Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avamere Olympic Rehabilitation Of Sequim during CMS and state inspections, most recent first.
Failure to follow bowel protocol and document bowel care: Two residents had no documented BMs for multiple days, yet PRN bowel meds were not given as expected under the facility protocol. One resident had severe cognitive impairment and daily stool incontinence, was discharged without constipation education to the spouse, and was later hospitalized with SBO, constipation, and impaction. Staff said bowel status was tracked in the EHR and that residents without a BM for 3 days should trigger nurse review and protocol interventions.
The facility failed to maintain two shower rooms in a clean, sanitary, and homelike condition, despite a policy requiring such an environment. Surveyors observed scratched toilet seats with encrusted material, black matter on tiles and under sinks, soft and damaged walls with black substances believed by staff to be mildew or mold, used wet washcloths left in the rooms, a full trash can with the lid open, a shower head resting on the floor, and black and pink matter on the shower floors. A cognitively intact, medically complex resident reported concerns about odor, lack of cleanliness, and dirty linen left from prior use, leading them to avoid further showers, while another cognitively intact resident avoided the hall shower due to its condition, a broken handle, and unstable water temperature. The housekeeping supervisor, Infection Control Nurse, DON, maintenance director, and administrator acknowledged ongoing issues with cleanliness, possible mold, poor ventilation, and the age and disrepair of the shower rooms, and no mold testing had been performed.
A resident admitted with MASD on the coccyx and a heel pressure ulcer developed worsening buttock/coccyx wounds that were inconsistently documented as MASD, pressure injuries, or unstageable ulcers. Staff did not consistently complete or document weekly skin checks, the MD was not documented as notified when the skin condition changed, and the resident was observed on a standard foam mattress instead of the ordered LAL mattress while reporting pain and prolonged sitting in a wheelchair. Staff also noted a fish-like odor during wound care, but no culture was ordered or completed.
A facility failed to ensure residents were sent to the hospital with required transfer information. For one resident with a suprapubic catheter, staff documented distress, catheter removal, and transfer to the ED, but there was no record of a pre-transfer handoff, and the SNF/NF to Hospital Transfer form was completed after the resident returned, with key fields left blank. Two other residents were also transferred without documentation showing the required information was sent at the time of transfer, and staff said the transfer form was typically completed after residents left.
Food quality and pureed recipe preparation were deficient when residents reported cold, burnt, overcooked, and poorly prepared meals, and a test tray shrimp item was dry and rubbery. A cook also added ingredients not listed on the pureed green bean recipe and did not consistently measure ingredients, while the DSD stated the gravy thickener measurements were not known and the liquid pump was not usually used as intended.
MDS assessments were inaccurate for multiple residents. One resident’s neurogenic bladder was not coded, another resident’s antiplatelet use was missed despite aspirin on the MAR, and two residents’ RT services were coded without documentation of an initial RT eval, written tx plan, or care plan details. The record also failed to code a resident’s fall with bruising, and another resident’s wander guard plus two falls with injury were not recorded; the MDSC acknowledged several errors.
Incomplete and Non-Person-Centered Care Plans: Surveyors found that multiple residents had missing, outdated, or generic care plan content for issues including PASRR mental health recommendations, catheter changes and MDRO precautions, restorative leg exercises, falls, CHF with edema and diuretics, PICC/IV antibiotic care, and dementia. Staff interviews confirmed several of these needs should have been care planned, but the records did not reflect comprehensive, individualized interventions.
Failure to Follow Orders and Document Care: Multiple residents had care and medication orders that were not followed or accurately documented. Issues included undocumented oxygen use, a BP med given outside hold parameters, pain meds given contrary to ordered pain levels, incomplete orthostatic BP checks, a lidocaine patch worn continuously instead of 12 hours on/12 hours off, delayed insulin administration without timely recheck, missing SBAR communication for a POA’s request to speak with the MD, and a resident with a pressure ulcer being signed off for LAL mattress checks before the mattress was actually in place.
Restorative services were not provided at the assessed frequency for two residents. One resident who was dependent on staff for cares and receiving passive and active ROM programs 6 days per week had inconsistent restorative documentation across several months, including days with no recorded services. Another resident with muscle weakness, difficulty walking, and need for assistance with personal care was assessed for ROM and dressing/grooming restorative programs 6 days per week, but charting showed the programs were typically provided only 5 days per week, with several days in December showing no completed restorative care.
A resident with edema and a fluid restriction had intake that was supposed to be recorded every shift and totaled each day, but the POC, TAR, and fluid restriction sheets did not match. The ADON/RN said nurses were supposed to calculate the shift totals, did not know what aides were charting, and the DON stated the numbers did not add up correctly.
Two residents with PICC lines and IV therapy had missing assessment and monitoring documentation. One resident with sepsis and cellulitis had no recorded PICC external length or arm circumference on admission or afterward, and a scheduled dressing change/measurement entry was blank. Another resident with sepsis had a PICC dressing change documented only as a reference to nurse notes, with no external length measurement recorded; the DON confirmed the missing documentation.
Oxygen therapy was not provided and documented in accordance with the physician’s orders for a resident with HF and pulmonary HTN. The resident was observed with a nasal cannula attached to an empty portable O2 cylinder on more than one occasion, reported no air flow through the cannula, and the TAR showed no O2 administration documented for the month. The humidifier bottle attached to the concentrator was also found empty and had not been changed weekly as ordered.
Failure to Reevaluate Bed Rails/Mobility Bars: The facility did not reassess the need and safety of bilateral mobility bars for two residents. One resident had dementia, severe cognitive impairment, and multiple documented falls; the other was cognitively intact with moderate fall risk and recent falls. Both had initial mobility bar evaluations in the EHR, but no reevaluation was found, and staff confirmed quarterly reassessment had not occurred.
Pharmacist medication review recommendations were not carried out for a resident with dementia, severe cognitive impairment, and a history of falls. The resident’s lidocaine patch remained ordered for 24 hours instead of the recommended 12-hour schedule, a GDR for an antipsychotic was not attempted despite no documented clinical contraindication, and recommendations to reduce tamsulosin and consider lowering melatonin and the antipsychotic after multiple falls, dizziness, and nose bleeds were not documented as addressed. Staff confirmed the lidocaine order was not followed and acknowledged the fall-related recommendations lacked documented discussion or rationale.
Improper food storage, thermometer sanitation, and resident snack refrigerator temperature control were observed. Undated food items were found in refrigerators, molded peppers were discarded, and a Cook wiped the food thermometer with the same disinfectant rag used on counters and the sink while checking food temps. A resident snack refrigerator was also found at 50 degrees, above the stated safe range, and staff confirmed the unit remained at that temperature.
Incomplete resident records and inaccurate physician documentation. The facility’s charting did not consistently match documented behaviors, hospitalization details, medication side effects, or off-site appointments. A resident with dementia had hallucinations and delusions documented in progress notes, but the behavior monitor entries were incomplete or missing. Other records lacked specific vital sign details, hospital discharge follow-up, CT appointment documentation, and correct PCP assignment, while a resident on a blood thinner had blood in the urine documented but the side effect monitor still showed no complications.
An RN administered insulin to a resident without gloves, and staff later confirmed gloves were expected for insulin administration. The facility also did not place a resident with a pressure ulcer and other open skin areas on EBP during wound care; two staff performed dressing care wearing gloves only, without gowns or EBP signage. In addition, infection surveillance was not completed for a resident with dysuria and foul urine, as vitals were not tracked at the frequency expected during the alert period.
Failure to obtain proper consent for safety devices: A resident with dementia and severe cognitive impairment had a wander guard and bilateral bed rails documented with verbal consent from the resident. During observation, the resident was seen with both devices in place, and the ADON and RCM stated the resident was not able to give informed consent and that consent should have come from the POA or primary contact. The ADON also acknowledged the wander guard consent form did not clearly state where the device was to be placed.
A facility failed to follow care plans and orders for several residents. One resident with HF and kidney failure had repeated rapid weight gains, but there was no documentation that the MD was notified. Another resident with acute respiratory failure developed SOB and was placed on O2, but the nurse did not document a respiratory assessment, the vital signs at the time, or MD notification, even though an O2 sat of 85% on RA was later found in the record. A third resident had no BM for several days and did not receive PRN bowel meds or bowel protocol documentation, and a fourth resident’s forearm bruise was observed but not monitored or documented on the skin record.
Unsafe room hazards and inadequate supervision were identified for several residents. A severely cognitively impaired resident with a history of multiple falls repeatedly had a call light placed out of reach, including while lying in a dark room. Another resident receiving O2 had coiled tubing stretched across the room and bathroom entry area, and staff acknowledged it was a tripping hazard. Two residents also kept 91% isopropyl rubbing alcohol at the bedside without a documented self-medication assessment or lock box, despite staff stating those controls were required.
Catheter Care and UTI Monitoring Failures: Two residents with urinary catheters did not receive consistent catheter care or monitoring. One resident’s catheter bag and tubing repeatedly dragged on the floor without a dignity cover, and after hospitalization for a catheter-associated UTI, the facility did not document receipt of the hospital antibiotic, follow-up labs, or specialist referrals. Another resident with dementia had repeated signs of possible UTI and catheter complications, including foul-smelling urine, dysuria, hematuria, mucus, and a catheter protruding through the prior suprapubic site, but documentation, temperatures, and culture follow-up were inconsistent.
A resident with a urostomy related to traumatic injury did not receive the ordered appliance and supplies. Staff documented that replacement bags were unavailable, used a dressing over the stoma instead, and relied on the resident’s family to bring supplies from home; the resident and family said the facility did not have replacement bags, and staff later confirmed there were no supplies in central supply.
Missing Annual CNA Performance Reviews: The facility failed to complete annual performance reviews for 5 of 5 CNAs reviewed. Record review showed multiple CNAs had no recent performance evaluation on file, and one CNA had no annual review completed at all. The Pay Benefits Coordinator said the reviews for the five named employees could not be found.
