Below average — CMS composite of the measures below.
A standard survey is most likely before 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 Healthcare - Tacoma during CMS and state inspections, most recent first.
A newly admitted hospice resident arrived restless, non-verbal, and repeatedly attempting to get out of bed, yet staff did not obtain vital signs, perform an admission nursing or skin assessment, complete a pain assessment, or develop a baseline care plan. RNs and CNAs reported placing the bed against a wall, using pillows and a floor mattress, and assigning staff to sit with the resident due to agitation and fall risk, but there was no documentation of 1:1 monitoring, consent for bed positioning, or details of care provided and the resident’s response. The electronic record contained only a brief nursing note describing restlessness and the hospice nurse’s involvement leading to transfer back to the hospital, and medical records staff confirmed no additional documentation existed, which the DON acknowledged did not meet expectations for new admissions.
Food was served at an unacceptable temperature. Several residents reported that meals were cold or lukewarm, including breakfast and lunch items, and one resident said the issue had been raised in resident council without resolution. Surveyors observed staff serving trays with cart doors left open on multiple halls, and resident council minutes showed cold food had been an ongoing concern for months. The dietary manager and administrator acknowledged the facility knew about the problem and that food temperatures did not meet expectations.
The facility failed to provide required Medicare beneficiary notices for 3 residents when SNF coverage ended or was ending. One resident with HF and encephalopathy did not receive a NOMNC, another resident with DM and difficulty walking received a NOMNC but not a SNF ABN, and a third resident with HF and Alzheimer’s disease received neither notice while remaining in the facility after skilled services ended.
Overbed light cords on multiple halls were observed to be made from tied plastic bags or too short to be pulled while in bed. A Regional Maintenance Director and the Administrator both stated the cords should be long enough for resident use and should not be made of plastic bags, and agreed the observed conditions did not meet expectations.
Improper Use of Bed Placement as a Physical Restraint: Two residents were observed with beds positioned against the wall or in a low-bed setup next to the wall. One resident with dementia, muscle weakness, and adult failure to thrive had the bed against the wall on multiple observations, with pillows placed under the mattress causing it to tilt toward the wall. Another resident with gastrostomy status, HF, convulsions, and anoxic brain damage was observed in a low bed next to the wall with a mattress beside the bed. Records lacked orders, assessments, consents, or care plan interventions for these bed arrangements.
PASARR assessments were not accurately completed for four residents with behavioral health diagnoses. One resident with anxiety, depression, schizophrenia, and PTSD had a level I PASARR completed after readmission instead of at readmission; another resident’s PASARR was voided and then redone with serious mental illness indicators and a level II referral; a third resident’s PASARR was not updated after a new psychotic disorder diagnosis; and a fourth resident’s PASARR listed anxiety only even though the MDS and EHR also showed depression and PTSD.
A facility failed to develop and implement individualized comprehensive care plans for 3 residents with dementia and behavioral health needs. One resident with PTSD had a care plan that listed PTSD only as a focus area without specific staff directions, another resident with dementia had care planning triggered by an MDS but the decision was documented as no and the dementia care plan was not created until later, and a third resident with dementia and psychosis had no dementia-focused care plan with specific interventions despite receiving a psychotropic medication.
Failure to document NPI before PRN pain meds: Two residents with dementia and pain-related diagnoses received PRN acetaminophen and oxycodone without documented NPI on multiple occasions. MAR and monitor records showed repeated gaps in NPI documentation, and staff stated the expectation was to assess pain, offer NPI, and document it before giving PRN analgesics.
Two residents with documented oral health problems did not receive timely dental follow-up. One resident had multiple cavities, stained teeth, and mouth pain with a provider order for a dental consult, but the consult was not entered into the dental binder for months. Another resident had lost lower dentures, had trouble chewing, and was identified by MDS staff as needing dental care, yet the consult was not promptly acted on by social services or nursing leadership.
Failure to implement an effective antibiotic stewardship program affected two residents. One resident with diabetes and kidney failure received amoxicillin for a presumed UTI despite a later urinalysis showing no bacterial growth and no documentation supporting continued use. Another resident with CHF and Alzheimer's disease received nitrofurantoin for several days even though the infection control line listing did not include the infection, lab results were negative for UTI with a low colony count, and no rationale for continued antibiotic treatment was documented.
Failure to assess, educate, and obtain consent for pneumococcal vaccines was identified for two residents. One resident had stroke and weakness and could not make needs known, and another had CHF and Alzheimer’s disease and could make needs known; neither EHR contained documentation of vaccine assessment or that the resident or representative was educated or offered the vaccine. The DON stated the facility had not assessed all residents for pneumococcal vaccination status or offered the vaccines as needed.
A resident with major depression, anxiety, diabetes, and insomnia was receiving scheduled psychotropic meds, including an antipsychotic and an antidepressant, while cognitively intact and under 1:1 supervision. The EHR lacked documentation of monitoring for adverse side effects and behaviors related to these meds, and the DON stated nurses were expected to document this monitoring in the EHR.
The facility failed to provide written bed hold notices at the time of hospital transfer or within 24 hours for two residents. One resident had dementia, adult failure to thrive, and alcoholic cirrhosis, and the other had DM2, HF, and kidney failure. Records showed both residents were transferred to the hospital and later returned, but there was no documentation that a bed hold was offered or that attempts were made to contact one resident about the bed hold.
A resident with Alzheimer's disease, DM, and depression began hospice services, but the facility did not complete a significant change MDS to reflect the change in condition. The MDS schedule showed an annual MDS and a quarterly MDS that did not address hospice, and the DON acknowledged the change of condition MDS was missing.
Inaccurate MDS coding affected two residents. One resident with dementia, adult failure to thrive, and alcoholic cirrhosis had hospice services documented in the EHR, but the quarterly MDS did not reflect hospice care. Another resident with type 2 DM and kidney failure received dialysis three days a week, but the MDS did not indicate dialysis. The MDS coordinator and DON both acknowledged the coding was inaccurate.
Care plans were not timely revised for two residents after changes in status. One resident had a discontinued fluid restriction order, but the care plan still listed the restriction, and another resident was no longer receiving psychotropic meds, but the care plan still reflected psychotropic use and related fall risk. The DON stated the plans did not reflect the residents’ current status and were not meeting expectations.
Failure to provide a resident's preferred activity. A resident with dementia, muscle weakness, and adult failure to thrive was dependent on staff for activities and unable to attend group activities. Although the care plan and activity review showed the resident liked to watch TV and news in the room, repeated observations found the TV off, angled away from the bed, and unplugged. Staff interviews confirmed the resident could not likely manage the TV independently and that this did not meet expectations.
Delayed integration of hospice care plans for two residents. One resident with dementia, adult failure to thrive, and alcoholic cirrhosis had hospice services and a hospice coordination of care document, but the facility’s hospice care plan was started later and did not include hospice location, a contact person, or specific hospice services/functions. A second resident with dementia, malnutrition, anorexia, and adult failure to thrive also had hospice services and a hospice plan of care received by the facility, but hospice was not integrated into the resident’s care plan until later. The DON stated the hospice information should have been incorporated sooner.
A resident with hemiplegia, psychotic disorder with delusions, and COPD had a stage 3 pressure injury to the R foot and an open area to the L buttock. Staff observed the resident lying on the back in bed on multiple occasions, with inflatable boots on the nightstand instead of on the resident, and the air mattress was set incorrectly with flashing indicators and a loud whirring control unit. The care plan included avoiding supine positioning, floating heels, and using a pressure-relieving mattress, but these interventions were not consistently in place.
A resident with dementia, psychosis, and bipolar disorder had access to a piece of rebar and a baton in the room. Staff observed the items repeatedly, and the resident had a recent altercation with another resident in which the resident used expletives and threatened to pulverize them. The DON stated residents with behavioral issues should not have access to weapons.
Failure to monitor and document a resident’s fluid restriction. A resident with DM2, kidney failure, and dialysis had an order for a 2000 mL daily fluid restriction, but the EHR did not show the amount of fluid received from nursing or dietary, and the daily total was not calculated or documented. The RN/RCM and DON acknowledged the fluid restriction orders were not clear and were not handled as expected.
A resident with a G-tube, heart failure, convulsions, and anoxic brain injury was dependent on staff for nutrition and could not communicate needs. Staff were observed administering tube feeding while the resident was flat in bed, with the HOB not elevated, and the formula and water bags were not consistently dated; an LPN stated the HOB should be elevated to prevent aspiration, and the DON said the observed bag handling and positioning did not meet expectations.
