prompt investigation of the complaints.
The facility failed to document the communication of necessary information to the receiving health care institution for two residents transferred to an acute care hospital. The facility's policy requires documentation of communicated information, including contact details, care instructions, and care plan goals, to ensure a safe transition. However, no such documentation was found for the transfers of these residents, as confirmed by the Unit Manager.
The facility failed to provide written bed hold notifications to two residents or their representatives during hospital transfers, as required by policy. One resident with impaired memory was hospitalized multiple times without receiving notifications, while another resident with complex medical conditions also did not receive the required notification. Admissions coordinators confirmed the oversight.
A facility failed to complete a Significant Change in Status Assessment (SCSA) within the required timeframe for a resident who was admitted to hospice care due to protein-calorie malnutrition. The SCSA was completed 76 days after the resident's hospice start date, contrary to the requirement for completion within 14 days. The MDS Coordinator acknowledged the oversight.
A facility failed to accurately complete a PASRR assessment for a resident with schizophrenia, anxiety, and major depression, omitting the major depression diagnosis and not conducting a required Level II evaluation. The resident, with moderately impaired cognition and on multiple psychiatric medications, was admitted without a complete assessment, risking inadequate mental health services. The Social Services Director admitted the oversight, acknowledging the need for a review at admission.
The facility failed to meet professional standards of practice, as evidenced by discrepancies in medication administration and documentation for several residents. A resident on a feeding tube received oral medications, another received pain medications without clear parameters, and a third had inaccurate tube feeding documentation. Additionally, a resident's frequent refusal of a laxative was not communicated to the provider.
A resident with impaired memory and unclear speech was not provided with a functional communication system. Despite a care plan indicating the need for evaluation and alternative communication methods, these were not implemented. Staff confirmed the resident was not evaluated for communication needs, and attempts to use a communication binder were unsuccessful and undocumented.
Two residents in an LTC facility did not receive necessary assistance with personal hygiene, including shaving and nail care, despite their care plans indicating dependency on staff. Observations showed one resident with long facial hair and another with long fingernails and facial hair. The DON confirmed the lack of documentation and assistance.
The facility failed to provide necessary care and services to three residents, including not treating or monitoring skin issues for two residents and improperly setting an air mattress for another. One resident had untreated wounds and fungal infection, another did not receive required weekly skin checks, and a third was uncomfortable due to incorrect air mattress settings. Staff interviews confirmed these deficiencies, which were contrary to the facility's policies.
A resident with existing stage 3 pressure ulcers did not receive consistent weekly skin assessments or necessary interventions, such as an air mattress, to prevent new ulcers. Observations showed the resident was often left lying on their back, contrary to care plan instructions. The facility failed to document a new deep tissue injury, and the lack of timely assessments and repositioning contributed to the development of new pressure ulcers.
A resident with impaired thought processes was at risk due to the improper use of a wedge cushion and pillows between the mattress and bed frame, intended to prevent falls. Staff used these devices without assessing their potential to restrain the resident, contrary to facility policy.
The facility failed to obtain informed consent for bed rails for three residents, violating policies and resident rights. Bed rails were used without attempting alternatives, conducting safety assessments, or obtaining consent. Residents were unaware of the bed rails' presence, and staff acknowledged the oversight.
The facility failed to document and implement pharmacist recommendations in a timely manner for three residents, leading to potential risks. A resident's medication regimen reviews were missing from records, another experienced delays in medication adjustments, and a third had unimplemented recommendations due to late receipt of the MRR form.
The facility failed to ensure two residents were free from unnecessary psychotropic medications. One resident received antianxiety medication without a proper stop date, while another was on long-term antianxiety medication without documented rationale or attempts at gradual dose reduction. Staff interviews revealed non-adherence to policies on psychotropic medication management.
A medication error rate of 8% was observed when an LPN failed to ensure a resident consumed all prescribed medications, resulting in two tablets being dropped and unnoticed until a surveyor intervened.
The facility failed to secure medications and biologicals for three residents, leading to potential risks of medication errors. A resident had unsecured skin treatments on a windowsill, another had OTC cough lozenges on a nightstand without a PO, and a third had wound treatment supplies on a dresser. Staff confirmed these items should be stored securely.
Failure to Follow and Clarify Physician Orders and Medication Parameters
Penalty
Summary
The facility failed to ensure services provided met professional standards of practice for 5 of 25 residents reviewed. The report states nursing staff did not clarify and/or follow physician orders and did not follow medication parameters, affecting Residents 11, 82, 69, 13, and 7. The facility policy required staff to verify the correct medication, dose, and rate against the MAR before administration. For Resident 11, who had brain dysfunction, anxiety, memory impairment, and was receiving hospice services, an antianxiety medication order remained on the MAR after hospice discharge and was administered on multiple dates after hospice services had ended. For Resident 82, who had heart failure, depression, and chronic pain, a blood pressure monitoring order lacked parameters for when to notify the provider of abnormal blood pressure, and a behavior monitoring order did not clearly identify what behaviors or interventions were to be documented. For Resident 69, who had fractures and was receiving narcotic pain medications, two pain medication orders both directed administration at a pain level of 6, creating unclear directions for staff. The report also found staff did not follow physician orders during medication administration. For Resident 13, an RN applied pain patches to both shoulders even though the MAR directed application to the chest area only. For Resident 11, pain medication was given when the resident’s pain level was documented as zero. For Resident 7, narcotic and non-narcotic pain medications were administered outside ordered pain parameters, and a blood pressure medication was not held when the resident’s systolic BP or pulse was below the ordered threshold. Staff interviews confirmed the orders were not followed or needed clarification.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5 percent, with surveyors identifying 6 medication administration errors out of 32 medications observed for 3 of 4 residents, resulting in an 18.75% error rate. The facility policy required staff to verify the medication name and dose on the MAR before administration, but observation and record review showed staff did not consistently follow physician orders during medication pass. For Resident 8, Staff G administered Vitamin D3 5,000 units instead of the ordered 50,000-unit capsule and did not offer or administer a prescribed pain-relieving patch during the observed medication pass. For Resident 119, Staff N applied only two pain patches instead of the ordered three and placed them on the right knee area rather than the ordered left lower leg, while documenting the medication as given as ordered. For Resident 120, Staff K administered eye drops to both eyes instead of the ordered left eye only, gave a 200 mg supplement when the order was for 220 mg, and applied a pain patch despite the order lacking a dosage; Staff K stated the order should have been clarified before administration.