An unlocked medication cart was observed at the Pine Ave nurses station with no staff nearby. The Infection Preventionist opened the cart without using keys after escorting a visitor out, and the ADNS later confirmed the cart should have been locked when staff walked away from it.
Antibiotic stewardship monitoring was incomplete when the facility failed to consistently document signs and symptoms, review infections in meeting minutes, or record staff education for multiple months. A resident on prophylactic azithromycin for COPD also had no antibiotic time-out or documented reassessment, and the resident was not tracked on the antibiotic review lists. Staff reported relying on progress notes and memory for criteria review, but documentation was missing or incomplete.
Incomplete Annual NA In-Service Training: The facility failed to ensure a nursing assistant completed the required 12 hours of annual in-service training. Record review showed the aide completed only 4.25 hours during the review period, and the Infection Preventionist confirmed the annual training requirement was not met.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility failed to provide adequate bathing assistance to several residents dependent on staff for this care. Despite policy requirements, residents did not receive showers as needed, with some going days without proper hygiene. Staff cited time management and care complexity as reasons for the deficiency.
Two residents in an LTC facility were not monitored for psychosocial harm following allegations of mistreatment by staff. Despite facility protocols requiring monitoring and documentation every shift, there were gaps in the progress notes for several days. The residents reported feeling mistreated and retaliated against, but the expected monitoring was not documented.
The facility failed to maintain effective infection control by not ensuring staff had appropriate PPE and did not properly don PPE for residents on droplet precautions. Staff were observed without necessary eye protection and did not change PPE between rooms. Additionally, the facility did not include the IP on the water management team and failed to implement all control measures of the Legionella Water Management Program, including routine chlorine testing and faucet inspections.
The facility failed to provide restorative nursing services for 16 residents due to staffing shortages, as the Restorative Nurse and Aide positions were vacant. This led to unmet restorative needs and long call light response times, as reported by the Resident Council. Call light audits confirmed significant delays, with some responses taking over 60 minutes.
The facility failed to provide restorative nursing programs for 16 residents due to staffing issues, leading to a lack of necessary care to maintain or improve range of motion, strength, and mobility. A resident with dementia and osteoarthritis did not receive recommended restorative therapy for contracture management, as the facility lacked a Restorative Aide until recently. This deficiency placed residents at risk for decline in physical abilities and increased dependence on staff.
The facility failed to label and store medications properly, affecting two medication carts and one medication room. Medications like Tuberculin Purified Protein and Insulin Lispro were found opened without dates, and a Fluticasone-Salmeterol Advair Diskus was expired. In the Dungeness cart, medications were undated or past discard dates. A resident had unauthorized medication in their room, contrary to facility policy.
The facility failed to maintain complete and accurate medical records for residents requiring restorative and hospice services. A resident receiving hospice care lacked current documentation, and the facility did not have records of hospice staff visits or care provided. Additionally, restorative services were discontinued due to staffing issues, and documentation for 16 residents was missing, leading to incomplete health records.
The facility failed to ensure accurate PASRR assessments for three residents, leading to potential risks in addressing their mental health needs. A resident's PASRR inaccurately documented a mood disorder and included a non-existent dementia diagnosis, while another resident's PASRR failed to indicate a serious mental illness, despite documented psychotic disorder and severe cognitive impairment. Staff acknowledged these errors and the responsibility of Social Services in managing PASRRs.
The facility failed to document and monitor behaviors and side effects related to psychotropic medications for several residents. Specific behaviors were not recorded, and necessary tests and consents were missing. Staff acknowledged the need for improved documentation and monitoring systems.
The facility failed to inform two residents of the risks and benefits of psychotropic medications and did not obtain their consent before administration. One resident was prescribed mirtazapine and Seroquel, while another was prescribed sertraline, without documented consent or information provided to them or their representatives.
A resident with arthritis and other conditions was not provided with adaptive equipment to cut food, despite a successful trial with a pizza cutter. The facility removed the tool without documented assessment or justification, leaving the resident to eat with their hands. Staff interviews revealed a lack of communication and documentation regarding the decision, and no alternative solutions were provided.
The facility failed to document advance directives for two severely cognitively impaired residents. Despite care conference notes indicating that advance directives were established, no copies were found in the residents' electronic health records. The Social Services Director admitted to not obtaining the necessary documentation, and the DON expected staff to document the ADs.
The facility failed to properly handle resident grievances, as grievances raised during Resident Council meetings and by individual residents were not logged or investigated according to policy. Issues included dissatisfaction with CNAs, meal setup concerns, and staff behavior. The use of incorrect forms led to grievances not being reviewed by the administrator, compromising the grievance process and affecting residents' quality of life.
A resident reported that a night nurse delayed pain medication due to personal grievances. The DNS investigated the issue as a grievance but failed to report it as an abuse allegation to the state. This oversight placed residents at risk for potential abuse and neglect.
A facility failed to notify the State LTC Ombudsman of a resident's transfer, as required. The resident, who was severely cognitively impaired, was transferred without documentation of notification. The Social Services Director confirmed the lack of documentation, and the DON stated that notification should have been documented.
The facility failed to accurately document the health status and care needs of three residents in their MDS assessments. One resident receiving hospice care was not coded with a terminal diagnosis, another was incorrectly noted as participating in a restorative program, and a third was inaccurately documented as being on a weight loss regimen. Staff confirmed these discrepancies, acknowledging errors in the MDS coding.
A resident with limited upper extremity function and arthritis was not consistently assisted with oral care, leading to poor hygiene. Despite being dependent on staff for personal hygiene, the resident reported infrequent assistance with brushing teeth, resulting in the use of a fingernail to remove plaque. The issue was reported to the Resident Care Manager but was not confirmed as oral care had been provided by then.
A facility failed to provide adequate pressure ulcer care for a resident at risk, resulting in a new unstageable ulcer. Despite having a skin care plan, the facility lacked consistent preventive measures and documentation, as revealed by staff interviews and missing skin audits.
A facility failed to ensure effective communication and coordination with a hospice provider for a resident receiving hospice services. The facility did not maintain a current hospice plan of care and lacked documentation of hospice staff visits in the resident's electronic health record. Despite requests, the facility did not receive necessary hospice visit notes, and staff were unable to provide details about recent visits or care provided.
The facility failed to maintain essential equipment, with kitchen and nourishment refrigerators showing unsafe temperatures, risking foodborne illness. Additionally, water temperatures in resident rooms and dining areas exceeded safe levels, risking burns. Inadequate monitoring and documentation contributed to these deficiencies.
The facility failed to follow professional standards, risking medication errors and health complications. Antihypertensives were given to a resident despite low blood pressure, compression stockings and toe separators were not applied as ordered, a Wanderguard was used without an order, and a dressing was applied without a physician's order.
A facility failed to provide necessary care to four residents as per their care plans. A resident with edema did not receive prescribed compression stockings, while another with Hallux valgus did not have toe spacers applied despite records indicating otherwise. A third resident's bruise was not monitored according to guidelines, and a fourth resident was not properly positioned for meals, impacting their ability to eat independently.
The facility failed to monitor and document the nutritional and fluid intake of two residents, leading to significant health risks. One resident experienced a significant weight loss due to inadequate weight monitoring and lack of follow-up on nutritional interventions. Another resident exceeded their fluid restriction due to improper reconciliation of fluid intake records, with no documentation of staff identifying the issue or educating the resident on adherence. These deficiencies compromised the residents' health and quality of life.
Failure to Follow Bowel Protocol and Document Bowel Care
Penalty
Summary
The facility failed to provide bowel care in accordance with provider orders and its bowel protocol for 2 residents reviewed for bowel management. The facility policy for constipation stated that additional interventions would begin on day 3 without a recorded bowel movement, with stool softener or stimulant laxative use, followed by MiraLAX or Milk of Magnesia on day 4, a suppository on day 5, and an enema on day 6. Resident 1 had severe cognitive impairment, required substantial to maximum assistance for toilet transfers, was frequently bowel incontinent, and was documented as not aware of toileting needs and incontinent of stool daily. The bowel record showed no recorded bowel movement for several consecutive days before discharge, and the MAR showed no as-needed bowel medications were given on the last two days before discharge. Resident 1 was discharged home without documentation of constipation education or need for bowel care to the spouse, and was admitted to the hospital the next day with small bowel obstruction, constipation, and intestinal impaction. Resident 2 was cognitively intact, required partial to moderate assistance for toileting, and had constipation present on admission. The bowel record showed no documented bowel movement for the last 10 days of the stay, and the MAR showed no as-needed bowel medications were documented during that period. Staff stated residents were monitored through EHR bowel documentation and that if no bowel movement was documented for 3 days, the nurse would be alerted and bowel protocol interventions could be used; staff also stated they would expect a resident leaving on day 4 without a bowel movement to receive medication and for the spouse to be informed.
Failure to Maintain Clean, Homelike Shower Rooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain two shower rooms (East and West) in a clean, sanitary, and homelike condition as required by its “Homelike Environment” policy. Surveyors observed multiple instances of unclean and deteriorated conditions, including deep scratches on toilet seats with brown and beige encrusted particles, black matter in shower tile grout and under sinks, soft and spongy wall areas with peeling and bubbling surfaces, and black substances believed by staff to be mildew or mold. In Shower Room East, surveyors also found used, wet washcloths left in the shower and under the sink, a full trash can with the lid open, the shower head touching the floor, and black and pink matter on the floor and tile lines. These conditions were observed on multiple dates in both shower rooms. A cognitively intact, medically complex resident reported that during their stay they were concerned about the shower room’s cleanliness, odor, and dirty linen left from previous use, which made them not want to shower again until discharge. Another cognitively intact resident residing on Dungeness Hall stated they did not use the hall’s shower room because it was a mess, the handle had broken off, and the water temperature fluctuated from hot to cold, so they preferred another unit’s shower room. The housekeeping supervisor reported that shower rooms were mopped daily and deep cleaned weekly but stated it was difficult to keep up due to the age and disrepair of the bathrooms and believed the black substance was mildew or mold, possibly colonized behind the walls. The Infection Control Nurse had not inspected the Grey Wolf and Dungeness Hall shower rooms for some time and was unaware of the current black substance, while the DON and Maintenance Director acknowledged staff-reported mold problems, lack of ventilation, and uncertainty about whether the black substance was mold, with no testing having been done. The administrator and maintenance director both conceded the rooms were old and could be better, and that they did not fully represent a clean, homelike environment.