Delayed follow-up on a dental referral left a resident with DM, HTN, and depression with missing and broken teeth and irritated gums without a documented scheduled dental appointment. The resident wanted extractions and dentures, and the dentist had recommended x-rays, evaluation, and extraction of all teeth, but the record showed no follow-up appointment was scheduled and staff stated the issue had not been addressed as expected.
Infection control data were not completed or analyzed for 3 sampled months, and no organisms were included in the line listing. No monthly summary identified trends or documented interventions, despite the facility policy requiring the IP to use surveillance data to track pathogens and trends. The DON acknowledged the missing tracking, trending, and interventions.
Missing Emergency Call Light in Resident Bathroom: A resident’s bathroom on the 300 hallway did not have an emergency call light system in place. Survey observations confirmed the absence of the call light, and the resident stated they had used the bathroom without noticing one was missing. The DON acknowledged the bathroom should have had an emergency call light, and the Administrator stated all resident bathrooms were expected to have one and that this bathroom had been missed during weekly environmental room rounds.
The facility did not adequately assess or care plan for residents with Substance Use Disorder, failing to implement or document individualized interventions, education on facility policies, or increased monitoring as required. Several residents with SUD histories experienced emergencies or exhibited ongoing substance use behaviors without appropriate care plan interventions or documentation.
The facility failed to create personalized discharge plans for four residents, leading to potential delays and unmet care needs. One resident faced insurance and funding barriers for a planned discharge to Hawaii, while another needed stair training before returning home. A third resident left against medical advice, and a fourth was unsure of discharge barriers. Weekly meetings were held, but documentation was lacking in individual files.
The facility failed to provide adequate hydration to residents, as observed when multiple residents did not have water pitchers at their bedside, contrary to their care plans. Interviews revealed that residents often had to request water, and staff acknowledged a shortage of water pitchers, which had not yet been resolved.
Two residents did not receive scheduled bathing due to outdated shower schedules and lack of coordination among staff. One resident, alert and oriented, relied on bed baths from their wife, while the other, with cognitive impairment, received only a bed and sponge bath. Staff interviews revealed the shower schedule was outdated and did not include the residents' room, leading to missed bathing opportunities.
Two residents suffered second-degree burns due to the facility's failure to implement a hot food and beverage policy. A resident with cognitive impairment was served hot coffee without a secured lid, leading to a spill and burns. Another resident with impaired mobility was given hot soup without a temperature check, resulting in burns. The facility's documentation showed inconsistencies in monitoring beverage temperatures, contributing to the incidents.
The facility failed to maintain appetizing food temperatures, as evidenced by resident complaints and improper food handling practices. A resident reported receiving cold eggs, while another noted inconsistent temperatures of hot and cold items. Observations revealed improper temperature measurement by a cook and unrefrigerated watermelon cups during meal service, contrary to the dietary manager's expectations.
The facility did not follow up on concerns raised by the resident council about care issues, such as missing laundry items, noise during sleep hours, long call light wait times, and staff turning off call lights without assisting residents. These concerns were documented in the council minutes but not reflected in the Grievance Log, indicating a lack of follow-up. A Recreation Assistant confirmed that grievances were documented and given to the Administrator but were not usually discussed in subsequent meetings.
A facility failed to provide weekend access to personal funds for a resident, who had communication challenges and whose money was held in a trust. The Business Office Manager confirmed that funds were only accessible during weekday business hours, with no posted information about after-hours availability.
The facility did not provide quarterly personal fund statements to a resident, impacting their ability to know the amount of money held in trust. The Business Office Manager, new to the role, admitted to not recalling when statements were last issued, confirming that no statement was provided in September.
The facility failed to maintain a clean and sanitary environment, with unsanitary bathroom conditions, insufficient housekeeping, and unresolved maintenance issues. Residents reported persistent problems with clogged toilets, inadequate cleaning, and unpleasant odors. The facility was understaffed in housekeeping, and maintenance issues, such as a hot pipe and fly infestation, were not promptly addressed.
The facility failed to implement comprehensive care plans for three residents, resulting in unmet needs and inadequate care. One resident did not receive necessary heel protectors, another had improper catheter care due to a lack of leg bag maintenance instructions, and a third resident's frequent refusal of showers was not documented or addressed in their care plan.
The facility failed to update care plans for two residents after significant health events and did not conduct a timely care conference for another resident. One resident experienced a fall without a subsequent care plan update, while another had a dental issue not reflected in their care plan. Additionally, a resident admitted with acute respiratory failure did not have a care conference within the required timeframe.
The facility failed to provide adequate care for a resident with skin issues, including a lack of documentation and unclear treatment orders. Another resident on anticoagulant therapy was not monitored for adverse side effects, and two residents did not receive proper bowel management, with no documentation of bowel movements or initiation of bowel protocols. Staff interviews confirmed these deficiencies did not meet expectations.
The facility failed to provide non-pharmacological interventions before administering pain medications to three residents, as required by their care plans. Additionally, a resident on Keppra for epileptic syndrome did not receive necessary lab tests to monitor medication levels, placing them at risk for unnecessary medications and diminished quality of life.
The facility failed to provide prescribed therapeutic diets, as observed on a specific date when regular and therapeutic diet menu items were not prepared or served correctly. The cook served all residents the same portion sizes, and some menu items were missing or substituted without proper communication or adjustment, as confirmed by the Dietary Manager.
The facility failed to implement an effective Antibiotic Stewardship Program, as evidenced by the lack of tracking and trending of antibiotic use and failure to report to QAPI for three months. A resident was prescribed an antibiotic despite lab results showing resistance, with no documentation of provider notification. The Regional Nurse Consultant confirmed the absence of required documentation.
The facility failed to educate and offer influenza and pneumococcal vaccines to two residents. One resident, with heart failure, kidney disease, and diabetes, refused the vaccines without documented education on their risks and benefits. Another resident, with acute kidney failure and morbid obesity, had no record of being educated or offered the influenza vaccine. The administrator expected residents to be informed about vaccine risks and benefits before offering.
The facility failed to educate and document the offer of COVID-19 vaccines for two residents. One resident, with heart failure, kidney disease, and diabetes, refused the vaccine without documented education on its risks and benefits. Another resident, with acute kidney failure and morbid obesity, also lacked documentation of vaccine education or an offer. The Regional Nurse Consultant confirmed the absence of documentation, highlighting a deficiency in the facility's vaccination process.
The facility failed to provide non-disposable cups during meals, affecting residents' dining experience across four halls. Staff interviews revealed a shortage of non-disposable cups, leading to the use of plastic cups. The Regional Nurse Consultant noted that more cups had been ordered, but staff were not informed.
A facility failed to honor a resident's right to choose life-saving interventions. Despite being capable of making decisions, a POLST form was not completed for the resident, who was then transitioned to DNR/DNI status without their input. Staff interviews revealed that the POLST form should have been reviewed upon admission and quarterly, but this was not done, leading to a deficiency in respecting the resident's autonomy.
A resident with osteomyelitis and diabetes reported missing pajama bottoms to the Housekeeping Manager, who failed to follow up or initiate a grievance due to a lack of awareness. The grievance was not documented, and the Interim DON confirmed that a grievance should have been initiated if the issue was unresolved.
A facility failed to provide a resident with written notification of the reason for transfer to the hospital. The resident, who had hypertension and chronic embolism, was discharged with an anticipated return, but there was no documentation of a written notice. The Social Services Director acknowledged the inconsistency in providing such notices.
The facility failed to provide a bed hold notice for two residents during their hospitalization, as required by regulations. One resident with hypertension and chronic embolism, and another with Crohn's disease, were not informed about their right to hold their bed. The Social Services Director and Interim Administrator acknowledged the oversight, which could impact the residents' quality of life.
A resident's smoking status was inaccurately recorded in their medical records, as the MDS indicated no tobacco use despite the resident smoking under supervision. Staff interviews confirmed the MDS was incorrectly coded.
A facility failed to update the PASRR for a resident who was newly diagnosed with significant mental illness, including major depressive disorder and psychotic disorder with hallucinations. Despite the facility's policy to review PASRRs quarterly and submit new ones as needed, the resident's PASRR was not updated to reflect these new diagnoses.