Failure to Follow Isolation Precautions and Hand Hygiene Practices
Penalty
Summary
The facility failed to maintain an infection prevention and control program as evidenced by multiple instances where staff did not follow posted precautions and hand hygiene practices. The facility policy stated the infection prevention and control program was to maintain a safe, sanitary, and comfortable environment to prevent the development and transmission of communicable diseases and infections, and that staff were to follow guidance for EBP, TBP, PPE use, and hand hygiene. The policy also stated the facility would monitor proper hand hygiene, PPE use, and infection prevention techniques during direct care, including medication administration. Resident 52 was admitted with a wound infection, received antibiotic medications daily during the assessment period, had an indwelling catheter, and required one-person assistance with toileting hygiene. A contact precaution sign was posted outside the resident’s room directing staff to perform hand hygiene and wear PPE before entering. Despite this, a CNA entered the room without PPE, left the room to fill an ice water pitcher and spoke with the floor nurse in the hallway, then re-entered the room without PPE and later entered again to deliver lunch without PPE. The CNA stated they did not have to wear gowns or gloves unless providing direct care, although they acknowledged the posted sign instructed staff to wear PPE before entering the room. Additional observations showed staff entering rooms on contact precautions and enhanced barrier precautions without following the posted directions. Staff were observed in Resident 78’s room and Resident 7’s room without gowns or gloves despite signs directing gown and glove use. Staff also provided IV treatment to Resident 67 without wearing a gown, and an RN administering medications through Resident 12’s feeding tube left the room without performing hand hygiene, returned wearing the same gown, and did not perform hand hygiene before putting on new gloves. During medication administration for another resident, an RN prepared medications without hand hygiene, handled a roommate’s topical treatment and dressing with gloves, then resumed medication preparation without hand hygiene and repeatedly returned to the medication cart and the room without performing hand hygiene. The DON stated nurses were expected to perform hand hygiene before entering a resident room, after leaving the room, and after each medication pass.
PASRR Level II Recommendations Not Incorporated Into Care Plan
Penalty
Summary
The facility failed to ensure that a Level II PASRR evaluation was incorporated into the care plan for Resident 13, who had multiple medically complex diagnoses and was identified through the state Level II PASRR process as having a Serious Mental Illness. An updated Level 1 PASRR showed staff identified the resident as needing a Level II evaluation, and the Level II evaluation was completed with recommendations for the resident’s plan of care. However, review of the resident’s comprehensive care plan showed that four months after the evaluation was completed, the Level II recommendations had not been incorporated into the care plan as required. In interview, the Social Services Director stated it was the expectation that Level II recommendations be incorporated into resident care plans once obtained and confirmed that the recommendations for Resident 13 should have been, but were not, included.
Care plans not updated to match residents’ current conditions and interventions
Penalty
Summary
The facility failed to update and revise care plans for 3 of 25 sampled residents whose records were reviewed. The deficiency involved Resident 91, Resident 2, and Resident 69, whose care plans did not reflect current conditions, interventions, or needs documented in assessments, observations, and staff interviews. Resident 91 was admitted with medically complex conditions including recent abdominal surgery. The admission MDS showed the resident could transfer and walk 10 feet with supervision or touching assistance, did not use a wheelchair, did not use bed rails, and required a pressure-reducing device for the chair. However, the care plan still included mobility bars that staff later confirmed were no longer needed for mobility, did not document the resident’s wheelchair use, and continued to show a pressure ulcer prevention need even though staff stated the resident was no longer at risk for pressure ulcer development. Observations showed the resident using a wheelchair without a cushion or pressure-reducing device and using the mobility bars only to hold a fan. Resident 2 had a history of falls, a fall since admission, limited range of motion in both lower legs, substantial assistance needs for bed-to-chair transfers, and use of a walker and wheelchair. After a fall in the room, staff revised the care plan to include a Call Don’t Fall sign as a visual reminder, but the revised falls care plan did not include that intervention. Observations later showed no fall intervention signs in the resident’s room. Resident 2’s dental assessment also documented broken teeth, but the comprehensive care plan only identified a risk for oral/dental problems and did not reflect the actual broken teeth. Resident 69 had a chronic digestive disorder, and the revised care plan directed staff to provide small frequent meals instead of three large meals, but observations showed the resident receiving regular portion meals and staff confirmed the resident was still being served three regular meals a day.