Inconsistent wound assessment and delayed provider notification for worsening pressure injuries
Penalty
Summary
The facility failed to adequately and consistently assess worsening skin conditions, follow ordered wound care and pressure-relief interventions, and notify the medical provider in a timely manner for a resident who was dependent on staff for all care and was admitted with MASD on the coccyx and an unstageable pressure ulcer on the right heel. The resident’s skin integrity care plan called for weekly skin assessments, monitoring and documentation of wound location and size, reporting abnormalities and signs of infection to the MD, and use of a low air loss mattress and pressure-relieving wheelchair cushion. The admission MDS documented cognitive impairment and dependence for all cares, and the resident’s coccyx area was already noted as an open area on admission. Facility documentation was inconsistent and incomplete. Weekly skin audits and progress notes did not consistently describe the coccyx area, and one daily skilled progress note documented the skin as intact with no wounds present. The matrix submitted to the department stated that no residents in the facility had pressure ulcers, despite the resident’s documented heel pressure ulcer and coccyx MASD. The first documentation showing a change from MASD to pressure injury appeared in a daily skilled progress note, but the EHR contained no documentation that the MD had been notified of the change in skin condition. Two wound evaluations later documented enlarged coccyx and right inner buttock areas still described as MASD, while the EHR had already identified the areas as pressure injuries three days earlier. The resident was observed sitting in a wheelchair and reported waiting two hours to be returned to bed and having pain from sitting too long because of the buttock pressure ulcer. The resident was later observed on a standard foam mattress rather than the ordered low air loss mattress, and daily observations over several days showed the standard foam mattress remained in place. Staff later stated the resident had two buttock wounds that they would assess as stage 2 pressure ulcers with 90% slough, while other staff said the wounds were pressure ulcers and not MASD, and that with 90% slough they should have been documented as unstageable. Staff also reported a fish-like odor during wound care, but no culture had been ordered or completed, and the EHR still showed no documentation that the provider had been notified of the worsening skin condition.
Incomplete Hospital Transfer Documentation
Penalty
Summary
The facility failed to ensure residents were sent to the hospital with required and necessary information to support a safe transition of care for 3 of 3 residents reviewed for hospitalization. The report states that the facility’s policy on transfer or discharge addressed scheduled transfers and discharge planning, but did not describe what documentation had to be provided to the hospital during an emergent transfer. The policy also did not outline steps for emergency transfers. For one resident with benign prostatic hyperplasia, urinary retention, ureter calculus, obstructive and reflux uropathy, and dementia, staff documented severe cognitive impairment and dependence on staff for care. The resident had a suprapubic catheter that frequently clogged and sometimes was refused for irrigation or catheter changes. On the day of transfer, nursing documented the resident was in extreme discomfort, could not be flushed, had a bladder scan showing urine retention, and the suprapubic catheter was removed. The record showed no documentation that a report or handoff was called to the ED before transfer. The ED record reflected conflicting information about the catheter history and noted the resident was evaluated using the resident and the chart as historians. The facility’s SNF/NF to Hospital Transfer form for this hospitalization was completed three days after the resident had already returned, and key fields such as the names of staff who called report were blank. The form also did not identify the size or type of the suprapubic catheter, and prior hospitalizations showed similar transfer forms were also completed late. For the other two residents, the record showed hospital transfers occurred without documentation that required information was sent with them at the time of transfer. One resident was sent to the hospital for increased confusion, weight gain, and abnormal lung sounds, and the transfer form was completed two days after discharge. The other resident was transferred to the hospital, and the transfer form was created two days after the transfer. Staff interviews showed the facility normally sent a face sheet, MAR, and sometimes a TAR, but there was no record of what was sent for the resident with the catheter issue, and staff stated the transfer form was filled out after residents left for the hospital rather than being sent with them.
Food Quality and Pureed Recipe Preparation Deficiencies
Penalty
Summary
The facility failed to provide appetizing and palatable food for 7 of 24 sampled residents and for 1 of 1 test tray sampled for food quality. Residents reported multiple food quality concerns, including cold food, a cold burger that was sent back, pasta that was not thoroughly cooked and did not taste good, fish served to a resident who did not like fish, burnt cake, overcooked food, a burnt grilled cheese, and three burnt chicken tenders that were blackened on the outside. One resident stated they ate what they could around the burnt part. On the test tray, the shrimp tasted dry and had a rubbery texture. The facility also failed to prepare pureed foods according to the written recipe to maintain nutritional value. A cook was observed making pureed green beans and added vegetable base and water even though those ingredients were not on the recipe. The cook stated they had found faults in the recipes and measurements and did not always measure everything. The Dietary Services Manager stated the vegetable base and water were not in the recipe for pureed green beans, did not know the measurements for the liquid pump used for gravy, and said the staff usually did not use the liquid pump on the serving line.
Inaccurate MDS Coding for Diagnoses, Medications, Therapy, Falls, and Alarm Use
Penalty
Summary
The facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected residents’ health status and care needs for five sampled residents. The report states that inaccurate coding occurred for diagnoses, medications, respiratory therapy services, falls, and use of a wander/elopement alarm. Staff H, the MDS Coordinator, acknowledged several of the assessments were inaccurate during interviews. For Resident 7, the admission MDS showed an indwelling urinary catheter but did not code neurogenic bladder. The hospital discharge summary documented neurogenic bladder with chronic suprapubic catheterization, and Staff H stated the MDS should have coded neurogenic bladder as an active diagnosis. For Resident 26, the admission MDS showed anticoagulant use and respiratory therapy services but did not code antiplatelet medication, even though the November 2025 MAR showed aspirin was given on six of seven days during the assessment period. The same resident had physician-ordered incentive spirometry for asthma, but the record did not show an initial evaluation by a respiratory therapist or trained respiratory nurse, a written treatment plan, or a care plan addressing the respiratory therapy, its goals, frequency, duration, or scope. The report also found that Resident 26’s incentive spirometry documentation did not identify lung sounds or show meaningful change in pre- and post-treatment assessments, and the resident stated nurses were not coming daily to instruct or watch use of the device. For Resident 2, the quarterly MDS coded respiratory therapy services for CHF, but the record likewise lacked an initial respiratory evaluation, written treatment plan, and care plan for the therapy. For Resident 8, the quarterly MDS did not record a fall even though the EHR showed a fall with bruising. For Resident 12, the quarterly MDS did not code a wander guard that was ordered and observed on the resident’s wheelchair, and it did not record two recent falls with injury, including bruising and a laceration. Staff H confirmed the wander guard and both falls with injury should have been coded, and the DON stated the expectation was for MDS assessments to be accurate.
Incomplete and Non-Person-Centered Care Plans
Penalty
Summary
The facility failed to ensure care plans were comprehensive and person centered for 7 of 22 sampled residents. Surveyors reviewed observation, interview, and record review findings showing that multiple residents had diagnoses, treatments, or care needs that were not fully reflected in their care plans, and in several cases existing interventions were incomplete, outdated, or missing altogether. Resident 52 had diagnoses of depression and urinary retention, was severely cognitively impaired, and had a level II PASRR with recommendations for mental health counseling, psychiatric assessment and medication evaluation, environmental and staff interventions, activities, and support if resistant to mental health services. The care plan did not include a level II PASRR care plan or a comprehensive list of those recommendations, and it did not document the effectiveness of the recommendations. The psychosocial well-being care plan used generic interventions without identifying specific coping skills, prior services tried, or the PASRR recommendation about explaining mental health services to a resistant resident. Resident 52 also had a change in urinary catheter status after hospitalization, but the Foley catheter care plan still contained prior suprapubic catheter interventions that had not been removed and did not include details about the old suprapubic site, monitoring, or penile erosion. The enhanced barrier precautions care plan also did not identify where the MDROs had been detected. Resident 54 was cognitively intact and receiving restorative services, including range of motion and dressing/grooming programs. During observation and interview, the resident demonstrated self-directed hamstring stretching using a step stool and weight and reported doing this two to three times daily by themself. The care plan did not include these self-directed leg strengthening details. Resident 12 had dementia and severe cognitive impairment, and the fall care plan listed 14 falls with a 30-minute checks intervention that lacked details about duration; staff later stated the intervention was no longer in effect and should not have remained on the care plan. Resident 1 had CHF, was on Lasix twice daily and daily weights, and had weeping edema to both lower extremities documented in SBARs, but no care plan had been developed or implemented for the CHF, diuretic use, daily weights, or edema. Resident 7 had edema management orders for TED hose and Lasix, but the comprehensive care plan did not address the edema, diuretic use, or daily TED hose. Resident 73 had sepsis, a PICC line in the right upper arm, and received IV Cefepime for cellulitis, but the comprehensive care plan did not address the PICC line or IV antibiotic treatment with goals and interventions for care and maintenance. Resident 9 had dementia with psychotic disturbance and severe cognitive impairment, but no dementia care plan was present. Staff interviews confirmed that these diagnoses and treatments should have been care planned, and staff were unable to identify corresponding care plan content for several of the residents reviewed.