Failure to Assess and Document Care for Newly Admitted Hospice Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide care and treatment to a newly admitted resident in accordance with professional standards of practice, including assessment, basic care tasks, and pain management. The resident was admitted for end-of-life care with multiple diagnoses and arrived at the facility appearing restless, under distress, non-verbal, and repeatedly attempting to get out of bed. A collateral contact reported that the resident had been calm and able to go out in a wheelchair while in the hospital, but shortly after admission to the facility the resident was groaning, restless, and appeared significantly different. Staff C, an RN, stated the resident was very restless on admission, that they were concerned about falls and placed a mattress on the floor next to the bed, and had a CNA sit with the resident. Staff D, a CNA, recalled the resident as very restless, confused, not making eye contact, repeatedly removing their hospital gown, and trying to get up, with staff trading off to sit with the resident to prevent self-injury. Staff F, an RN manager on duty, reported working remotely to enter medications into the medical record and being informed that the resident was very agitated and crawling out of bed, and then learning that the hospice nurse had arrived and the resident was sent back to the hospital. Record review showed the resident was in the facility for approximately 2.5 hours, and the electronic chart contained only a single nursing note and a later social services note about a declined bed hold. The nursing note documented the resident’s arrival time, restlessness, distress, attempts to get off the stretcher and out of bed, assignment of a CNA to sit with the resident, and that the hospice nurse contacted the hospice physician, who ordered the resident sent to the hospital. There was no documentation of vital signs, weight, admission nursing assessment, skin assessment, pain assessment, baseline care plan, consent for positioning the bed against the wall, or documentation of 1:1 monitoring or the specific care provided and the resident’s response. Staff C acknowledged that no assessment or vital signs were obtained due to the resident’s restlessness, and Staff E confirmed there were no additional documents beyond what was in the electronic record. The DON confirmed that the absence of these assessments and documentation did not meet the facility’s expectations for care of newly admitted residents.
Food Served at Unacceptable Temperature
Penalty
Summary
The facility failed to ensure food was served at a palatable temperature. Multiple residents reported that meals were cold or lukewarm, including breakfast waffles, lunch broccoli, and other meals served on the units. One resident stated the food was cold for all three meals, another said the food was cold all the time, and another reported the issue had been raised in resident council but had not been resolved. A resident also stated they told their nurse their food was cold and it was not resolved. Survey observations showed staff serving meals on the 300, 200, and 100 halls with the doors left ajar between trays. On another observation, staff began serving a food cart on the 400 hall, left the cart open while serving, prepared and passed drinks during tray pass, and completed tray pass over a 10-minute period. Resident council minutes documented that cold food was a problem in March, April, and May 2025, and the May minutes noted the issue was still ongoing and insulated carts had been ordered. The dietary manager and administrator acknowledged the facility was aware of the concern about cold food and that the food temperature did not meet expectations.
Failure to Issue Required Medicare Coverage Notices
Penalty
Summary
The facility failed to issue required Medicare beneficiary notices for 3 of 3 reviewed residents when skilled nursing facility coverage ended or was ending. Resident 64, who was admitted with diagnoses including heart failure and encephalopathy and was usually able to make needs known, had Medicare services that started on 04/16/2025 and ended on 05/01/2025, with discharge from the facility on 05/01/2025; the SNF Beneficiary Protection Notification Review showed that a NOMNC was not issued. Resident 65, who was admitted with diagnoses including diabetes and difficulty walking and was able to make needs known, had Medicare services that started on 01/27/2025 and ended on 03/05/2025, remained in the facility after skilled services ended, and the review showed that a NOMNC was issued but a SNF ABN was not issued.
Overbed light cords were nonfunctional and not homelike
Penalty
Summary
The facility failed to ensure overbed light cords were functional or conformed with homelike standards on 4 of 4 halls, including 100, 200, 300, and 400 Halls. On 07/23/2025 and again on 07/29/2025, bed 303-A was observed with an overbed light cord made from multiple plastic bags tied together. On 07/29/2025, additional rooms were observed with overbed light cords made from multiple plastic bags tied together, including 106-A, 309-A, 404-B, and 408-B. Also on 07/29/2025, rooms 103-A, 107-A, 205-A, and 413-A were observed with overbed light cords shorter than three inches and not able to be pulled while in bed. During interview, the Regional Maintenance Director stated overbed light cords should be four to five feet in length and usable by residents while in bed, and stated the short cords and plastic bag cords did not meet expectations. The Administrator also stated the cords should not be made of plastic bags and should be long enough for a resident to use while in bed, and agreed the observations did not meet expectations.
Improper Use of Bed Placement as a Physical Restraint
Penalty
Summary
The facility failed to ensure that beds placed against the wall and low beds were not used as physical restraints for 2 sampled residents. Resident 55 was admitted with dementia, muscle weakness, and adult failure to thrive, and was unable to make needs known. Observations showed Resident 55 in bed with the bed against the wall on multiple occasions, with the resident's right arm and leg touching the wall. On later observations, three pillows were placed under the mattress, causing the bed to tilt toward the wall, and the resident attempted to recenter but slid toward the wall. Review of the provider's orders showed no order for the bed against the wall, and the care plan did not include an intervention for it. Resident 5 was admitted with gastrostomy status, heart failure, convulsions, and anoxic brain damage, and was not able to communicate needs. Observations showed Resident 5 lying in a low bed placed next to the wall, with a mattress next to the bed. The EHR showed no care plan related to the low bed and bed by the wall, and no assessments or consents for that setup. The DON stated that a bed against the wall or a low bed next to the wall could be considered a restraint and that staff were expected to complete evaluation and consents before use; the resident's records did not meet expectations.
PASARR Assessments Not Accurately Completed for Residents With Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure PASARR assessments were accurately completed for 4 of 5 sampled residents reviewed for PASARRs and unnecessary medications. The report states that the facility’s PASARR screening process required completion prior to admission and referral to the state-designated agency when a resident with a mental disorder or intellectual disability had a significant change in status or newly evident serious mental disorder, intellectual disability, or related condition. The deficiency was identified during interview and record review and was cited under WAC 388-97-1915 (1)(2)(a-c), with the facility stating that the residents’ PASARRs did not meet expectations because they were not completed accurately or updated to reflect the residents’ behavioral health diagnoses. Resident 8 was readmitted with diagnoses including anxiety disorder, depression, schizophrenia, and PTSD, but the level I PASARR was completed later and staff stated it should have been completed when the resident readmitted. Resident 37 was readmitted with vascular dementia with behavioral disturbance, adult failure to thrive, and a history of traumatic brain injury; a level I PASARR dated 03/13/2025 was marked void, and a later level I PASARR identified serious mental illness indicators and required a level II referral. Resident 2’s PASARR documented mood disorder and PTSD, but the resident’s admission record was later updated with a new diagnosis of psychotic disorder with delusions due to a known physiological condition, and staff stated the PASARR should have been updated to reflect the new mental health diagnosis. Resident 21’s PASARR documented anxiety disorder only, while the resident’s MDS and EHR showed anxiety, depression, and PTSD; staff stated the depression and PTSD diagnoses should have been included on the initial PASARR form.
Incomplete Care Plans for Residents With Dementia and Behavioral Health Needs
Penalty
Summary
The facility failed to develop and/or implement individualized comprehensive care plans for 3 of 19 sampled residents whose care plans were reviewed. The facility policy titled, Comprehensive Care Plans, stated the interdisciplinary team would develop and implement a comprehensive, person-centered care plan for each resident with measurable objectives and timeframes to meet identified medical, nursing, physical, mental, and psychosocial needs. The deficiency involved residents with dementia and behavioral health needs whose care plans did not include specific directions or were not created when required. Resident 36 was admitted with diagnoses including metabolic encephalopathy, COPD, and depression, and stated during interview that they had PTSD and had been raped multiple times in the past. A social service evaluation titled Post-Traumatic Checklist was completed, and the care plan dated 07/07/2025 listed PTSD as a focus area without specific directions or instructions for staff. Resident 37 had diagnoses including dementia and adult failure to thrive, and a significant change in condition MDS dated 04/17/2025 triggered care planning for cognitive loss/dementia, but the care plan decision was documented as "No." The focused care plan for impaired cognitive function and communication related to dementia was not initiated until 07/28/2025. Resident 2 was admitted with multiple conditions including heart and lung disease, hemiplegia, dementia, depression, and PTSD, and was receiving a psychotropic medication for distress related to dementia with psychosis, but the care plan contained no focus care plan related to dementia with specific interventions for staff to provide the necessary care and services.