Failure to Support Resident Communication Needs
Penalty
Summary
The facility failed to maintain residents’ ability to communicate for 2 of 3 sampled residents. The facility policy stated health information and services would be provided in ways that were easy for the resident and/or representative to understand, and that language assistance services, qualified sign language interpreters, or auxiliary aids would be offered as needed. For Resident 13, the MDS identified Spanish as the preferred language and indicated the resident needed or wanted an interpreter to communicate with health care staff. The communication care plan identified a language barrier and noted the resident preferred to communicate in Spanish. During interview and observation, Resident 13 stated they had a hard time understanding and preferred Spanish, was seen making hand gestures, and there was no signage or directions for interpreter services available in the room. Staff stated communication was difficult, that they usually figured out what the resident needed by connecting sentences or by the resident pointing, and the unit manager stated staff were expected to communicate in the resident’s preferred language and use an interpreter as needed. For Resident 69, the admission MDS documented clear speech, no memory impairment, and minimal difficulty hearing with the use of a hearing aid or other hearing appliance. The inventory of personal items showed one hearing aid on admission, but the revised communication care plan only identified minimal difficulty hearing and did not identify the hearing aid or a need for other hearing devices. During interview, Resident 69 repeatedly asked for sentences to be repeated, stated both hearing aids were broken, and reported staff used a hearing device headphone once when they first arrived but it was never offered again. Observations showed no hearing aids or hearing device headphones in the room. Staff stated the resident was hard of hearing and did not have hearing aids or hearing devices, and the unit manager stated they were unaware of residents on the unit currently using hearing device headphones, though several devices were available in the office.
Failure to Provide ADL Grooming and Hygiene Assistance
Penalty
Summary
The facility failed to provide assistance with activities of daily living related to cleanliness and grooming for residents who were dependent on staff for care. The deficiency involved 3 sampled residents and 1 supplemental resident who needed help with bathing, nail care, shaving, and personal hygiene, but were observed with long fingernails, debris under the nails, and long facial hair. The facility policy stated that residents unable to carry out ADLs were to receive the necessary services to maintain grooming and personal hygiene. Resident 70 had diabetes, muscular dysfunction, and weakness, and the MDS showed no refusal of care or memory impairment. The care plan directed staff to provide substantial assistance with bathing and nail trimming on shower days, and the Kardex scheduled showers every Wednesday and Saturday. However, observations on multiple dates showed nails extending about half an inch past the nail bed with brown debris and dry skin underneath. The bathing record documented several bed baths as completed, but no refusal was documented, and Resident 70 stated they did not receive a bed bath and that when a bath was offered and refused because the room was cold, staff did not return to offer it again. Resident 69’s admission MDS showed dependence on staff for personal hygiene and no rejection of care, yet observations showed long, uneven fingernails that remained untrimmed on repeated checks. Resident 17’s MDS showed moderate one-person assistance was needed for personal hygiene, showers, and toileting, and the care plan identified a need for one-person assistance with personal hygiene and oral care; observations showed the resident lying in bed in a hospital gown with long facial hair and long fingernails with black debris. Resident 52’s MDS showed one-person assistance was needed for personal hygiene, toileting, and showers, and the care plan and physician orders directed weekly nail care; observations showed long fingernails with black debris, and the resident stated they needed staff assistance to clip them. Staff interviews confirmed that dependent residents were expected to receive ADLs including nail care, shaving, and personal hygiene, and that refusals should be documented when care was not provided.
Activity Program Did Not Meet Residents’ Individual Needs
Penalty
Summary
The facility failed to ensure activity programs met the needs of each resident for 2 of 3 residents reviewed for activities, leaving residents at risk of boredom and a diminished quality of life. The facility’s policy stated that the activities program would be ongoing and based on each resident’s comprehensive assessment, care plan, and preferences to support physical, mental, psychosocial well-being, and independence. Resident 15 had a mood disorder, respiratory failure, and weakness, and the MDS identified books, newspapers, religious services, music, and going outside as very important interests. The care plan directed staff to provide leisure materials and assist with the television, but the November activity record showed documentation only once. Resident 15 stated they needed someone to push them around so they could go to activities, yet observations showed the resident lying in bed with the room dark and the television off on multiple occasions. Resident 69 had no memory impairment and the MDS identified books, newspapers, magazines, favorite activities, and religious services as very important. The care plan directed staff to post the activity calendar in the room, invite the resident to activities, encourage participation, and provide leisure materials, but observations showed the resident in bed with no reading materials, no music, and the television off, and the activity schedule was posted where the resident could not view it. Documentation showed limited activity participation, offers, and independent activities across October and November, and the Recreation Director stated these were not always documented.
Failure to Provide Ordered ROM and Functional Maintenance Services
Penalty
Summary
The facility failed to provide restorative and functional maintenance services for two residents with limited ROM and mobility. Facility policy stated residents should be assisted to obtain and maintain their highest practicable functional levels. Resident 5’s MDS showed slight memory impairment, muscle weakness, and functional limitation in ROM to both legs. The care plan directed staff to provide gentle ROM daily as tolerated, but the November 2025 caregiver task records showed no documentation that ROM activities were provided. In interview, Resident 5 stated they needed help with mobility because of recent falls, believed exercises would be provided in their room, and said staff had not discussed ROM exercises with them in over a month. Resident 70’s MDS showed no memory impairment but documented generalized muscle weakness, paralysis, and dependence on staff for mobility. The care plan and caregiver task sheets directed staff to provide active ROM daily while assisting with dressing, grooming, and personal hygiene, but no documentation was provided showing ROM was completed. Resident 70 stated they wanted therapy to help them get stronger, had weak arms and legs, and said staff did not offer exercises in their room because it was difficult to get to the activity room. The DON stated the facility did not have designated staff to provide restorative and ROM exercises, was setting up a functional maintenance program that was not yet in place, and expected CNAs to provide and document ROM as stated in the care plan.