Failure to Follow Orders and Document Care
Penalty
Summary
The facility failed to ensure professional standards of care were followed for multiple residents related to provider orders, medication administration, provider notification, and documentation. The report identified concerns for 7 of 22 sampled residents, including failures involving oxygen administration, blood pressure medication parameters, pain medication selection, orthostatic blood pressure monitoring, insulin administration timing and reassessment, communication with a resident’s POA about medications, and use of a low air loss mattress for pressure injury care. For one resident with heart failure who received supplemental oxygen, an order required oxygen 1-2 liters via nasal cannula as needed for shortness of breath and to notify the physician when oxygen was used. The resident was observed receiving oxygen on multiple occasions, but the December MAR/TAR had no nurse signatures documenting oxygen administration. Staff confirmed the resident was receiving oxygen and acknowledged there was no documentation on the TAR. Another resident had an order for hydralazine to be held if systolic blood pressure was less than 120, but the medication was administered when the systolic blood pressure was 116. Staff later confirmed it should have been held. A resident with pain management orders for acetaminophen and two oxycodone doses based on pain level was documented with pain rated at 5 and was given acetaminophen instead of the ordered oxycodone 2.5 mg on two occasions, with no documentation that the resident requested the alternate medication. Another resident with severe cognitive impairment had orders for orthostatic blood pressures every 28 days due to antipsychotic use, but the required readings were not fully completed on multiple occasions. The same resident’s lidocaine patch was documented as being worn for 24 hours a day for months, and staff confirmed the patch was being worn continuously even though they stated their expectation was 12 hours on and 12 hours off. The report also described a resident whose long-acting insulin was administered later than scheduled after an earlier blood sugar of 73 and orange juice was given, but the blood sugar was not rechecked before administration. Staff acknowledged the recheck, provider notification, and administration did not occur until later. For another resident, the POA requested to speak with the doctor about medications, but there was no SBAR documentation of those requests despite staff stating communication should have been sent and followed up. Finally, a resident admitted with an unstageable heel pressure ulcer and MASD was documented as having a low air loss mattress order, yet the resident was observed on a standard foam mattress for several days while staff signed off that the low air loss mattress settings were being checked, even though maintenance confirmed the mattress had not been installed until later and there were no reports of a broken mattress or control box.
Restorative services not provided at assessed frequency
Penalty
Summary
The facility failed to provide restorative services at the assessed frequency for 2 residents. Resident 52 was admitted to the facility and, on the 10/02/2025 MDS, was documented as dependent on staff for cares and receiving passive and active ROM restorative programs 6 days per week. However, review of restorative charting for September through 12/03/2025 showed the program was not consistently provided at that frequency, with 6 days documented in September, 8 days in October, 5 days in November, and no documentation found for 12/01/2025 through 12/03/2025. The 10/30/2025 restorative quarterly review documented the resident was participating in the programs and pain was not an issue, with recommendations to continue current programs and monitor participation and progress. Resident 54 was admitted with diagnoses including muscle weakness, difficulty walking, limitations of activities due to disability, and need for assistance with personal care. The 10/07/2025 annual MDS showed the resident was cognitively intact and receiving ROM and dressing/grooming restorative programs 6 days per week. Review of restorative charting for October through 12/04/2025 showed the programs were not consistently provided at that frequency, with about 5 days per week after the first week in October, Sunday through Thursday in November, and no restorative program completed from 12/01/2025 through 12/04/2025. During interview, staff confirmed Resident 54's program was written for 6 days per week, but the aide was only scheduled Sunday through Thursday, so the resident was only receiving the program 5 days per week.
Inaccurate Fluid Intake Monitoring and Documentation
Penalty
Summary
The facility failed to ensure staff monitored and accurately recorded fluid intake for Resident 3, who was admitted with edema and was documented as cognitively intact on the admission MDS. Resident 3 had a care plan and physician orders for a fluid restriction of 1800 mL per 24 hours, with intake to be recorded every shift and total 24-hour intake documented each night shift. The facility policy also directed staff to follow specific instructions concerning fluid intake or restrictions and to be accurate when recording fluid intake. Record review showed Resident 3's POC response history for fluid intake had entries documented one to three times a day, while the November and December 2025 TAR documented fluid intake for every shift and the 24-hour total. During interviews, the ADON/RN stated nurses were supposed to calculate the day, evening, and night shift totals for 24 hours in the TAR and said she did not know what the aides were charting on the POC. She also provided only some fluid restriction sheets and stated, "this is all I've got." The DON later stated the numbers on the POC, TAR, and fluid restriction sheets did not add up correctly and said, "I don't know where they are getting those totals."
PICC Lines Not Assessed or Documented per Orders
Penalty
Summary
Provide for the safe, appropriate administration of IV fluids when needed was not met when the facility failed to assess, maintain, and monitor PICC lines for 2 residents receiving IV therapy. The facility policy required baseline measurement of PICC external length and arm circumference on admission or insertion, weekly external length checks with dressing changes, regular needleless cap changes, and flushing of valved vascular access devices with NS before and after infusion. For Resident 73, who had moderate cognitive impairment, sepsis, and IV antibiotics via central catheter for right lower extremity cellulitis, the admission record identified a PICC in the right upper arm but did not document the number of lumens, external catheter length, or arm circumference. Orders included PICC dressing changes, external length measurement, site monitoring each shift, and flushing instructions, but the record showed no documentation that external length or arm circumference were measured on admission or afterward, and a scheduled dressing change and measurement entry was left blank. For Resident 84, who was admitted with sepsis and had central IV access, the orders required PICC dressing changes with external catheter length measurement each Wednesday evening shift, and the care plan directed documentation of IV line measurements. The TAR showed a notation of "9 = other/see nurse notes" for the dressing change, but the nursing progress note did not document any external length measurement. During interview, the DON stated she did not see documentation of external catheter length for Resident 84 or arm circumference for either resident, and she confirmed the expectation that external length be measured on admission and weekly with dressing changes and that arm circumference be documented on admission or insertion.
Oxygen Therapy Not Documented or Maintained Properly
Penalty
Summary
The facility failed to ensure oxygen therapy was provided according to physician orders and accepted professional standards for Resident 73, who had diagnoses of heart failure and pulmonary hypertension and was receiving oxygen therapy. The resident’s 11/04/2025 orders included oxygen 1-2 liters via nasal cannula as needed for shortness of breath, notification of the physician when oxygen was started, weekly humidifier bottle changes when oxygen was in use, and changing oxygen tubing when visibly soiled. On 12/02/2025, Resident 73 was observed in a wheelchair using pursed lip breathing with a nasal cannula attached to a portable oxygen cylinder secured to the wheelchair; the regulator was set at 2 liters per minute, but the cylinder gauge read 0 PSI, indicating it was empty. On 12/04/2025, the resident was again observed with a nasal cannula attached to a portable cylinder that also read 0 PSI, and the resident stated they could not feel any air blowing through the cannula. Staff KK later confirmed the cylinder was empty and said it would be replaced, and also stated nurse aides transferred the resident from the concentrator to the portable cylinder. Review of the December 2025 TAR showed no documentation that oxygen had been administered that month. On 12/09/2025, the humidifier bottle attached to the oxygen concentrator was observed to be empty, and Staff E confirmed it needed replacement; the TAR showed the humidifier bottle had not been changed from 12/01/2025 through 12/09/2025 despite the weekly change order.
Failure to Reevaluate Bed Rails/Mobility Bars
Penalty
Summary
The facility failed to reevaluate the necessity and safety of bed rails/mobility bars for 2 residents who had them in place. Resident 12 was admitted with dementia and was assessed as severely cognitively impaired on the quarterly MDS. Their falls care plan identified them as high risk for falls related to limited mobility, incontinence, cognitive problems, gait and balance problems, history of falls, lack of impulse control, poor communication and comprehension, poor insight and judgment, psychoactive drug use, being unaware of safety needs, and hearing problems. The care plan listed 14 falls between 05/24/2025 and 11/14/2025. The EHR showed an initial mobility bar evaluation on 08/06/2025, but no reevaluation was found, and on 12/01/2025 the resident’s bed was observed with bilateral mobility bars on the top of the bed. Resident 8 was cognitively intact and had a falls care plan identifying moderate fall risk related to deconditioning and gait/balance problems, with recent falls noted as a fall with bruises and a no-injury fall. The EHR showed an initial mobility bar evaluation on 05/01/2025, but no reevaluation was found, and on 12/02/2025 the resident’s bed was observed with bilateral mobility bars on the top of the bed. During interview, the ADON/RN and the RCM/LPN stated mobility bars were to be reassessed quarterly and confirmed this had not occurred for Resident 8. The DON also stated the expectation was for bedrails/mobility bars to be reassessed quarterly.
Pharmacist Medication Review Recommendations Not Followed
Penalty
Summary
The facility failed to ensure monthly pharmacist recommendations were carried out accurately and timely for Resident 12, a resident with dementia who was severely cognitively impaired and had a history of falls. Review of the facility policy showed pharmacist recommendations were to be followed up on and acted upon within 30 calendar days or per facility protocol, with physician rationale documented if a recommendation was rejected. For Resident 12, a July 2025 pharmacy recommendation directed that the lidocaine patch be applied in the morning and removed at night for a total of 12 hours, but the November 2025 MAR showed the patch was ordered for 24 hours. During interview, an LPN confirmed the resident was wearing the patch 24 hours a day. A November 2025 pharmacist review also recommended a gradual dose reduction of Resident 12’s antipsychotic medication, noting the resident was a reasonable candidate because behaviors had remained stable and there was no clinical rationale documented for not attempting the GDR. The form indicated the POA rejected the GDR attempt. Another pharmacist review, completed in response to multiple falls, dizziness, and nose bleeds, recommended decreasing tamsulosin because the resident was receiving double the general dose and was at risk for orthostatic hypotension, dizziness, headache, falls, and nose bleeds; it also included considerations to lower melatonin and the antipsychotic. The section for nursing staff/physician contained no documentation of the decision or rationale, and the MAR showed none of these recommendations had been implemented. During interviews, staff acknowledged the lidocaine order had not been followed as intended and that there was no discussion documented for the fall-related recommendations.