Failure to Document Non-Pharmacological Interventions Before PRN Pain Medications
Penalty
Summary
The facility failed to consistently provide non-pharmacological interventions before administering PRN pain medications for 2 of 5 sampled residents, Residents 55 and 37. Resident 55 was admitted with dementia, muscle weakness, and adult failure to thrive and was unable to make needs known. The June 2025 MAR showed orders for PRN acetaminophen and nonpharmacological interventions, but acetaminophen was given without NPI on 8 of 10 opportunities. The July 2025 MAR showed orders for PRN acetaminophen, PRN oxycodone, and NPI, but acetaminophen was given without NPI on 2 of 3 opportunities and oxycodone was given without NPI on 5 of 12 opportunities. Resident 37 was readmitted with dementia and osteoarthritis and was able to make needs known. The July 2025 MAR and monitors record showed orders for PRN oxycodone, pain monitoring, and documentation of NPI with a code number and number of episodes. Documentation showed no NPI recorded on eight days when oxycodone was provided once or twice a day. Staff interviews confirmed the expectation that pain should be assessed and NPI offered and documented before PRN pain medication was given, and that Resident 37's pain and NPI documentation was inconsistent and did not meet expectations.
Failure to Arrange and Follow Up on Dental Consults
Penalty
Summary
The facility failed to provide assistance and follow up on dental care for two residents who had documented oral health needs. Resident 21 was admitted with multiple diagnoses including heart and lung disease, anxiety, and depression, and required substantial assistance with ADLs. The admission MDS documented obvious or likely cavities or broken natural teeth, mouth or facial pain, discomfort, or difficulty chewing. A provider order dated 04/24/2025 directed a dental consultation and treatment as needed, and the care plan identified risk for decline in oral status related to missing carious teeth with interventions for staff to coordinate dental care and transportation as needed. When observed on 07/23/2025, the resident was in bed and had multiple teeth deeply stained dark brown; the resident stated they had bad teeth with multiple cavities and had not been seen by a dentist since admission. Resident 41 was admitted with multiple diagnoses including heart and lung disease, stroke, and malnutrition, and also required substantial assistance with ADLs. The admission MDS documented broken or loosely fitting partial dentures, no natural teeth, and obvious or likely cavities or broken natural teeth. During interview, the resident stated they had lost their lower denture plate and were supposed to see a dentist but had not been seen. The care plan identified oral/dental problems, and an email from MDS staff noted the resident had no teeth, wore only upper dentures with one tooth missing, had lost the bottom dentures in November of the prior year, and reported trouble chewing and needing a dental consult. Staff interviews showed the dental needs had not been placed into the consultation binder until later, and social services stated they were unaware of the email until interviewed.
Failure to Implement Effective Antibiotic Stewardship
Penalty
Summary
The facility failed to implement an effective Antibiotic Stewardship Program to promote appropriate antibiotic use, reduce unnecessary antibiotic use, and decrease the development of adverse side effects and antibiotic resistance for 2 sampled residents. The facility policy stated it would follow national standards, including revised McGeers criteria, to guide treatment for infections, and the revised criteria required specific signs or symptoms and a positive urine culture for a resident with a urinary catheter. Resident 29 was admitted with diagnoses of type 2 diabetes and kidney failure and was able to make needs known. The resident had an order for amoxicillin daily for 10 days for a presumed UTI and received all 10 doses. A provider note documented suprapubic pain, but a urinalysis collected the next day returned no bacterial growth, and the infection control line listing for the month showed infection criteria was not met. No documentation was found on the electronic health record to support the continued administration of the antibiotic. Resident 45 was admitted with congestive heart failure and Alzheimer's disease and was able to make needs known. The resident received nitrofurantoin four times a day for 7 days and received all 27 doses. The infection control line listing did not include this infection, lab results showed negative UTI results with a 20,000-49,000 colony count, and no documentation was found for the rationale for continued antibiotic administration.
Failure to Assess and Offer Pneumococcal Vaccines
Penalty
Summary
The facility failed to offer, educate, and obtain consent for pneumococcal vaccines for 2 of 5 sampled residents, Resident 31 and Resident 45, when their immunizations were reviewed. Resident 31 was admitted with diagnoses of stroke and weakness and was not able to make needs known; the EHR contained no documentation that the resident was assessed for the need for a pneumococcal vaccine and no documentation that the resident or representative was educated or offered the vaccine. Resident 45 was admitted with diagnoses of congestive heart failure and Alzheimer's disease and was able to make needs known; the EHR also contained no documentation that this resident was assessed for pneumococcal vaccine need or that the resident or representative was educated or offered the vaccine. During interview, the DON stated the facility had not assessed all residents for pneumococcal vaccination status or offered the vaccines to all residents as needed.
Failure to Document Monitoring of Psychotropic Medications
Penalty
Summary
The facility failed to ensure psychotropic medications were regularly monitored and that adverse side effects and effectiveness were documented for Resident 49. Resident 49 was admitted with diagnoses of major depression, anxiety, diabetes, and insomnia, and the quarterly MDS showed the resident was cognitively intact. On observation, Resident 49 was in their room with a staff member providing one-on-one supervision. Review of the EHR showed the resident was receiving scheduled psychotropic medications, including an antipsychotic and an antidepressant, but there was no documentation of monitoring for adverse side effects or behaviors related to these medications. During interview, the DON stated nurses were expected to monitor and document behaviors and adverse side effects in the EHR, and that the lack of documentation for Resident 49 did not meet expectations.
Failure to Provide Written Bed Hold Notices After Hospital Transfers
Penalty
Summary
The facility failed to provide bed hold notices in writing at the time of transfer to the hospital or within 24 hours of transfer for 2 of 2 sampled residents reviewed for hospitalization. Resident 37 was admitted with diagnoses of dementia, adult failure to thrive, and alcoholic cirrhosis of the liver, and was able to make needs known. The record showed the resident was transferred to the hospital and later readmitted, but there was no documentation that a bed hold was offered for the transfer or discharge to the hospital. Resident 29 was admitted with diagnoses of type 2 diabetes, heart failure, and kidney failure, and was also able to make needs known. The record showed the resident was discharged to the hospital and later returned to the facility in a different room, but there was no documentation that a bed hold was offered at the time of transfer. During interviews, the SSD stated a bed hold should have been offered and documented for both residents, and the Administrator stated there should have been a completed bed hold form or a progress note documenting the offer and any attempts to contact Resident 37, and that this did not meet expectations.
Failure to Complete Significant Change MDS After Hospice Start
Penalty
Summary
The facility failed to identify a significant change of condition for Resident 58, who was admitted with diagnoses including Alzheimer's disease, diabetes, and depression. The record showed the resident began hospice services on 02/20/2025, but the MDS schedule reflected an annual MDS on 12/31/2024 and a quarterly MDS on 04/02/2025 that did not address hospice services. During interview, the DON stated Resident 58 should have had a change of condition MDS after hospice services were initiated and acknowledged that the lack of a change of condition MDS did not meet expectations.
Inaccurate MDS Coding for Hospice and Dialysis Services
Penalty
Summary
The facility failed to ensure accurate MDS assessments for 2 of 19 sampled residents, Residents 37 and 29. Resident 37 was readmitted with diagnoses of dementia, adult failure to thrive, and alcoholic cirrhosis of the liver, and was able to make needs known. The EHR showed a hospice certification and plan of care order dated 04/11/2025 indicating hospice services were being provided and documented, but the quarterly MDS dated 07/10/2025 showed the resident was not receiving hospice care services. During interview, the MDS Coordinator stated the resident was receiving hospice care and the quarterly MDS should have been coded for hospice care, and the DNS stated the hospice coding was inaccurate and did not meet expectations. Resident 29 was admitted with diagnoses of type 2 diabetes and kidney failure and was able to make needs known. The EHR showed the resident required dialysis three days a week from 05/12/2025 to 07/29/2025, but the MDS dated 07/10/2025 showed the resident was not receiving dialysis. During interview, the MDS Coordinator stated the resident should have been marked yes to indicate dialysis during the stay, and the DNS stated it was their expectation that the MDS assessment included the resident's dialysis services.