Failure to Follow Feeding Tube Orders
Penalty
Summary
Failure to assess the gastrostomy tube placement before starting enteral feeding and water flushes, to provide formula on time, and to follow physician orders was identified for Resident 13. Resident 13 had multiple medically complex diagnoses, including difficulty swallowing, and required a feeding tube for more than 50 percent of total calories received, according to the 08/29/2025 Significant Change MDS. The November 2025 MAR and TAR included orders for 150 ml of water via feeding tube every four hours, checking tube placement and residual before feeding and water flushes, and enteral nutrition formula five times daily at 12:00 AM, 7:00 AM, 11:00 AM, 5:00 PM, and 9:00 PM. During observation on 11/19/2025, Staff G administered 160 ml of water instead of the ordered 150 ml, did not check tube placement or residual volume before the water flush or formula, and did not ask the resident about symptoms of not tolerating the feeding. Staff G then administered 237 ml of formula at 10:15 AM, three hours after the 7:00 AM scheduled dose, and stated this was the first formula given that shift. Staff G later stated they should have followed the orders and that they did not have enough time to give the formula at the scheduled time.
Failure to Implement Pharmacy Medication Review Recommendations
Penalty
Summary
The facility failed to implement pharmacy recommendations for 2 residents reviewed for pharmacy services and medication regimen review. The facility policy required a pharmacist to conduct monthly medication regimen reviews and for the facility to act on reported irregularities to minimize medication-related problems and other irregularities. For one resident with recent major orthopedic surgery and active care needs, a physician order dated 09/24/2025 directed Vitamin D3 50,000 units every morning. A pharmacy consultation on 10/17/2025 noted the dose was above the recommended daily range and recommended a blood test to determine the resident’s vitamin D level, with a change to 50,000 units weekly if the level was less than 30 or 2,000 units daily if greater than 30. The physician accepted and signed the recommendation on 10/20/2025, and a lab result on 10/24/2025 showed a vitamin D level of 47, but the resident continued to receive Vitamin D3 50,000 units daily through 11/19/2025. For another resident with multiple medically complex diagnoses including fractures and a condition causing weak and brittle bones, the record showed a consultant pharmacist medication review on 10/10/2025 with a note to see the report for irregularities and recommendations, but the completed report was not in the resident’s record. Staff later printed the report from the pharmacy website and found recommendations that calcium and iron supplements be given separately from many medications for proper absorption. The November 2025 MAR still showed the calcium and iron supplements scheduled at the same time as the resident’s other medications. The DON stated the facility had not previously realized it needed to obtain the completed reports from the pharmacy website and stated the recommendations needed to be addressed.
Expired and Improperly Labeled Medications Found in Storage Areas
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications in the West Station medication room and the West 2 medication cart. In the West Station medication room, surveyors observed a bottle of medication used to treat itching with an expiration date of 10/25/2025 and nine bags of IV medications with an expiration date of 10/13/2025. Staff D, the Unit Manager, confirmed the itching medication was expired and should have been discarded, and stated the IV medications had been discontinued on 10/03/2025 and should have been discarded or returned to the pharmacy at that time. In the West 2 medication cart, surveyors observed three opened multi-dose injectable medications used to treat a blood sugar disorder that had no open dates, and one additional opened multi-dose injectable medication with an open date that was smeared and illegible. Staff E, an LPN, stated the medications were to be discarded 28 days after opening and that the open date was needed to determine when to discard them. The DON later stated that if multi-dose injectable medications were not labeled with the open date, they would be discarded, and confirmed that expired medications should be discarded.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to assess and obtain consent before implementing bed rails for two residents, leading to a deficiency. Resident 1, who had severe memory impairment and vision issues, was not assessed for the safe use of bed rails, nor was consent obtained. Despite not being part of the care plan, bed rails were left on Resident 1's bed from a previous occupant, resulting in the resident sustaining a cut above the left eyebrow. Staff interviews confirmed the lack of assessment and consent, and the expectation that these should have been completed prior to bed rail use. Resident 2, who required substantial assistance with bed mobility but had no memory impairment, was also found to have bed rails installed without prior assessment or consent. The comprehensive care plan for Resident 2 did not indicate the use of bed rails, and staff confirmed that assessments and consents were expected but not obtained. These oversights placed both residents at risk for injury and highlighted a failure in the facility's procedures for implementing bed rails.
Failure to Implement Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective Antibiotic Stewardship Program (ASP) to ensure the appropriate use of antibiotics (ABO) for six residents. The facility's policy required validation of ABO prescriptions for correct indication, dose, route, and duration, and the use of McGeer's and Loeb's criteria to guide ABO prescribing. However, the facility did not maintain accurate and complete ABO line listing documentation, and there was no evidence of McGeer's or Loeb's criteria being met for the residents reviewed. Additionally, the facility did not maintain an ASP binder with necessary documentation, such as meeting minutes and tracking information. Specific deficiencies were noted for each resident. Resident 204 had two ABOs not documented on the ASP line listing. Residents 80 and 77 completed ABOs without documentation of symptoms meeting McGeer's or Loeb's criteria. Resident 64 was admitted on an ABO for colitis, but hospital records indicated the colitis was resolved, and there was no evidence of pneumonia. Residents 47 and 3 completed ABOs without any assessment or ABO time-out. The Infection Preventionist, who also held multiple roles, acknowledged the lack of up-to-date ASP documentation and assessments, citing workload challenges.