Improper food storage, thermometer sanitation, and resident snack refrigerator temperature control
Penalty
Summary
Food was improperly stored and labeled in the facility’s refrigerators during observation and record review. In the dairy refrigerator, an unidentified cake was found without a date, and a partially used stick of butter was observed with crumbled paper around it and no date. In the refrigerator along the back wall with the clock and electrical panel, a cup of undated dressing was observed. In the produce refrigerator, a greenish substance was observed on peppers, and the Dietary Services Manager stated the peppers were molded and discarded them. The Dietary Services Manager later stated the butter should have been placed in a clean container and properly labeled. During meal preparation, a Cook wiped the thermometer used to check food temperatures with the same rag from the disinfectant bucket that was also used to wipe counters, then returned the rag to the bucket. The Cook repeated this process while checking temperatures of noodles and hamburgers and while cleaning counters and the sink. The Dietary Services Manager stated it was not sanitary to use the rag from the disinfectant bucket to wipe the thermometer when it was also used to wipe kitchen counters, and said alcohol wipes were preferred or a separate disinfectant rag and bucket should be used. In addition, the resident snack refrigerator near the dining room and administrator’s office was observed at 50 degrees, above the stated safe temperature of below 41 degrees, and staff later emptied the refrigerator and freezer after confirming the temperature remained at 50 degrees.
Incomplete resident records and inaccurate physician documentation
Penalty
Summary
The facility failed to ensure resident records were accurate and complete for 10 of 24 sampled residents, including failures to document resident information correctly and to identify the primary care physician accurately. The report cited deficiencies involving behavior monitoring, hospitalization follow-up, medication side effect monitoring, appointment documentation, and physician assignment in the medical record. For Resident 9, who had dementia with psychotic disturbance and was severely cognitively impaired, progress notes documented hallucinations and delusions on multiple dates in July 2025. However, the corresponding behavior monitors did not consistently reflect those behaviors, and one monitor used only a positive sign without identifying which behavior was present. The DNS confirmed the behavior monitor entries did not match the documented behaviors and stated the missing documentation did not meet expectations. For Resident 81, nursing documentation of the events leading to hospitalization lacked specific times and did not record the actual vital signs when the nurse stated they remained stable. For Resident 6, the record showed hospitalization for chest pain and possible UTI, but there was no follow-up documentation or discharge summary in the EHR, and the DNS stated recommended follow-up such as urology and nephrology referrals, repeat CBC and UA, and continuation of antibiotics had not been completed. For Resident 52, who was severely cognitively impaired and dependent on staff, blood was documented in the urine on multiple dates while the resident was on a blood thinner, but the side effect monitor continued to show no complications noted. For Resident 10, documentation showed a CT appointment was scheduled, but the progress notes did not show the resident leaving for or returning from the appointment. The record also listed the medical director as the primary care physician for Residents 10, 26, 31, 7, 1, and 37, even though the medical director stated she was not the physician for those residents and had never seen Resident 10.
Failure to Follow Standard Precautions, Use EBP, and Track Suspected Infection
Penalty
Summary
The facility failed to ensure staff followed standard precautions when an RN administered insulin to a resident without wearing gloves. During observation, the Resident Care Manager/LPN gave the resident insulin with an insulin pen while not wearing gloves, and later stated they did not have to wear gloves because the medication was given with an insulin pen. The Infection Preventionist/RN later stated that gloves were expected for insulin administration. The facility also failed to implement enhanced barrier precautions for a resident with wounds requiring dressing changes. Resident 24 was admitted with an unstageable pressure ulcer on the right heel and moisture associated skin damage on the coccyx, and the admission MDS documented the resident was cognitively impaired and dependent on staff for all cares. During observed wound care, two staff members wore gloves but no gowns while uncovering and rolling the resident, removing the old dressing, cleansing the wound, and applying a new foam dressing. The wound was described as smelling like fish, and two distinct open areas on the buttock were confirmed. Staff later stated the resident should have been on EBP for wound care, and the DON and Administrator agreed that appropriate PPE and EBP signage should have been in place. The facility also failed to perform infection surveillance for Resident 52. The resident had diagnoses including urinary retention, obstructive and reflux uropathy, and dementia, and the quarterly MDS showed severe cognitive impairment and dependence on staff for care. Nursing notes documented pain and burning with urination and foul, slimy urine, and the resident was placed on alert for dysuria. However, the temperature log showed a temperature on one date and then not again until nearly a month later. The Infection Preventionist stated that during an alert period vitals should be taken at least daily, usually every shift, and said temperatures should have been taken during that period.
Failure to Obtain Proper Consent for Safety Devices
Penalty
Summary
The facility failed to ensure safety devices were consented for Resident 12, who was admitted with dementia and was assessed on the Quarterly MDS as severely cognitively impaired. Review of the resident’s safety device assessment and consent form for a wander guard device, dated 06/05/2025, showed the device was being used to remind the resident not to leave the facility without assistance. The form listed the potential risk as leaving the facility without assistance and injuring self, and staff documented that verbal consent had been obtained from the resident. A separate safety device assessment and consent form for bilateral mobility bars/bed rails, dated 08/06/2025, also documented verbal consent from the resident. During observations, Resident 12 was seen with bilateral mobility bars on the bed and a wander guard on the wheelchair. In a joint interview, the ADON/RN and RCM/LPN stated that if a resident showed signs of dementia, consent would need to be obtained from the POA or primary emergency contact, and that Resident 12 was not able to give informed consent, so the wife would need to be contacted. The ADON acknowledged the wander guard consent form did not specify where the resident was consenting to have the device placed. The DON stated that risks and benefits should be reviewed for informed consent and that residents unable to sign for themselves should not be signing consent.
Failure to document and provide ordered care for bowel status, skin changes, respiratory distress, and weight changes
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards and the residents’ care plans for four sampled residents. The cited issues involved bowel care, skin monitoring, respiratory assessment and documentation, and monitoring of daily weights with physician notification for significant changes. The report identified that these failures placed residents at risk for unidentified or avoidable decline, delayed treatment, pain or discomfort, unmet care needs, and other negative health outcomes. For one resident with heart failure and kidney failure who was receiving diuretics and had an order for daily weights, the record showed multiple rapid weight gains over a short period of time. The care plan directed staff to notify the physician and resident or representative of significant or severe weight loss or gain, but the record did not define those terms. The chart contained no documentation that the physician was notified of the resident’s weight gains of 5.7 pounds in 24 hours, 4 pounds in 24 hours, or 5.4 pounds in 24 hours. The DON stated the physician should have been notified but could not find documentation that it occurred. For another resident admitted with acute respiratory failure with hypoxia, an order directed oxygen at 2 liters per minute as needed for shortness of breath or cyanosis and instructed staff to notify the MD once oxygen was applied. The nursing note documented that the resident reported mild shortness of breath when lying flat and was placed on oxygen, but it did not document a respiratory assessment, the vital signs at the time oxygen was applied, or notification of the provider. The note also stated vital signs were stable, yet the record showed an oxygen saturation of 85% on room air at 12:57 PM, which was not consistent with stable vital signs. Staff later stated that a respiratory assessment, vital signs, lung sounds, oxygen saturation, and provider notification should have been completed and documented. For a third resident, bowel movement records showed no bowel movement for six consecutive days, and the MAR did not show any PRN bowel medications being given. Staff reviewed the record and found no progress notes showing that PRN medications were offered and refused. The DON stated the bowel protocol should have been started. For a fourth resident, staff observed a bruise on the left forearm, but the record contained no monitoring, no skin assessment documentation, no care plan entry, and no accident or incident report related to the bruise. Staff confirmed there was no documentation and stated they would have expected the bruise to be monitored and documented on a skin assessment.
Unsafe Room Hazards and Inadequate Supervision
Penalty
Summary
The facility failed to ensure residents were free from accident hazards and adequately supervised for 4 of 5 residents reviewed for accident hazards: Residents 12, 73, 59, and 17. The deficiency was based on observations, interviews, and record review showing unsafe conditions in resident rooms and a lack of effective supervision or controls for identified hazards. Resident 12, who had dementia and was severely cognitively impaired, was identified as high risk for falls with a history of 14 falls listed in the care plan. The care plan included having the soft touch call light within reach, but observations showed the call light repeatedly placed on the far corner of the nightstand near the wall, behind mobility bars and other items, making it out of reach. Staff observed Resident 12 in a dark room without the light on, and the resident stated the call light was not within reach. Staff later stated they expected the call light to be in reach and that staff should have offered to turn the light on rather than make assumptions. Resident 73, who had heart failure and pulmonary hypertension and was receiving oxygen, had a 15-foot section of coiled oxygen tubing trailing from the bed across the floor in front of the room’s entry/exit door and into the bathroom to an oxygen concentrator. The tubing coils were elevated only about 5.5 inches off the floor. The roommate stated the tubing was not safe and reported a family member had stumbled over it. Staff acknowledged the tubing was a safety tripping hazard and explained the concentrator had been moved into the bathroom because it was loud. Resident 59, who had dementia and mild cognitive impairment, had a 32-ounce bottle of 91% isopropyl rubbing alcohol on the bedside table and reported using it for athlete’s foot. Staff stated a chemical product in a resident room required a lock box and a self-medication assessment, but no such assessment or lock box was found. Resident 17, who was mildly cognitively impaired, also had a 32-ounce bottle of 91% isopropyl rubbing alcohol at the bedside and reported using it around catheter tubing; staff again found no self-administration assessment and no lock box.