Care plans were not updated after changes in resident status
Penalty
Summary
The facility failed to ensure care plans were timely revised when residents’ conditions or treatments changed for 2 of 19 sampled residents. Resident 48 was admitted with diagnoses including respiratory failure, diabetes, heart failure, and end stage renal disease with dialysis. The resident was able to communicate needs and stated during interview that they were on a fluid restriction of 40 ounces a day. The care plan for oral intake, initiated on 09/20/2023, still showed a 1000 mL fluid restriction even though the provider order for fluid restriction was discontinued on 07/18/2025. The Director of Nursing stated the care plan should have been updated after the order was discontinued and that the fluid consumption care plan did not meet expectations. Resident 37 was readmitted to the facility and had diagnoses including vascular dementia with other behavioral disturbance, adult failure to thrive, and history of traumatic brain injury. Review of current provider orders showed the resident was not prescribed psychotropic medications, but the current care plan dated 04/22/2025 still stated the resident used psychotropic medications and was at risk for falls related to psychoactive drug use and antianxiety medication. The Director of Nursing stated care plans were to be revised quarterly, annually, and with a change in condition, and that if a problem or issue was identified or resolved, the care plan should be revised as soon as possible. The Director of Nursing also stated the psychotropic medication use documented in the care plan no longer reflected the resident’s status and needed to be revised.
Failure to Provide Resident's Preferred Activity
Penalty
Summary
Provide activities to meet all resident's needs. Based on observation, interview, and record review, the facility failed to ensure Resident 55 was provided an activity program. Resident 55 was admitted with dementia, muscle weakness, and adult failure to thrive, and was unable to make needs known. The care plan, initiated 03/27/2025, identified the resident as dependent on staff for activities and unable to attend outside room activities. An Activities Recreation Quarterly/Annual Review dated 05/16/2025 showed the resident liked to watch television in the room. Observations on 07/23/2025, 07/24/2025, and 07/25/2025 showed Resident 55 lying in bed with the TV off and angled away from the bed. During interview, the Activity Assistant stated the resident sometimes had the TV on and did not think the resident could turn it on or re-angle it. The Activity Director stated the resident enjoyed watching the news and would request it be put on, and stated the resident's TV was unplugged and this did not meet expectations. The Administrator stated CNAs were responsible for ensuring residents had their TVs on if that was their preferred activity, and agreed the observations of the TV being off, angled away from the bed, and unplugged did not meet expectations.
Delayed Integration of Hospice Care Plans
Penalty
Summary
The facility failed to timely develop a collaborative comprehensive care plan that integrated hospice care services for two residents. The report states that the facility’s policy required the facility and hospice to establish a coordinated plan of care identifying the specific services and functions each provider was responsible for performing. For one resident, who had diagnoses including dementia, adult failure to thrive, and alcoholic cirrhosis of the liver and was able to make needs known, hospice services began with a hospice certification and plan of care order and a hospice coordination of care document signed by hospice and facility staff, but the resident’s focused hospice care plan was not initiated until later and did not include hospice location, a point of contact, or specific hospice services/functions. Staff stated the plan did not meet expectations because it should have been started when the order was obtained and should have incorporated the hospice coordination of care information. For the second resident, who had diagnoses including dementia, malnutrition, anorexia, and adult failure to thrive and was not able to make needs known, hospice services were admitted and a hospice plan of care/coordination of care was received by the facility, but the hospice services were not integrated into the resident’s plan of care until later. The DNS stated the facility should have created a care plan integrating hospice services sooner, but it was not done until the later date noted in the record.
Pressure Injury Prevention Interventions Not Provided
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not ensured for one resident with a stage three pressure injury to the right foot and a small open area to the left buttock. The resident was admitted with diagnoses including hemiplegia, psychotic disorder with delusions, and chronic obstructive pulmonary disease, and was unable to make needs known. The care plan, initiated on 04/11/2025, included interventions to avoid positioning the resident on their back, float heels, and use a pressure relieving mattress. Observations showed the resident lying on their back in bed on multiple occasions, with two inflatable boots on the nightstand rather than on the resident. The resident’s air mattress was observed set to 660 to 750 pounds, with lights flashing on the extra firm and low pressure indicators and the control unit emitting a loud whirring sound. The DON stated the mattress should have been set to 174 pounds and that the inflatable boot should have been applied; the RN/Resident Care Manager stated the observations of the resident’s heels not being floated did not meet expectations.
Resident had access to weapons in room
Penalty
Summary
The facility failed to ensure that Resident 38 did not have access to weapons. Resident 38 was admitted with diagnoses including heart disease, dementia, unspecified psychosis, and bipolar disorder, and was able to make needs known. The care plan, initiated on 03/06/2023, identified the resident as being at risk for potential alteration in mood and behaviors due to bipolar disorder and unspecified psychosis, with ineffective coping skills and poor impulse control. Observation showed a piece of rebar next to Resident 38's sink and a baton sticking out from the bedside table drawer, which was left ajar. These items were observed repeatedly during multiple visits. The record also showed an incident report dated 06/25/2025 in which Resident 38 had an altercation with another resident, called the other resident an expletive, and threatened to pulverize them. During interview, the DON stated residents with behavioral issues should not have access to weapons and that staff were expected to observe the rebar and baton and intervene as needed.
Failure to Monitor and Document Fluid Restriction
Penalty
Summary
The facility failed to ensure accurate monitoring and documentation of fluid restrictions for Resident 29, who was admitted with diagnoses of type 2 diabetes and kidney failure and was receiving dialysis services. The resident was able to make needs known. A provider order dated 05/10/2025 specified a daily fluid restriction of 2000 milliliters, but there was no documentation of the amount of fluid received from nursing or dietary, and the daily total was not calculated or documented in the EHR. During interviews, the RN/Resident Care Manager stated the facility should divide fluids between dietary and nursing and calculate the totals at the end of the day, and the DON stated the fluid restriction orders were not clear and should have been clarified.
Tube Feeding Not Managed per Orders and Standards
Penalty
Summary
Enteral nutrition was not administered in accordance with provider orders and professional standards of practice for one sampled resident with a gastrostomy tube. The resident was admitted with diagnoses including gastrostomy status, heart failure, convulsions, and anoxic brain damage, and was unable to communicate needs. The quarterly MDS showed the resident was dependent on staff for ADLs, including nutrition. During observation, the resident was receiving tube feeding in bed. The feeding formula bag was hanging on a pole next to the bed and was dated 07/21/2025 at 3:00 AM, while the water bag next to it had no date. On later observations, the water bag remained undated on 07/24/2025 and 07/25/2025. Another observation showed the resident in bed receiving tube feeding with the bed low to the floor and flat; an LPN stated the head of the bed should be elevated to prevent aspiration. A later observation showed the water bag dated 07/28/2025 at 10:32 PM. The DON stated the water bag and formula bag were to be changed every day during night shift and that the observed bags and the resident being flat in bed while receiving formula did not meet expectations.
Delayed Follow-Up on Dental Referral
Penalty
Summary
The facility failed to provide prompt follow up on a provider’s referral for dental care services for Resident 44. Resident 44 was admitted with diagnoses of diabetes, high blood pressure, and depression, was able to communicate needs, and was observed with missing and broken upper and lower teeth. The resident stated a desire to see a dentist to have the teeth removed so dentures could be obtained. The admission MDS documented obvious or likely cavities or broken natural teeth, and the care plan identified oral/dental health problems with a goal of being free of infection, pain, or bleeding in the oral cavity. A dental consult documented red and irritated gums and broken and missing upper and lower teeth, and the dentist referred the resident for x-rays, evaluation, and extraction of all teeth, with a recommendation for hygiene cleaning and discussion with family. The record contained no documentation of a scheduled follow-up dental appointment after the referral. During interviews, the Social Services Assistant stated the resident needed a follow-up appointment for teeth extraction but documentation of a scheduled appointment could not be located and the family still needed to be contacted. The Administrator stated the dental referral and recommendation should have been followed up on prior to now and did not meet expectations.