Failure to Provide Written Transfer Notifications
Penalty
Summary
The facility failed to provide required written notices to residents and their representatives at the time of transfer or discharge to an acute care hospital. This deficiency was identified for seven residents who were transferred to hospitals on various dates. The facility's policy, dated July 2018, mandates that a notice of transfer must be provided to the resident or their representative when an emergency transfer to an acute care facility is ordered. However, record reviews showed no documentation of such notifications being provided for any of the residents reviewed, including Residents 94, 31, 1, 20, 26, 23, and 59. During an interview, the facility's administrator acknowledged the absence of a process for written transfer notifications, resulting in the failure to provide these notifications to residents transferred to hospitals. The lack of written notification placed residents at risk for discharges that were not aligned with their stated goals for care and preferences. The deficiency was noted under the Washington Administrative Code (WAC) 388-97-0120 (2)(a-d).
Inaccurate and Outdated Care Plans in LTC Facility
Penalty
Summary
The facility failed to ensure that care plans (CPs) were accurately reviewed and revised to reflect the current status and needs of residents, as required. This deficiency was identified for five residents during a survey. For Resident 41, the CP inaccurately documented a pressure ulcer (PU) on the coccyx area, while the resident actually had PUs on the right and left buttocks. The resident reported not receiving assistance for repositioning, and staff interviews confirmed the CP was not updated to reflect the resident's actual condition. Resident 61's CP inaccurately included instructions for monitoring an intravenous (IV) medication site, despite the resident not receiving IV medications. Observations and staff interviews confirmed the absence of an IV site and the lack of current IV medication orders. Similarly, Resident 6's CP contained contradictory information regarding their ability to transfer independently, with observations and interviews indicating the resident was mostly independent, yet the CP and Kardex were not updated to reflect this. Resident 68's CP failed to include goals or interventions related to hospice care, lacking instructions for staff on coordinating care with hospice services. For Resident 32, the CP directed staff to keep the bed in a low position, but observations showed the resident preferred and was able to adjust the bed independently. Staff interviews confirmed the CP was not updated to reflect the resident's preferences and non-compliance with the plan of care.
Failure to Provide Restorative Nursing Programs for Residents with Limited ROM
Penalty
Summary
The facility failed to provide restorative/rehabilitative treatment and services for seven residents with limited range of motion (ROM) and mobility, which was necessary to maintain or improve their highest level of functioning. The facility's policy on Quality of Care Restorative Nursing Programs (RNP) required that these programs be developed and formalized by a supervising nurse. However, the facility did not have dedicated staff to provide RNPs, and the responsibility was expected to be incorporated into the duties of Certified Nursing Assistants (CNAs) during the provision of Activities of Daily Living (ADL) care. Resident 47, who had functional limitations in ROM to both arms and legs, was not provided with a RNP despite being assessed as needing one to prevent ADL decline. The resident was informed that they could not receive restorative nursing services until approved for Medicaid insurance. Similarly, Resident 20, who had limited ROM in the right shoulder, was not assisted with walking as required, and there was no documentation of staff assisting with daily walking. Resident 40, who required assistance with mobility and ROM exercises, did not receive the interventions as care planned, and there was no task documentation for staff to sign off on. Other residents, including Residents 41, 61, 32, and 59, also did not receive the necessary RNPs. Resident 41, who had a below-the-knee amputation, did not receive exercises after therapy services ended. Resident 61, who had limited ROM in the right arm, was not provided with a RNP despite being non-weight bearing. Resident 32, who had limited ROM in upper and lower extremities, did not receive the RNP as care planned. Resident 59, who had limited ROM due to a stroke, did not have a RNP in place, and there was no documentation of staff providing the necessary care. The facility's failure to implement RNPs as required placed these residents at risk of further decline in ROM, loss of function, and permanent immobility.
Sanitation Deficiencies in Food Handling and Storage
Penalty
Summary
The facility failed to maintain sanitary conditions in food preparation, storage, and service, as observed during a survey. Staff members did not consistently perform hand hygiene while preparing meal trays for residents. Specifically, a dietary aide was seen touching their face and hair with gloved hands and then handling food items without changing gloves or washing hands. Similarly, the dietary manager was observed touching their face and clothing and then continuing to handle food without proper hand hygiene. These actions compromised the sanitary conditions of the meal service. The facility's dishwasher machine was not maintained according to professional standards. Observations revealed a significant build-up of grime and debris on the machine. Staff failed to correctly perform chemical tests for chlorine concentration, which is crucial for ensuring proper sanitization of dishware. The test strips used were ineffective, and the dishwasher's temperature was recorded as higher than recommended for a low-temperature machine. Documentation discrepancies were noted in the Dish Machine Log, with incorrect temperature and chlorine concentration levels recorded. Unit refrigerators and freezers were not managed according to the facility's policy. Observations showed that food items were not labeled with resident names or use-by dates, and expired items were not discarded. Unlabeled and undated food items, including perishable goods, were found in the refrigerators, posing a risk of foodborne illness. The facility's administrator confirmed the expectation for staff to adhere to hand hygiene protocols and to dispose of food items after three days, which was not consistently followed.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by several observed deficiencies. Staff did not consistently perform hand hygiene (HH) before and after resident care or contact, nor did they apply or remove personal protective equipment (PPE) in accordance with the transmission-based precaution (TBP) signs posted outside resident rooms. For instance, a certified nursing assistant (CNA) was observed handling meal trays and assisting residents without performing HH, and another staff member failed to change gloves and wash hands between dirty and clean care during incontinence care. Additionally, the facility did not implement necessary interventions to prevent Legionnaires' disease, a serious respiratory infection caused by bacteria in the water system. The maintenance director was unaware of the areas at higher risk for Legionella development and did not have monitoring or prevention techniques in place. Furthermore, the infection preventionist was not involved in the Legionella prevention process, indicating a lack of coordination and oversight in infection control measures. The facility also failed to document infection surveillance using McGeer's or Loeb's criteria for residents on antibiotics, which is part of their antibiotic stewardship program. A review of records showed no documentation of these assessments for a sample of residents, and the infection preventionist admitted that the software used did not support detailed documentation of symptoms or criteria met. This lack of documentation and oversight placed residents and staff at risk for contracting and spreading infections, as well as potential antibiotic resistance.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to inform residents or their representatives about the risks and benefits associated with psychotropic medication therapy and did not obtain consent before administering these medications. This deficiency was identified for two residents. Resident 61, who had moderately impaired cognition and diagnoses of schizophrenia, anxiety, and depression, was regularly administered antipsychotic, antianxiety, and antidepressant medications without documented consent. The Director of Nursing acknowledged the lack of documentation and stated that consent should have been obtained prior to medication administration. Similarly, Resident 34, diagnosed with dementia with agitation, received antipsychotic medication without documented evidence that the risks and benefits were discussed with the resident or their legal guardian. Although a family member provided consent over the phone, there was no documentation of a discussion regarding the medication's risks and benefits. Staff members confirmed that guardians should be informed and provide consent for such medications.