Catheter Care and UTI Monitoring Failures
Penalty
Summary
The facility failed to ensure appropriate care and monitoring for residents with urinary catheters, including pre- and post-hospitalization follow-up and adherence to hospital discharge instructions, for two residents. One resident was cognitively intact, relied on staff for most cares, and had a urinary catheter for urinary retention. The resident’s catheter bag and tubing were repeatedly observed dragging on the floor underneath the wheelchair, with no dignity cover in place, and staff confirmed the bag and tubing were not secured and should have been off the ground and covered. For that same resident, the record showed a urinalysis on 11/03/2025 with a handwritten note indicating the specimen was likely contaminated, but there was no documented provider review or follow-up. The resident was hospitalized from 11/04/2025 to 11/05/2025, and the hospital discharge summary documented a urinary tract infection associated with an indwelling urethral catheter. The discharge instructions included follow-up with urology and nephrology, repeat CBC and urine testing, and a 7-day course of doxycycline. The facility record contained no documentation that the antibiotic was received or given, no new antibiotic order, no documented follow-up with urology or nephrology, and no repeat CBC or urine test. The second resident had diagnoses including benign prostatic hyperplasia, urinary retention, ureteral calculus, obstructive and reflux uropathy, and dementia, and was dependent on staff for care. Nursing notes documented multiple catheter-related concerns, including the penile Foley protruding through the prior suprapubic catheter site, foul-smelling urine, pain and burning with urination, blood in the urine, thick mucus, and very bloody drainage. The record showed inconsistent alert documentation, limited temperature monitoring, and only one urinalysis in November that showed 3+ leukocytes and positive nitrites, with a provider note to follow up with culture and sensitivity; no culture and sensitivity documentation was found for that result. A later urinalysis again showed 3+ leukocytes, positive nitrites, and many bacteria, and culture identified Providencia rettgeri and Morganella morganii. Staff interviews confirmed that documentation and monitoring were incomplete and that the catheter system should have been changed when the catheter was found protruding through the suprapubic site.
Failure to Provide Urostomy Supplies and Appliance
Penalty
Summary
The facility failed to ensure appropriate urostomy care and supplies were provided for Resident 10, who was admitted with acute pancreatitis and had a documented urostomy related to traumatic injury. The resident’s care plan and physician orders required urostomy care every shift, bag changes as needed for leakage or drainage, and weekly appliance changes as needed for malfunction. The resident was cognitively intact and had a urostomy noted on the Minimum Data Set assessment. Staff documented that they were unable to change the urostomy bag because supplies were on order, and the resident’s family was bringing supplies from home. In the meantime, staff placed a brief and/or dressing over the stoma and instructed the resident to change the dressing frequently and use the call light when it became wet or soiled. During observation, the resident was seen with a dressing covering the stoma and without the urostomy appliance, and the resident and family stated the facility did not have replacement bags. Staff later stated the resident preferred using personal supplies from home, that the facility had no central supply available, and that staff were placing a dressing on the site while trying to locate supplies.
Missing Annual CNA Performance Reviews
Penalty
Summary
The facility failed to complete annual performance reviews for 5 of 5 CNAs reviewed: Staff EE, FF, GG, HH, and II. Record review showed Staff GG’s most recent annual performance review was signed on 02/22/2024 for the period of 01/30/2023 - 01/30/2024, with no annual performance review completed in the previous 22 months. Staff HH’s most recent performance review was for the period of 08/01/2023 - 08/01/2024, with no performance review completed in the previous 16 months. Staff II’s most recent annual performance review was signed on 01/06/2024, with no annual performance review completed in the previous 23 months. Staff FF, hired on 11/06/2023, had no annual performance review completed. Staff EE’s most recent annual performance review was signed on 07/11/2024 for the period of 09/2022 - 09/2023, with no performance review completed in the previous 27 months. On 12/08/2025 at 12:14 PM, Staff JJ, Pay Benefits Coordinator, said they could not find performance reviews for the five named employees that were conducted in the previous year.
Unlocked Medication Cart at Nurses Station
Penalty
Summary
The facility failed to maintain a locked medication cart at the Pine Ave nurses station for 1 of 5 medication storage carts reviewed. On 12/09/2025 at 10:57 AM, an unlocked medication cart was observed parked at the Pine Ave nurses station with no staff present around it. At 11:11 AM, Staff R, the Infection Preventionist, walked past the cart with a visitor, then returned and opened the medication cart without using keys. When asked about the expectation when staff walk away from a medication cart, Staff R stated the cart should have been locked. At 11:24 AM, Staff C, the Assistant Director of Nursing Services, was informed of the observation and also stated the medication cart should have been locked.
Antibiotic Stewardship Program Not Monitored or Documented
Penalty
Summary
The facility failed to implement an Antibiotic Stewardship Program with monitoring, documentation, reevaluation, and education for August, September, and October 2025, and for a resident receiving prophylactic azithromycin for COPD. The facility’s Antibiotic Stewardship Policy stated the program was intended to monitor antibiotic use and that staff orientation, training, and education would emphasize the importance of antibiotic stewardship and the effects of inappropriate antibiotic use. The facility also had a document titled Minimum Criteria for Initiating Antibiotics for a UTI, which listed required signs and symptoms for starting treatment. For August 2025, the Antibiotic Line Listing and Infection by Unit report showed 16 indicated infections, but seven did not have signs and symptoms listed on the line list. The Antibiotic Stewardship Meeting Minutes from 08/21/2025 showed that 12 of the 16 indicated infections were not reviewed. The line listing included two residents with UTIs who had no signs and symptoms documented, and one of those residents was not listed in the meeting minutes. Staff R stated that symptoms were usually taken from progress notes or provider notes and entered into the line list, but also stated that if a case was closed, the system would not allow her to go back and enter information. For September 2025, the line listing and Infection by Unit report showed 16 indicated infections, with four lacking associated signs and symptoms. The meeting minutes from 09/11/2025 showed 11 of the 16 indicated infections were not reviewed. For October 2025, the line listing and Infection by Unit report showed 32 indicated infections, with 12 lacking signs and symptoms. The line listing documented 13 UTIs that month, but there was no associated documentation of education provided to staff. The 10/23/2025 meeting minutes showed 21 of the 32 indicated infections were not reviewed. The October line listing included one resident with two UTI entries, one with dysuria and one with no signs and symptoms, and another resident listed as asymptomatic despite a provider note documenting cloudy and malodorous urine. Staff R stated that she knew what was required to meet criteria, that she did not document criteria screening, and that she could not go back into the system once a case was closed. She also stated that she believed education had been done with CNAs on peri care, but she could not locate documentation of that education. The facility also did not monitor a resident receiving prophylactic azithromycin three times weekly for COPD. The resident had an order for azithromycin as prophylaxis, but no antibiotic time-outs were present under evaluations. The resident was not included on the August, September, or October 2025 antibiotic meeting minutes or line listings. Staff R stated that residents on long-term antibiotics were supposed to have antibiotic time-outs and that residents on prophylactic antibiotics were reviewed once a year in a progress note, but she did not identify this resident when asked about residents on prophylactic antibiotics. She also stated that the resident’s pulmonology notes were supposed to be reviewed, but no pulmonology notes were found in the record.
Incomplete Annual NA In-Service Training
Penalty
Summary
The facility failed to develop, implement, and maintain an in-service training program that ensured nursing assistants completed the required 12 hours of annual in-service training. Review of one nursing assistant’s employee file showed the aide was hired on 09/29/2022, and the in-service training record for the period of 09/29/2024 through 09/29/2025 showed only 4.25 training hours completed, which was 7.75 hours short of the annual requirement. During an interview on 12/08/2025, the Infection Preventionist stated that the nursing assistant did not complete the required 12 hours of training annually.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide Adequate Bathing Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living, specifically bathing, for five residents who were dependent on staff for this care. The facility's policy required that residents unable to perform ADLs independently receive necessary services to maintain good hygiene, including bathing. However, records and interviews revealed that several residents did not receive showers as needed. Resident 4, for example, reported receiving only one shower in 15 days, while Resident 5's family member noted the resident had not had a shower in nine days. Similar issues were noted for Residents 6, 7, and 8, who also did not receive showers or bed baths as frequently as required. Staff interviews indicated that the failure to provide showers was attributed to time management issues and the complexity of care required by residents. Nursing assistants and registered nurses acknowledged the difficulty in completing all assigned tasks, including showers, during their shifts. The Director of Nursing Services and other staff members were aware of the grievances related to missed showers and attributed the issue to staff organization and time management. Despite reviewing and adjusting the shower schedule, the facility continued to face challenges in ensuring residents received the necessary bathing assistance.
Failure to Monitor Residents for Psychosocial Harm After Allegations
Penalty
Summary
The facility failed to provide care and services consistent with professional standards for two residents, leading to a deficiency in monitoring for psychosocial harm following allegations against staff members. Resident 1, who had mild cognitive impairment and was medically complex, alleged mistreatment by staff, including being left in bed and not being assisted with toileting. Despite these allegations, there were gaps in the documentation of monitoring for psychosocial harm, as no nursing notes were recorded for several days following the incidents. Similarly, Resident 2, who was cognitively intact and medically complex, reported feeling disrespected and retaliated against by staff, which included being made to receive care in pairs and experiencing delayed call light response times. The facility's investigation revealed that there was no documentation of monitoring for psychosocial harm in the progress notes for several days after the allegations. Staff interviews confirmed that residents should have been placed on alert and monitored with documentation every shift, which did not occur for these residents.
Inadequate Infection Control and Water Management Practices
Penalty
Summary
The facility failed to maintain an effective infection control program by not ensuring that staff had appropriate personal protective equipment (PPE) available and did not properly don PPE for residents on droplet precautions. Observations revealed that staff members were not wearing the required eye protection and did not change masks and gloves between rooms for residents on droplet precautions. Staff members were also observed entering and exiting rooms without the necessary PPE, and PPE carts were found to be inadequately stocked with essential items such as eye protection, gloves, and gowns. Additionally, the facility did not include the Infection Preventionist (IP) on the water management team and failed to implement all control measures of the Legionella Water Management Program. This included not performing routine chlorine testing and not conducting regular inspections and cleaning of resident room faucets. The water management team lacked a clinician with expertise in infection prevention, and the facility did not have the necessary equipment for chlorine testing until after the deficiency was identified. The report highlights specific instances where staff did not adhere to infection control protocols, such as not wearing eye protection or changing PPE between resident rooms. It also notes the absence of the IP from the water management team and the lack of routine testing and inspections as required by the facility's water management program. These deficiencies were observed during a period of an influenza outbreak, further emphasizing the importance of strict adherence to infection control measures.