Infection Control Data Not Tracked or Trending
Penalty
Summary
Provide and implement an infection prevention and control program. The facility failed to maintain an infection prevention and control program by completing and analyzing infection control data, identifying trends, and completing follow-up activities in response to those trends for 3 of 3 sampled months, April, May, and June 2025. Review of the facility policy titled Infection Preventions and Control Program dated 08/2022 showed the surveillance log was to include the pathogen and the infection preventionist was to use the information to identify trends to minimize further spread and to implement changes and/or education to address the trends. Review of the facility infection control line listing documentation for 04/2025, 05/2025, and 06/2025 showed no identified organisms were included in the data, no monthly summary was completed showing the data was analyzed or trends identified, and there were no interventions to address the trends. During an interview on 07/29/2025 at 2:22 PM, the DON stated they were aware of the missing tracking, trending, and interventions, and this did not meet their expectations.
Missing Emergency Call Light in Resident Bathroom
Penalty
Summary
The facility failed to have an emergency call light system in place that allowed a resident to call for help from the bathroom in room [ROOM NUMBER] on the 300 hallway. Observations on 07/24/2025 and 07/25/2025 showed that the bathroom in room [ROOM NUMBER] had no emergency call light system. During an interview on 07/24/2025, Resident 1, who resided in room [ROOM NUMBER], stated they used the bathroom and had not noticed that there was no call light in the bathroom. During interviews on 07/25/2025, the DON stated there was not an emergency call light in room [ROOM NUMBER]'s bathroom and there should be, and the Administrator stated their expectation was that all resident bathrooms had an emergency call light within reach for residents to use. The Administrator also stated they had not been aware that the bathroom in room [ROOM NUMBER] did not have an emergency call light and that it somehow got missed during weekly environmental room rounds.
Failure to Assess and Care Plan for Residents with Substance Use Disorder
Penalty
Summary
The facility failed to adequately assess residents with a history of Substance Use Disorder (SUD) for associated risks, develop comprehensive individualized care plans, and implement interventions to ensure their safety. For five sampled residents with SUD, the facility did not consistently perform or document risk assessments, provide education on facility policies regarding substance use, or increase monitoring as care planned. In several cases, residents with known SUD histories were not given individualized care plans addressing their specific risks, and interventions such as increased monitoring or education were either not implemented or not documented. One resident with a history of polysubstance abuse and homelessness experienced repeated late-night visits from outsiders and was later found unresponsive in their room alongside a visitor, requiring emergency intervention with Narcan and hospitalization. Despite care plan interventions calling for increased monitoring and assessment, there was no documentation that these actions were carried out. Another resident with opioid abuse and polysubstance use was administered Narcan after being found drowsy and unresponsive, but their care plan did not address SUD-related risks, and there was no evidence of education on facility policies regarding substance use. Other residents with SUD histories were noted to leave the facility unsupervised, associate with individuals known for drug use, and return with signs of substance use, yet their care plans lacked specific interventions for SUD risk management. Staff interviews revealed a lack of standardized assessment tools for SUD, inconsistent care planning practices, and failure to educate residents on facility policies regarding substance use. Admission staff did not review facility rules or policies on drug use with residents, and there was no documentation that residents were informed of expectations regarding substance use and possession of illegal substances. The facility's own policy required individualized, resident-centered interventions for SUD, but these were not consistently implemented or documented for the affected residents.
Failure to Develop Personalized Discharge Plans
Penalty
Summary
The facility failed to develop personalized discharge plans for four residents, which led to a risk of delayed discharge and unmet care needs post-discharge. For Resident 4, the facility did not have an active discharge plan despite the resident's goal to return to the community. The resident's stepdaughter was involved in discussions about a potential discharge to Hawaii, but there were barriers such as funding and insurance issues. The facility's Social Services Director acknowledged that discharge planning information was not documented in the resident's record, and the stepdaughter was unaware of the discharge status. Resident 1 also lacked an active discharge plan, despite expressing a desire to return home to live with their wife and cats. The resident faced barriers such as limited use of their right side and the need for stair training, which had not been addressed. Similarly, Resident 3's discharge plan was incomplete, and the resident left the facility against medical advice. The facility's staff acknowledged that there should have been a discharge care plan in place. Resident 5 expressed a desire to return home but was unsure of the barriers to discharge. The facility held weekly meetings to discuss discharge planning, but documentation was not included in the residents' individual files. The lack of personalized discharge plans for these residents indicates a failure to meet their identified needs, goals, and preferences, as required by regulations.
Deficiency in Resident Hydration Due to Inadequate Water Provision
Penalty
Summary
The facility failed to ensure that residents received drinks consistent with their needs and preferences, leading to a deficiency in maintaining resident hydration. Observations on March 11, 2025, revealed that 11 out of 13 sampled residents did not have water pitchers at their bedside, which is contrary to their care plans. For instance, Resident 5 was observed without a water pitcher, despite a care plan intervention to offer fluids at bedside and every meal. Similarly, Resident 4 reported not receiving enough to drink and noted that the facility ran out of orange juice, which was part of their care plan intervention to have commonly used items like ice water within reach. Interviews with residents and staff highlighted systemic issues in providing adequate hydration. Residents such as Resident 7 and Resident 9 expressed that they had to request water, and it was not routinely provided. Staff interviews revealed that there was a shortage of water pitchers, and the facility had ordered more to address this issue. However, the Food Service Manager admitted that the plan to distribute water pitchers had not yet been implemented. This lack of consistent access to water placed residents at risk of insufficient fluid intake, as evidenced by the observations and resident statements.
Failure to Provide Scheduled Bathing for Residents
Penalty
Summary
The facility failed to ensure that activities of daily living (ADLs) related to bathing and showers were provided for two dependent residents, Resident 1 and Resident 5. Resident 1, who was alert and oriented, required partial/moderate assistance for bathing and was scheduled for showers twice a week. However, documentation showed that Resident 1 only received a shower once since admission, with refusals and missed opportunities noted without proper documentation. Resident 1 reported not having a shower since admission and relied on bed baths provided by their wife. Similarly, Resident 5, with cognitive impairment, required supervision or touching assistance for bathing. The documentation indicated that Resident 5 received a bed bath and a sponge bath but was not offered a shower on scheduled days, with refusals and missed opportunities also noted. The deficiency was attributed to the facility's failure to update and maintain accurate shower schedules for the residents. Staff interviews revealed that the shower schedule was outdated and did not include the room where Residents 1 and 5 resided, as it had been converted from office space to a resident room. Staff members acknowledged the oversight, noting that the shower schedule in the binder and electronic medical record did not match, leading to the residents not being scheduled for showers. This lack of coordination and communication among staff resulted in the residents not receiving the necessary bathing care as per their care plans.
Failure to Implement Hot Food and Beverage Policy Results in Resident Burns
Penalty
Summary
The facility failed to implement a hot food and beverage policy, resulting in two residents suffering second-degree burns. Resident 1, who had moderate cognitive impairment and required setup assistance, was served hot coffee without a secured lid, which spilled in their lap, causing burns. The facility's investigation revealed that the coffee was served at a temperature higher than the policy's limit, and the resident's personal coffee mug was not properly closed, leading to the spill. Resident 2, who was alert and oriented but had impaired mobility, was served hot soup that was not temperature-checked before being given to them. The soup spilled in their lap, causing burns to their thighs and groin. The CNA responsible for serving the soup was from a staffing agency and was unaware of the need to check the temperature, which was a contributing factor to the incident. The facility's documentation showed inconsistencies in monitoring and recording beverage temperatures, with some entries missing or exceeding the policy's temperature limits. The lack of adherence to the hot food and beverage policy and inadequate staff training on temperature checks contributed to the incidents, placing residents at risk for burns and injuries.
Deficiency in Food Temperature Management
Penalty
Summary
The facility failed to provide food at appetizing temperatures, which was identified during a review of kitchen services. This deficiency was highlighted by resident complaints and observations made by surveyors. Resident 44 expressed dissatisfaction with receiving cold eggs, while Resident 35 noted that hot items were not sufficiently hot and cold items were served at room temperature on multiple occasions. During an observation of lunch tray preparation, Staff U, a cook, was seen taking temperatures of food on the steam table by poking holes through foil coverings, which is not the correct method for accurate temperature measurement. Additionally, Staff X, a dietary aide, was observed preparing watermelon cups that were left unrefrigerated for the duration of the meal service, contrary to the facility's expectations as stated by Staff V, the dietary manager.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to address concerns raised by the resident council regarding resident care, as evidenced by the review of the resident council meeting minutes from September 2024. The concerns included issues with missing laundry items, loud talking during sleep hours, long call light wait times, and staff entering resident rooms and turning off call lights without providing assistance. Despite these concerns being documented in the resident council minutes, there were no corresponding entries in the Grievance Log from March 2024 to September 2024, indicating a lack of follow-up on these issues. During an interview, the Recreation Assistant, Staff P, confirmed that concerns voiced by residents were documented on a grievance form and given to the Administrator for follow-up, but they were unaware of any subsequent actions taken and noted that grievances were not typically discussed in the following month's meeting.