Failure to Ensure Advanced Directives and Guardianship Documentation
Penalty
Summary
The facility failed to ensure that two residents had appropriate Advanced Directives (AD) in place, which is a violation of the residents' rights to have their medical treatment preferences honored. For Resident 61, the facility did not have a copy of an AD in the resident's record, and there was no documentation of attempts to obtain guardianship, despite the resident having moderately impaired memory and being their own responsible party. Interviews with the Social Services Director and the Director of Nursing revealed that Resident 61 was unable to make decisions and had no appointed guardian, and the facility was working on appointing one but could not provide documentation. For Resident 6, the facility's records showed that a letter of limited guardianship had expired, and although the admission record listed a guardian as the responsible party, there was no documentation of an AD or current guardianship paperwork in the resident's record. Interviews with the Social Services Director and the Administrator confirmed that Resident 6 had a guardian, but the necessary paperwork was not uploaded in the resident's record. This lack of documentation and failure to ensure current guardianship and ADs placed the residents at risk of not having their medical treatment preferences honored.
Failure to Initiate Grievance Process for Resident Complaints
Penalty
Summary
The facility failed to initiate a grievance process for two residents who reported issues, which is a violation of their grievance policy. Resident 1, who had no memory impairment, reported missing personal items, including gowns, potted plants, and snacks, after returning from a hospital stay. The resident had informed a staff member about the missing items, but no grievance form was completed, and the administrator was unaware of the issue due to not reviewing the care partners' checklists. Resident 47 reported long call light response times during the night shift, which was documented in their electronic health record. Despite the Social Service Director notifying the administrator about this complaint, no grievance form was filled out, and the administrator was not informed. This lack of action prevented the facility from investigating the complaint promptly.
Failure to Document Transfer Information
Penalty
Summary
The facility failed to document the communication of necessary resident information to the receiving health care institution for two residents who were transferred to an acute care hospital. According to the facility's policy on Admission, Transfer, & Discharge, when a resident is transferred or discharged, the facility must document that appropriate information was communicated to the receiving provider. This information includes contact details of the resident's practitioner, resident representative information, advance directive information, special instructions for ongoing care, comprehensive care plan goals, and other necessary documentation to ensure a safe and effective transition of care. For Resident 1, there was no documentation that any information regarding the resident's health condition or contact information was provided to the acute care hospital when the resident was transferred on May 28, 2024. Similarly, for Resident 31, there was no documentation of information being provided to the hospital for transfers on May 27, 2024, and June 4, 2024. In an interview, the Unit Manager acknowledged the lack of documentation and emphasized the importance of providing a thorough report to the receiving facility to ensure appropriate care for the residents.
Failure to Provide Bed Hold Notifications
Penalty
Summary
The facility failed to provide written notifications of bed hold policies to residents or their representatives when residents were transferred to the hospital or went on therapeutic leave. This deficiency was identified during a review of records for two residents, Resident 59 and Resident 23, who were transferred to the hospital multiple times. The facility's policy, revised in November 2018, required that residents be informed of their right to hold their bed at the time of transfer or within 24 hours if the transfer was emergent. However, there was no documentation indicating that such notifications were provided for the hospitalizations of Resident 59 on four occasions and Resident 23 on one occasion. Resident 59, who had impaired memory and thinking abilities, was hospitalized several times between November 2023 and March 2024, but there was no record of bed hold notifications being provided. Similarly, Resident 23, who had complex medical conditions including diabetes and pressure ulcers, was sent to the hospital in January 2024, yet no documentation of a bed hold notification was found. During an interview, the admissions coordinators confirmed that the notifications were not completed as required, as evidenced by their review of the binder used to track hospitalizations and bed hold notifications.
Failure to Timely Complete SCSA for Hospice Resident
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) within the required 14 days for a resident who experienced a significant change in condition. The resident, identified as Resident 68, was admitted to hospice services on April 5, 2024, due to protein-calorie malnutrition and an inability to absorb nutrients, with a life expectancy of less than six months. Despite this significant change, the facility did not complete the SCSA until June 20, 2024, which was 76 days after the hospice start date. This delay in assessment was acknowledged by the MDS Coordinator, who confirmed that the SCSA should have been completed when the resident began hospice care.