Deficiency in Restorative Nursing Services Due to Staffing Shortages
Penalty
Summary
The facility failed to ensure sufficient qualified nursing staff to provide restorative nursing services for all 16 residents reviewed for such services. This deficiency was identified through interviews and record reviews, revealing that the facility had stopped providing restorative nursing services six to eight months prior due to staffing issues. The Restorative Nurse had transferred to another position, and the Restorative Aide had left, leading to a lack of restorative staff. Consequently, some restorative programs were transitioned to functional maintenance programs, but no restorative referrals were made during this period due to the absence of restorative staff. Additionally, the Resident Council minutes from June, July, and August 2024, highlighted ongoing resident complaints about staffing issues, including long call light response times and unmet care needs. Call light audits conducted in response to these complaints showed significant delays in response times, with some exceeding 60 minutes. The facility's assessment indicated that restorative aides were responsible for supporting residents' activities of daily living, but the lack of staff led to unmet restorative needs, placing residents at risk for a decline in their physical abilities and quality of life.
Failure to Provide Restorative Nursing Programs Due to Staffing Issues
Penalty
Summary
The facility failed to provide restorative nursing programs (RNPs) to maintain or improve range of motion (ROM), strength, and mobility for 16 residents who were assessed to require them. This deficiency occurred when the facility stopped providing restorative services in December 2023 due to staffing issues, as the Restorative Nurse transferred to another position and the Restorative Aide left. The facility attempted to transition some of the restorative programs to functional maintenance programs (FMP) to be performed by floor aides during activities of daily living (ADL) care, but no assessments or evaluations were conducted to support this transition. Furthermore, the facility was unable to provide documentation of the specific restorative programs each resident required or any evaluations indicating that the programs were no longer necessary. Resident 2, who was admitted with a diagnosis of dementia and osteoarthritis, was identified as requiring a restorative range of motion program to manage and prevent contractures. Despite recommendations from physical therapy and a care plan indicating the need for ROM exercises three to five times a week, Resident 2 did not receive the necessary restorative therapy. The facility's failure to provide these services was attributed to the absence of a Restorative Aide until one was hired, and Resident 2 was not included on the new Restorative Aide's list. This lack of restorative care placed residents at risk for a decline in strength, ROM, contracture formation, increased dependence on staff for ADLs, and decreased quality of life.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to properly label and store drugs and biologicals in accordance with accepted professional principles, affecting two medication carts and one medication room. During an observation of medication room one, a vial of Tuberculin Purified Protein and a vial of Insulin Lispro were found opened without a date, which is against the protocol that requires these medications to be discarded after a specific period post-opening. Additionally, a Fluticasone-Salmeterol Advair Diskus Inhalation medication on the [NAME] medication cart was found to be expired, as it was opened for more than one month. Staff interviews confirmed these medications were not dated or removed as required, which did not meet the facility's expectations. In the Dungeness medication cart, several medications were found either undated or past their discard date, including Fluticasone propionate aerosol inhalers and Humolog insulin. Furthermore, Resident 27 had a bottle of Nystatin Topical Powder left on their dresser without proper authorization for self-administration, as confirmed by staff interviews. The facility's policy requires medications to be kept in a resident's room only if the resident has been assessed and provided with a lock box and key, which was not the case for Resident 27.
Incomplete Medical Records and Documentation Failures
Penalty
Summary
The facility failed to ensure that residents' medical records were complete, accurate, and readily accessible, affecting 16 residents who required restorative services and one resident receiving hospice care. For the resident receiving hospice services, the facility did not maintain current hospice documentation, including the comprehensive assessment and plan of care, which had expired. There was no documentation in the electronic health record (EHR) to indicate hospice staff visits, assessments, or care provided. Despite multiple requests by the Director of Nursing, the hospice visit notes were not provided, leaving the facility without necessary information about the resident's hospice care. Additionally, the facility discontinued restorative nursing services due to staffing changes, affecting 16 residents who had been assessed to require these services. The facility did not maintain documentation of the restorative programs, assessments, or transitions to functional maintenance programs (FMPs). Staff were unable to locate the restorative binders containing specific programs and associated flowsheets for these residents. This lack of documentation resulted in incomplete and inaccurate health records, placing residents at risk for unmet care needs.
Inaccurate PASRR Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate Pre-Admission Screening and Resident Review (PASRR) assessments for three residents, which is crucial for identifying mental health or intellectual disability needs. Resident 25 was admitted with diagnoses of generalized anxiety, major depressive disorder, and bipolar disorder, but the Level I PASRR inaccurately documented a mood disorder without specifying the type and incorrectly included a diagnosis of dementia, which was not present. Staff D, the Social Services Director, acknowledged that the incorrect dementia diagnosis and the omission of anxiety should have been addressed. Staff B, the Director of Nursing Services, indicated that PASRRs were managed by Social Services and agreed that these errors should have been corrected upon admission. Resident 171's PASRR assessment was also inaccurate. The resident, who had diagnoses of dementia and generalized anxiety disorder, was readmitted to the facility with a Level 1 PASRR that did not indicate a serious mental illness, thus not triggering a Level 2 PASRR. The annual MDS noted psychotic disorder and severe cognitive impairment, but these were not reflected in the PASRR. Staff D stated that their process involved reviewing PASRRs within one to two days of admission, and acknowledged that Resident 171 should have been marked as having a mood disorder. Staff B reiterated that Social Services was responsible for correcting PASRR errors.
Deficiency in Behavior Monitoring for Psychotropic Medications
Penalty
Summary
The facility failed to adequately document and monitor the behaviors and side effects associated with the use of psychotropic medications for several residents. For Resident 25, the Medication Administration Records (MAR) and Treatment Administration Record (TAR) indicated anxiety, depressive, and psychotic behaviors on multiple occasions, yet there were no specific behaviors documented, nor were there progress notes in the Electronic Health Records (EHR) on the dates these behaviors were observed. Staff acknowledged the need for documentation of specific behaviors observed. Resident 62 was prescribed mirtazapine and Seroquel without documented consent or an Abnormal Involuntary Movement Scale (AIMS) test, which is necessary for antipsychotic medications. The behavior monitoring care plan included target behaviors that the resident had not demonstrated, such as hallucinations, raising questions about the appropriateness of the medication use. Staff confirmed that target behaviors should reflect the resident's demonstrated behaviors to evaluate the medication's effectiveness. For Residents 63 and 372, there was a lack of behavior monitoring to ensure the effectiveness and side effects of prescribed psychotropic medications. The MAR and TAR did not document specific behaviors, and there were no progress notes in the EHR. Staff were unable to explain or demonstrate how behavior monitoring was conducted, and there was no system in place to track interventions or their effectiveness. Resident 171 was readmitted without an order for behavior monitoring for an antidepressant, which was acknowledged as not meeting expectations by the staff.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents were informed of the risks and benefits associated with proposed psychotropic medication therapy and did not obtain consent from the residents or their representatives before administering the medication. This deficiency was identified for two residents, Resident 62 and Resident 63, who were reviewed for unnecessary medications. Resident 62, who was cognitively intact, had diagnoses of depressive and anxiety disorders and was receiving antidepressant and antianxiety medications. The facility's records showed that Resident 62 was prescribed mirtazapine and Seroquel, but there was no documentation indicating that the resident or their representative was informed about the risks and benefits of these medications or that consent was obtained. Similarly, Resident 63, who was also cognitively intact, had diagnoses including generalized anxiety, major depressive disorder, hallucinations, panic disorder, and hydrocephalus. The facility's records indicated that Resident 63 was prescribed sertraline, but again, there was no documentation showing that the resident or their representative was informed of the risks and benefits or that consent was obtained. Interviews with facility staff confirmed the lack of documentation for both residents, highlighting a failure in the facility's process to ensure informed consent for psychotropic medication therapy.
Failure to Provide Adaptive Equipment for Resident's Needs
Penalty
Summary
The facility failed to provide adaptive equipment for a resident, identified as Resident 63, who had specific physical needs due to arthritis in both hands, malnutrition, and other conditions. The resident was admitted with a comprehensive assessment indicating the need for assistance with eating. Despite being alert and oriented, the resident required help with cutting food due to difficulty gripping utensils. An occupational therapist had previously introduced a pizza cutter as an adaptive tool, which the resident found effective and allowed for greater independence. However, the facility removed the pizza cutter without documented assessment or justification, leaving the resident unable to cut their food independently. Observations revealed that the resident was left with uncut food during meals, leading them to eat with their hands, which was not conducive to their dignity or independence. Interviews with staff indicated a lack of communication and documentation regarding the decision to remove the pizza cutter. The occupational therapy assistant confirmed the resident's ability to use the pizza cutter safely, as documented in a therapy progress note. Despite this, the facility did not provide alternative solutions or document any assessment of the resident's safety with the pizza cutter, resulting in a failure to accommodate the resident's needs and preferences.
Failure to Document Advance Directives for Cognitively Impaired Residents
Penalty
Summary
The facility failed to properly document advance directives (AD) for two residents who were severely cognitively impaired. Resident 2 was admitted to the facility and had a care conference note indicating that ADs were established, but no copy of the AD was found in the electronic health record (EHR). Staff D, the Social Services Director, acknowledged not having a copy and admitted to not asking for it during the care conference. Similarly, Resident 40 was admitted with a care conference note stating that ADs were established, yet no AD copy was present in the EHR. Staff D admitted to not following up with the family to obtain the AD. The Director of Nursing expressed that the expectation was for staff to attempt to obtain and document the AD.