Lack of Weekend Access to Resident Funds
Penalty
Summary
The facility failed to provide residents with access to their personal funds on weekends, which was identified during a survey. This deficiency was observed in the case of Resident 10, who was admitted to the facility on an unspecified date. The electronic health record indicated that Resident 10 was rarely understood, suggesting potential communication challenges. During an interview, a collateral contact confirmed that the facility held Resident 10's money in a trust. Further interviews with the Business Office Manager revealed that residents could only access their funds between 8:00 AM and 4:30 PM from Monday to Friday. Additionally, there was no posted information in the facility indicating that money was available after business hours, contributing to the deficiency.
Failure to Provide Personal Fund Statements
Penalty
Summary
The facility failed to provide quarterly personal fund statements to residents with personal fund accounts, specifically affecting one resident who was reviewed for personal funds. Resident 10, who was admitted to the facility and was rarely understood according to their electronic health record, did not receive statements regarding their personal funds held in a trust by the facility. During an interview, a collateral contact for Resident 10 expressed that they were unaware of the amount of money in the trust due to the lack of statements. The Business Office Manager, Staff Q, acknowledged that residents were supposed to receive personal fund statements at the beginning of each month but admitted they could not recall when the last statements were provided, as they were new to the position and still learning the process. It was confirmed that residents did not receive a statement in September.
Facility Fails to Maintain Sanitary and Safe Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment, as evidenced by multiple observations of unsanitary bathroom conditions across several rooms. Toilets were found with brown stains, broken tiles, and in some cases, were clogged or backed up, forcing residents to use alternative facilities. Residents reported that these issues had persisted for some time, and staff interviews confirmed that maintenance problems were known but not adequately addressed. The lack of timely cleaning and repair contributed to an undignified living environment for the residents. Housekeeping services were insufficient, with reports of rooms not being cleaned daily and debris accumulating on floors. Interviews with residents and staff revealed that the facility was understaffed in housekeeping, leading to inadequate cleaning routines. The facility had only one housekeeper for a shift, and the absence of weekend coverage exacerbated the situation. The lack of regular vacuuming and carpet cleaning contributed to unpleasant odors and a generally unclean environment. The facility also had maintenance issues, such as a hot pipe in the dining room with inadequate insulation, posing a safety risk. Staff interviews indicated that the maintenance reporting system was not effectively utilized, and there was no permanent maintenance staff on-site. The presence of flies in the facility was attributed to an open door, and this issue, along with others, was not promptly addressed. These deficiencies in maintenance and housekeeping compromised the residents' right to a safe and comfortable environment.
Deficiencies in Care Plan Implementation for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive and person-centered care plans for three residents, leading to unmet needs and inadequate care. Resident 309, who was admitted with a fracture of the left femur, diabetes, and muscle weakness, required heel protector boots to prevent skin impairment. However, observations over several days showed the resident lying in bed without the boots or any alternative measures to offload pressure from the heels. Staff interviews revealed that the boots were unavailable, and a temporary solution using a pillow was suggested but not documented in the care plan. Resident 20, with a diagnosis of obstructive uropathy and a urinary tract infection, had an indwelling catheter and preferred using a leg bag. The care plan lacked specific instructions for the care and maintenance of the leg bag, leading to observations of the resident with a discolored urine bag positioned incorrectly. Staff interviews indicated a lack of awareness and documentation regarding the resident's use of a leg bag. Resident 39, diagnosed with schizophrenia and anxiety, was observed with poor personal hygiene, and the care plan did not document the resident's frequent refusal of showers. Staff interviews confirmed that refusals were not documented, and the care plan lacked interventions for managing these refusals.
Care Plan and Conference Deficiencies
Penalty
Summary
The facility failed to revise and update the care plans for two residents and did not conduct a care conference for another resident, leading to deficiencies in care. Resident 1, who was admitted with vascular dementia and absence of the larynx, experienced a fall on 09/06/2024. However, the facility did not complete a fall risk assessment or update the care plan following the incident. The Interim Director of Nursing Services acknowledged that the care plan should have been updated to reflect new interventions after the fall. Resident 30, who was readmitted with anemia and anxiety disorder, reported a dental issue where a filling had fallen out, affecting their ability to chew. Despite a provider's note indicating the need for dental follow-up and monitoring for infection, the care plan was not updated to include these concerns. Additionally, Resident 209, admitted with acute respiratory failure and chronic kidney disease, did not have a care conference within the required timeframe. The Social Services Director confirmed that a care conference should have been held within 72 hours of admission, but this did not occur.
Deficiencies in Skin Care, Anticoagulant Monitoring, and Bowel Management
Penalty
Summary
The facility failed to accurately assess, monitor, document, care plan, and provide necessary care for a resident with multiple skin issues. Resident 209, who had diabetes, peripheral vascular disease, and a history of toe amputation, was admitted with various skin conditions, including a hemodialysis fistula, moisture-associated skin damage, and fragile skin. Despite these conditions, the facility did not document measurements for the skin issues, nor did they have orders to wrap the resident's foot or monitor the fistula. The care plan lacked interventions for these issues, and the treatment orders were unclear and not followed as documented in the medication administration record. The facility also failed to monitor and document adverse side effects for a resident on anticoagulant therapy. Resident 21, who had heart failure, diabetes, and venous hypertension, was on blood-thinning medication but had no documentation of monitoring for adverse side effects for 30 days. Interviews with staff revealed that the lack of documentation did not meet expectations, indicating a failure in monitoring the resident's condition as required. Additionally, the facility did not consistently monitor and document bowel movements for two residents, nor did they implement the bowel program when needed. Resident 31, with epileptic syndrome and dementia, had no documented bowel movements for several days, and no as-needed medications were administered for constipation. Similarly, Resident 44, who was on medications causing constipation, had multiple days without documented bowel movements, and the bowel protocol was not initiated. Staff interviews confirmed that the facility's actions did not meet the expected standards for bowel management.
Failure to Provide Non-Pharmacological Interventions and Conduct Lab Testing
Penalty
Summary
The facility failed to provide non-pharmacological interventions for three residents before administering as-needed pain medications, as required by their care plans. Resident 17, who was admitted with hypertension and chronic embolism, received tramadol without any documented non-pharmacological interventions. Similarly, Resident 24, with diagnoses including high blood pressure and intervertebral disc degeneration, was given oxycodone outside the prescribed pain level parameters, and non-pharmacological interventions were not documented. Resident 46, diagnosed with skin infection, diabetes, and opioid use, received narcotic pain medication multiple times without the required non-pharmacological interventions being documented. Additionally, the facility failed to conduct necessary laboratory testing for Resident 31, who was prescribed Keppra for epileptic syndrome. Since admission, no lab tests were performed to check the resident's Keppra blood levels, which should have been done every six to twelve months according to the Advanced Registered Nurse Practitioner. This oversight placed the resident at risk of receiving unnecessary medications and a diminished quality of life.
Failure to Provide Prescribed Therapeutic Diets
Penalty
Summary
The facility failed to prepare and provide the menu items included in regular or therapeutic diets for all residents, which compromised the required nutritive value for each meal. On 10/07/2024, the lunch menu for residents on regular diets was supposed to include glazed baked ham, maple roasted sweet potatoes, spinach, a white roll, and chocolate chess pie. However, observations revealed that no white rolls or glazed baby carrots were prepared for meal service. Additionally, during the lunch tray preparation, all residents were served the same portion sizes regardless of their dietary needs. Staff U, the cook, admitted to not having glazed carrots and not providing white rolls with the meal. Furthermore, when spinach ran out, green beans were served to the remaining residents on the last hall. Staff V, the Dietary Manager, confirmed that the expectation was for therapeutic diets and resident preferences to be followed according to the tray card, and all menu items should have been prepared or communicated if unavailable for necessary adjustments.