Inaccurate PASRR Assessment for Resident with Mental Health Needs
Penalty
Summary
The facility failed to ensure accurate completion of Pre-Admission Screening and Resident Review (PASRR) assessments for a resident, which is crucial for determining appropriate placement and necessary mental health services. The facility's policy mandates that all residents undergo PASRR screening before admission, with the Social Services department responsible for maintaining accurate records. However, the PASRR Level 1 assessment for a resident with schizophrenia, anxiety, and major depression was incomplete, as it did not include the major depression diagnosis, and a Level II evaluation was not conducted as required. The resident, who had moderately impaired cognition and was on antipsychotic, antianxiety, and antidepressant medications, was admitted without a complete PASRR assessment. The Social Services Director acknowledged the oversight during an interview, noting that the Level 1 PASRR form was inaccurate and should have been reviewed for accuracy at the time of admission. This inaction left the resident at risk of not receiving the necessary mental health services tailored to their needs.
Deficiencies in Medication Administration and Documentation
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice for several residents, as evidenced by the nursing staff's failure to follow and/or clarify Physician Orders (POs) and notify providers of resident refusals of treatment. For Resident 66, there was a discrepancy in medication administration as the resident, who was on a feeding tube and had an NPO order, received medications that were ordered to be administered by mouth. Additionally, the staff did not hold a high blood pressure medication as ordered on specific days prior to dialysis. Resident 32, who was capable of understanding and communicating, had POs for pain management that lacked specific parameters for administering opioid medication. The staff administered opioid medication for low pain levels and over-the-counter medication for higher pain levels, contrary to the expected practice. Resident 59, with severe cognitive impairment and on tube feeding, had discrepancies in the documentation of the amount of tube feeding administered, with staff failing to accurately record the amounts as observed on the pump. Resident 67, who had no memory impairment, frequently refused a prescribed laxative medication, yet there was no documentation that the provider was notified of these refusals. The staff failed to document the refusals and notify the provider, as expected by the facility's standards. These deficiencies highlight a lack of adherence to professional standards in medication administration and documentation, potentially placing residents at risk for unmet care needs.
Failure to Provide Adequate Communication Support for Resident
Penalty
Summary
The facility failed to provide a functional communication system for a resident with impaired memory and unclear speech, identified as Resident 61. Upon admission, the resident was assessed to have communication difficulties, with no behaviors or rejection of care noted. Observations revealed that the resident was unable to communicate effectively, relying on head shakes for yes or no responses. Despite the communication care plan indicating the need for evaluation by occupational therapy or physical therapy for a communication board, and alternative communication methods like a computer or sign language, these interventions were not implemented. Interviews with staff, including the Director of Nursing and the Rehab Director, confirmed that the resident was not evaluated for communication needs by a speech therapist, and the occupational therapy evaluation was not documented. The staff attempted to use a communication binder, which was unsuccessful, but this was not documented in the resident's records. The lack of appropriate communication tools and evaluations placed the resident at risk for unmet care needs and social isolation.
Failure to Assist Residents with Personal Hygiene
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADL) for two residents, specifically in the areas of personal hygiene and grooming. Resident 61, who was admitted with impaired memory and required maximal assistance with personal hygiene, was observed on multiple occasions with long facial hair. Despite the resident's care plan indicating dependency on staff for personal hygiene, there was no documentation of the resident's preferences or any refusals of care, as confirmed by the Director of Nursing. Similarly, Resident 62, who required one-person assistance with personal hygiene and had no memory impairment, was observed with long fingernails and facial hair. The resident reported not having a razor for shaving and needing help with nail care. The care plan for Resident 62 also indicated a need for maximal assistance with personal hygiene, yet the necessary care was not provided. The Director of Nursing acknowledged that staff should have assisted with shaving and nail care but failed to do so.
Deficiencies in Resident Care and Monitoring
Penalty
Summary
The facility failed to provide necessary care and services to three residents in accordance with professional standards and their comprehensive person-centered care plans. Resident 41, who was admitted with a below-the-knee amputation and other medical conditions, had unhealed pressure ulcers and other wounds. Despite observations of multiple open and scabbed areas on the resident's left shin and macerated toes with debris, the facility did not treat or monitor these skin issues. The Treatment Administration Record showed no treatment or monitoring for these conditions, and staff interviews confirmed the lack of treatment orders and awareness of the resident's fungal infection. Resident 67, admitted with cellulitis and skin tears, also did not receive the required weekly skin checks as per the facility's care plan. The last documented skin check was over a month prior to the survey, and staff interviews revealed that the expected weekly skin checks were not performed or documented. This oversight left the resident's skin conditions unmonitored and untreated, contrary to the facility's policy. Resident 59, who had severe cognitive impairment and was at risk for pressure ulcers, was found lying on an air mattress set incorrectly for their weight. The resident expressed discomfort due to the firmness of the mattress, and staff confirmed that the mattress settings were not adjusted according to the resident's weight. The care plan lacked specific instructions for the air mattress settings, leading to improper use and discomfort for the resident.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with pressure ulcers (PUs), as per professional standards of practice. Resident 41, who was admitted with stage 3 PUs on the buttocks and was at risk for developing new PUs, did not receive consistent weekly skin assessments as required. The facility was aware of the resident's existing PUs and risk factors but did not evaluate or implement additional pressure relief measures until over a month after admission. Observations showed the resident was frequently left lying on their back, contrary to care plan instructions to avoid such positioning. The facility's inaction included not updating the care plan with necessary interventions like an air mattress and heel floater, which were not ordered despite the resident's condition. The wound care provider and nursing staff failed to acknowledge and document a new deep tissue injury on the resident's foot, which was identified later by the Director of Nursing. The lack of timely skin assessments and failure to reposition the resident as needed contributed to the development of new pressure ulcers, diminishing the resident's quality of life.
Failure to Assess Safety of Assistive Devices
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for Resident 68, who was part of a sample reviewed for such hazards. Resident 68, who had severely impaired thought processes and was receiving end-of-life services, was observed on multiple occasions with a wedge cushion and pillows placed between the mattress and bed frame. These devices were intended to prevent the resident from falling out of bed. However, there was no assessment conducted to determine if these devices restrained the resident's movement, which could pose an entrapment risk. Staff interviews revealed that the wedge and pillows were used to prevent falls, but the Director of Nursing acknowledged that these items should not be placed in such a manner as they could restrain the resident. The facility's policy on accident hazards and supervision required consideration of the risks and benefits of assistive devices before implementation, but this was not adhered to in the case of Resident 68. The lack of assessment and improper use of devices placed the resident at risk for accidents and injury.
Failure to Obtain Consent for Bed Rails
Penalty
Summary
The facility failed to obtain informed consent for the use of bed rails for three residents, which was a violation of their own policies and resident rights. The facility's policy required that alternatives be attempted before using bed rails, and if bed rails were necessary, an assessment for safety risks should be conducted, and informed consent should be obtained from the resident or their representative. However, for Residents 1, 297, and 20, the facility did not attempt alternative measures, did not assess the residents for the safe use of bed rails, and did not obtain informed consent. Resident 1 had bed rails attached to their bed without consent, despite having no memory impairment and being capable of making their own decisions. Similarly, Resident 297 had bed rails without a physician's order, screening, evaluation, or consent, and was unaware of why the bed rails were present. Resident 20 also had bed rails without consent, although an enabler bar screening evaluation and physician order were present in their records. Staff interviews confirmed the lack of consent and the importance of involving residents in their care decisions.
Failure to Document and Implement Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that the licensed pharmacist's monthly Medication Regimen Reviews (MRRs) were properly documented in the resident records and that the recommendations were reviewed and implemented in a timely manner. This deficiency was observed in three residents. For Resident 34, the pharmacist made recommendations in May and June 2024 regarding the medication regimen, but these MRRs were not available in the resident's records. The Director of Nursing confirmed the absence of these records, indicating a lapse in documentation. For Resident 67, a pharmacy recommendation made on March 20, 2024, to adjust medication and monitoring was accepted by the physician on March 24, 2024, but was not noted by a facility nurse until April 10, 2024, resulting in a delay in implementing the changes. Similarly, for Resident 32, the pharmacist recommended a gradual dose reduction of psychotropic medications in May 2024, but this recommendation was not implemented because the MRR form was not received by the staff until July 2024. These lapses in documentation and timely action placed residents at risk for adverse side effects and negative outcomes.
Failure to Implement Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that two residents, identified as Residents 24 and 32, were free from unnecessary psychotropic medications. Resident 24, who had diagnoses of bipolar disorder, anxiety disorder, and depression, was receiving antianxiety medication as needed without a proper stop date, contrary to the facility's policy that such medications should be limited to 14 days unless otherwise documented. The staff did not clarify the order with the provider to establish a stop date, resulting in the resident receiving the medication multiple times over a short period without proper oversight. Resident 32, diagnosed with anxiety and depression, had been on antianxiety medication three times daily for nearly 18 months without a documented rationale for continuation or attempts at gradual dose reduction (GDR). The interdisciplinary team (IDT) had not reassessed the resident's medication use quarterly as recommended, and the last documented review was over six months prior. Despite recommendations from a pharmacy consult to discuss GDRs, there was no documentation indicating attempts to reduce the medication or reasons for contraindication. Interviews with facility staff revealed a lack of adherence to policies regarding the management of psychotropic medications. Staff acknowledged the importance of GDRs and monitoring resident behaviors to evaluate the necessity of continued medication use. However, the facility did not follow through with these practices, leaving residents at risk for unnecessary medication use and potential adverse effects.
Medication Administration Error
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in an 8% error rate during a medication pass. This deficiency involved one of five nurses, specifically a Licensed Practical Nurse (Staff N), who did not properly administer medications to Resident 203. During the observation, two out of 25 medications intended for Resident 203 were not consumed as they fell into the resident's lap. Staff N did not notice the dropped tablets and began to leave the room until a surveyor intervened. Upon being alerted, Staff N returned to the resident and handed them the tablets to take. Staff N admitted in an interview that they usually ensured residents swallowed their medications but failed to do so in this instance.
Failure to Secure Medications and Biologicals
Penalty
Summary
The facility failed to ensure that drugs and biologicals were secured for three residents, leading to potential risks of medication errors and unauthorized self-administration. For Resident 52, several skin treatments and ointments were observed on the windowsill in their room, which were used by the wound care team and then returned to the same unsecured location. This practice was contrary to the facility's policy, which requires medications to be stored in a locked compartment within the resident's room unless there is a Physician's Order (PO) for bedside storage. Similarly, Resident 90 had a large bag of over-the-counter cough suppressant lozenges on their nightstand without a PO or assessment for self-administration. Staff O, a registered nurse, confirmed the presence of the lozenges and acknowledged the need for a PO and secure storage. For Resident 23, several wound treatment supplies were found on top of a dresser in their room. Staff P, the Unit Manager, indicated that once treatment supplies were brought into a resident's room, they remained there, which was not in line with the facility's policy. The Director of Nursing confirmed that medicated treatment supplies and over-the-counter medications should not be left unattended at a resident's bedside.
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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
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Nursing homes near Federal Way
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Garden Terrace Healthcare Center Of Federal Way | 0.1 mi | ★★★★★ | 1 | 0 |
| Hallmark Manor | 0.8 mi | ★★★★★ | 3 | 0 |
| Life Care Center Of Federal Way | 1.9 mi | ★★★★★ | 1 | 0 |
| Auburn Post Acute | 5.2 mi | ★★★★★ | 12 | 2 |
| Canterbury House | 5.3 mi | ★★★★★ | 22 | 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.