Failure in Antibiotic Stewardship Program Implementation
Penalty
Summary
The facility failed to implement an effective Antibiotic Stewardship Program, which is crucial for promoting appropriate antibiotic use, reducing unnecessary antibiotic use, and decreasing the development of adverse side effects and antibiotic resistance. This deficiency was identified for one resident and involved the facility's failure to complete tracking and trending of antibiotic use and report these findings to the Quality Assurance and Performance Improvement (QAPI) program for three consecutive months. The facility's policy required that infections, antibiotic usage, sensitivity, and resistance patterns be tracked and reported to QAPI monthly, but this was not done for June, July, and August 2024. Resident 20 was admitted with diagnoses of obstructive uropathy and a urinary tract infection and was prescribed ceftriaxone sodium. However, laboratory results showed that the bacterium causing the infection was resistant to ceftriaxone. There was no documentation in the electronic health record that the provider was notified of these results, which is a critical step in ensuring appropriate antibiotic use. During an interview, the Regional Nurse Consultant confirmed the lack of documentation for tracking and trending being brought to QAPI and stated that staff should notify the provider and change the antibiotic if the organism is resistant.
Failure to Educate and Offer Vaccinations
Penalty
Summary
The facility failed to offer, educate, and obtain consent for influenza and/or pneumococcal vaccines for two of five sampled residents. Resident 18, who was admitted with diagnoses of heart failure, kidney disease, and diabetes, refused the influenza and pneumococcal vaccinations. However, there was no documentation indicating that the resident was educated on the risks and benefits of these vaccines prior to refusal. Similarly, Resident 50, admitted with acute kidney failure and morbid obesity, had no documentation in their electronic health record showing that they were educated on the risks and benefits of the influenza vaccine or that it was offered to them. During an interview, the facility's administrator stated that it was expected that residents be educated on the risks and benefits of available vaccines before they are offered.
Failure to Educate and Document COVID-19 Vaccine Offer
Penalty
Summary
The facility failed to offer, educate, and obtain consent for COVID-19 vaccines for two residents, identified as Residents 18 and 50, during a review of immunizations. Resident 18, who was admitted with diagnoses of heart failure, kidney disease, and diabetes, had refused the COVID vaccination. However, there was no documentation indicating that the resident was provided with education on the risks and benefits of the vaccine prior to making this decision. Similarly, Resident 50, admitted with acute kidney failure and morbid obesity, also lacked documentation in their electronic health record (EHR) regarding education on the risks and benefits of the COVID vaccine or an offer to receive it. During an interview, the Regional Nurse Consultant confirmed the absence of documentation for both residents, indicating a failure in the facility's process to ensure informed decision-making regarding COVID-19 vaccinations.
Failure to Provide Non-Disposable Cups During Meals
Penalty
Summary
The facility failed to ensure a dignified dining experience for residents by not providing non-disposable cups during meals across four sampled halls. Observations on multiple occasions revealed that staff were using plastic cups to serve beverages such as juice and milk to residents. This practice was consistent across the 100, 200, 300, and 400-halls, indicating a widespread issue within the facility. Interviews with staff members, including Certified Nursing Assistants (CNAs), revealed that the use of plastic cups was due to a shortage of non-disposable cups. Staff O mentioned the lack of sufficient non-disposable cups, while Staff N admitted to not checking the kitchen for additional supplies. Staff M, a recently hired CNA, confirmed that they were trained to use plastic cups. The Regional Nurse Consultant, Staff B, acknowledged that more cups had been ordered, but the floor staff had not been informed, leading to the continued use of disposable dishware.
Failure to Honor Resident's Right to Choose Life-Saving Interventions
Penalty
Summary
The facility failed to honor a resident's right to choose the level of life-saving interventions, specifically for Resident 39. The resident was admitted with diagnoses including pulmonary emboli, schizophrenia, and anxiety. Despite being deemed capable of making decisions during the admission assessment, a POLST form, which details the resident's wishes for life-saving measures, was not completed or reviewed with the resident. Instead, a provider note indicated a decision was made to transition the resident to a DNR/DNI status without the resident's input, citing their inability to make complex decisions. Interviews with facility staff revealed that the POLST form should have been reviewed and completed upon admission and then reviewed quarterly. Staff C, the Social Services Director, acknowledged that the POLST form was not completed as required. Staff B, the Regional Nurse Consultant, confirmed that the facility's protocol in the absence of a decision-maker would default to full code, which was not followed in this case. The lack of a completed POLST form and the resident being listed as DNR/selective treatment did not meet the facility's expectations.
Failure to Address Resident Grievance on Missing Property
Penalty
Summary
The facility failed to initiate and resolve a grievance for a resident regarding missing personal property. The resident, who was admitted with osteomyelitis and diabetes, reported missing black pajama bottoms to the Housekeeping Manager. Despite being informed, the Housekeeping Manager did not follow up or initiate a grievance, as they were unaware of their ability to do so. The grievance was not documented in the facility's Grievance Log, and the Interim Director of Nursing Services confirmed that a grievance should have been initiated if the issue could not be resolved immediately.
Failure to Provide Written Notification for Hospital Transfer
Penalty
Summary
The facility failed to provide written notification of the reason for transfer to the hospital to a resident or responsible party for one of the sampled residents reviewed for hospitalization. Resident 17, who was admitted to the facility with diagnoses including hypertension and chronic embolism, was able to make their needs known. The electronic health record indicated a discharge with anticipated return, but there was no documentation showing that the resident was provided a written notice for the reason of transfer. During an interview, the Social Services Director admitted that they did not consistently provide residents with written notice for the reason of transfer to the hospital.
Failure to Provide Bed Hold Notice for Hospitalized Residents
Penalty
Summary
The facility failed to provide a bed hold notice at the time of transfer to the hospital for two residents, which is a requirement under WAC 388-97-0120 (4). Resident 17, who was admitted with conditions including hypertension and chronic embolism, was hospitalized and later readmitted to the facility. However, there was no documentation in the electronic health record (EHR) indicating that a bed hold was offered to this resident. During an interview, the Social Services Director acknowledged the absence of documentation and confirmed that a bed hold should have been offered. Similarly, Resident 109, who was admitted with Crohn's disease, experienced a complication that necessitated hospitalization. The resident was readmitted to the facility after the hospital stay, but again, there was no documentation in the EHR that a bed hold was offered. The Social Services Director admitted to not offering a bed hold to Resident 109, and the Interim Administrator stated that it was their expectation that a bed hold should have been offered. This oversight placed the residents at risk of not being informed about their right to hold their bed during hospitalization, potentially affecting their quality of life.
Inaccurate Assessment of Resident's Smoking Status
Penalty
Summary
The facility failed to accurately assess a resident's smoking status, which led to inaccurate data in the resident's medical records. The resident, who was admitted with diagnoses including stroke, heart failure, and respiratory failure, was noted in the admission minimum data set (MDS) as not using tobacco. However, during an interview, the resident stated they smoked outside in the designated smoking area under staff supervision. This was corroborated by an observation of the resident smoking in the courtyard. Interviews with the Clinical Reimbursement/MDS Nurse and the Regional Nurse Consultant confirmed that the MDS was incorrectly coded and should have indicated tobacco use.
Failure to Update PASRR for Resident with New SMI Diagnosis
Penalty
Summary
The facility failed to obtain an updated preadmission screening and resident review (PASRR) for a resident who was newly diagnosed with significant mental illness (SMI). Resident 16 was admitted with a diagnosis of chronic obstructive pulmonary disease and initially had no significant mental illness according to the PASRR dated 10/20/2022. However, the resident later received diagnoses of major depressive disorder and psychotic disorder with hallucinations on 11/20/2023 and 04/24/2024, respectively. Despite these new diagnoses, the most recent PASRR dated 10/18/2023 still showed no SMI, and no further assessment was conducted. During an interview, the Social Services Director acknowledged that the facility's policy required reviewing PASRRs on admission and quarterly, and submitting a new one if needed, but this was not done for Resident 16.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 1,016 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Tacoma
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heartwood Extended Healthcare | 0.9 mi | ★★★★★ | 30 | 0 |
| Tacoma Nursing And Rehabilitation Center | 1.4 mi | ★★★★★ | 10 | 0 |
| Alaska Gardens Health And Rehabilitation | 1.6 mi | ★★★★★ | 20 | 1 |
| Avamere At Pacific Ridge | 2.5 mi | ★★★★★ | 36 | 0 |
| Birch Creek Post Acute & Rehabilitation | 3.5 mi | ★★★★★ | 35 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.