Failure to Properly Handle Resident Grievances
Penalty
Summary
The facility failed to properly handle grievances from residents, as evidenced by the lack of initiation, investigation, and logging of grievances. The facility's grievance policy required that grievances be communicated to the administrator and logged, but this was not consistently done. During Resident Council meetings, several grievances were raised, such as insufficient sandwich options, potential fire hazards from piled leaves, long call light wait times, and staff behavior issues. None of these grievances were logged, indicating a failure to adhere to the facility's grievance policy. Additionally, specific grievances from residents were not appropriately addressed. For instance, Resident 27 expressed dissatisfaction with certain CNAs and requested not to receive care from them. However, this grievance was not formally documented or investigated at the time. Similarly, Resident 63 filed a grievance regarding meal setup and assistance, but the facility did not explore alternatives or document a critical review of the grievance to reach a resolution. The grievance was signed off without evidence of a thorough investigation or resolution. The facility's process for handling grievances was further compromised by the use of Resident Response Forms instead of the designated Grievance Forms. This practice led to grievances not being reviewed by the administrator, as required. Staff members, including the Social Services Director and Activities Director, acknowledged the improper handling of grievances and the failure to log them, which prevented the administrator from reviewing and signing off on them. This systemic issue in grievance management placed residents at risk of having their concerns unaddressed, affecting their quality of life.
Failure to Report Alleged Abuse and Neglect
Penalty
Summary
The facility failed to report an allegation of abuse and neglect to the state agency for one resident, identified as Resident 46, who was cognitively intact. The resident reported that a night nurse would delay administering pain medication due to personal grievances, stating that the nurse was in control and indifferent to being reported. The resident believed they had informed the Director of Nursing (DNS), Staff B, about the issue, and the nurse in question was no longer employed at the facility. Staff B acknowledged having investigated the allegation in July, treating it as a grievance rather than an abuse allegation, and did not log or report it to the state. It was only after being questioned again that Staff B initiated a formal investigation and reported the incident to the state. This oversight in reporting placed residents at risk for potential abuse and neglect, as the facility did not adhere to its policy of timely reporting such allegations as required by federal regulations.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to properly notify the Office of the State Long-Term Care Ombudsman regarding the transfer of a resident, identified as Resident 40. This deficiency was identified through interviews and record reviews. Resident 40, who was admitted to the facility and assessed as severely cognitively impaired, was transferred on January 1, 2024. However, there was no documentation in the Electronic Health Record indicating that the Ombudsman was notified of this transfer. Staff D, the Social Services Director, confirmed the absence of such documentation, and Staff B, the Director of Nursing, acknowledged that the expectation was for the Ombudsman notification to be documented and completed.
Inaccurate Resident Assessments in MDS Documentation
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected their health status and care needs for three residents. Resident 11, who had been receiving hospice services since October 2021, was not documented as having a terminal diagnosis on multiple Minimum Data Set (MDS) assessments, despite having a hospice certification and plan of care indicating a terminal illness. This oversight was confirmed by the Assistant Director of Nursing, who acknowledged that the terminal diagnosis should have been coded on the MDS assessments. Resident 2 was incorrectly documented as participating in a restorative nursing program for passive range of motion, despite no evidence in the clinical record supporting this. The MDS coordinator admitted to mistakenly capturing these minutes, and the Director of Nursing Services confirmed that Resident 2 was not on a restorative program. Additionally, Resident 4 was inaccurately coded as being on a prescribed weight loss regimen, although there were no physician or dietitian orders for such a program. Staff, including the Resident Care Manager and Chief Medical Director, confirmed that Resident 4 was not on a weight loss program, and the MDS coding was incorrect.
Failure to Assist Resident with Oral Care
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADLs) for Resident 58, who was dependent on staff for personal hygiene due to limited functional range of motion in both upper extremities and arthritis. Despite being cognitively intact and having natural teeth, Resident 58 reported that staff did not assist with oral care, which led to poor oral hygiene. The resident expressed that they were unable to brush their teeth themselves and had resorted to using their fingernail to remove plaque, which was observed as yellowish/white debris under the fingernail and along the upper gum line. Resident 58, who was admitted to the facility earlier in the year, had an ADL self-care deficit care plan indicating the need for one-to-two-person assistance with personal hygiene. However, the resident reported that only one male nursing aide and one male therapist had assisted with brushing their teeth since admission. The resident expressed a preference for oral care to be provided at least once daily, either after breakfast or dinner. The lack of consistent oral care assistance was reported to the Resident Care Manager, but the issue was not confirmed as oral care had been provided by that time.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to provide pressure ulcer care consistent with professional standards for a resident who was at risk for pressure ulcers. The resident, who was severely cognitively impaired and on hospice, had two pressure ulcers, one of which was present upon admission. Despite being at risk, the facility did not have adequate interventions in place to prevent new pressure ulcers. The resident's skin care plan included interventions such as bruise monitoring, encouraging nutrition and hydration, and weekly skin assessments. However, a new unstageable pressure ulcer developed on the resident's right heel, indicating a lapse in preventive measures. The facility's documentation showed inconsistencies and omissions in weekly skin audits, with one audit missing entirely. Staff interviews revealed that typical interventions for pressure ulcer prevention, such as turning, repositioning, and using pressure-relieving devices, were not consistently applied. The Director of Nursing Services acknowledged that there were no interventions in place initially to prevent new pressure ulcers for the resident, and that the weekly skin audits should have documented the new skin issue when it was identified.
Lack of Coordination and Documentation in Hospice Care
Penalty
Summary
The facility failed to ensure effective communication, collaboration, and coordination of care between the facility and the hospice provider for a resident receiving hospice services. The facility did not maintain a current hospice coordinated plan of care for the resident, as the existing plan was expired and a current one was not obtained. Staff members, including the Assistant Director of Nursing (ADON) and the Medical Records Director, acknowledged the absence of the current plan and indicated that it had not been provided by the hospice. Additionally, the facility's electronic health records lacked documentation of hospice staff visits, including details of who visited, when, and what care was provided. The facility's hospice contract identified a Social Services Director as the hospice liaison, but this individual only made initial referrals and did not engage in ongoing communication or coordination of hospice services. Despite requests for hospice visit notes from the Director of Nursing, the facility did not receive the necessary documentation from the hospice provider. The ADON confirmed that there was no documentation in the resident's electronic health record regarding hospice visits, and staff were unable to provide details about recent hospice visits or the care provided. This lack of documentation and communication placed residents at risk for not receiving necessary care and services.
Failure to Maintain Safe Equipment Conditions
Penalty
Summary
The facility failed to maintain essential equipment in working condition, specifically concerning the refrigeration units and water temperature controls. In the facility's kitchen, one refrigerator was observed to have a digital thermometer reading of 47 degrees Fahrenheit, with potentially hazardous foods inside measuring temperatures above the safe range. Staff W, the Kitchen Manager, noted that the refrigerator was not cooling properly, and all foods were subsequently removed. Additionally, the nourishment refrigerators at nursing stations were found to have temperatures logged above the safe range, with potentially hazardous foods like yogurt and cheese stored inside. Staff interviews revealed that the temperature logs used were intended for monitoring COVID-19 vaccines, not food safety. The facility also failed to maintain hot water temperatures at safe levels in several resident rooms and dining areas. Water temperatures were recorded above the recommended safe range, with some readings as high as 122.1 degrees Fahrenheit. The Maintenance Director, Staff V, was present during the temperature checks and acknowledged the discrepancies, noting that the boiler was set at 118 degrees Fahrenheit. However, the facility lacked a formal policy for water temperature testing, and the temperature logs were inadequately documented, with no dates indicating when the temperatures were taken. These deficiencies placed residents at risk for foodborne illness and serious burns, as the facility did not ensure that essential equipment was functioning correctly. The lack of proper monitoring and documentation for both refrigeration and water temperatures contributed to the facility's failure to maintain a safe environment for its residents.
Failure to Adhere to Professional Standards of Practice
Penalty
Summary
The facility failed to adhere to professional standards of practice for several residents, leading to potential risks for medication errors and other health complications. For Resident 62, antihypertensive medications were administered despite the resident's systolic blood pressure being below the threshold specified in the physician's orders. This occurred on multiple occasions, as confirmed by the Assistant Director of Nursing. Resident 30 did not have the ordered compression stockings applied, yet the treatment administration record was signed as if the task had been completed. Similarly, Resident 10's toe separators were not applied as ordered, although the treatment administration record indicated otherwise. Additionally, Resident 42 was fitted with a Wanderguard device without a physician's order, contrary to the facility's expectations. For Resident 54, a wet to dry dressing was applied without a corresponding physician's order when wound vac supplies were unavailable. The Resident Care Manager confirmed that an order should have been obtained for the temporary dressing. These deficiencies highlight a pattern of failing to follow or clarify physician orders and inaccurately documenting care tasks, which could lead to negative health outcomes for the residents involved.
Deficiencies in Resident Care and Service Delivery
Penalty
Summary
The facility failed to provide necessary care and services to four residents according to their comprehensive person-centered care plans. Resident 30, who was admitted without edema, developed pitting edema in both lower extremities. Despite an order for knee-high compression stockings to manage the edema, the resident was found without them, and the compression stockings were not located in the room. The Treatment Administration Record (TAR) inaccurately indicated that the stockings had been applied. Resident 10, with a history of Hallux valgus, had an order for toe spacers to prevent tissue damage. However, the resident reported not wearing the spacers for approximately three months, despite the TAR showing daily application. Resident 62, who was cognitively intact and on antiplatelet medication, had a bruise under the left eye from a fall. The facility did not document assessments or monitoring of the bruise as per their wound management guidelines. Resident 63, with multiple diagnoses including arthritis and malnutrition, required assistance with positioning for meals. Observations showed the resident was frequently slumped in bed with meals out of reach and uncut, contrary to the care plan. Staff acknowledged the resident's dependence on assistance for positioning but failed to ensure proper positioning during meals. The facility's documentation did not reflect any refusals by the resident to get out of bed, and there was a lack of communication between nursing and occupational therapy regarding the resident's positioning needs.
Deficiencies in Nutritional and Fluid Monitoring
Penalty
Summary
The facility failed to accurately document, monitor, and assess the fluid intake and nutritional status of two residents, leading to significant health risks. Resident 4, who was severely cognitively impaired and on hospice care, had a nutritional care plan due to risks associated with COPD and dysphagia. Despite physician orders to obtain weights regularly, the facility did not adhere to the schedule, resulting in missing weight records and a failure to address a significant weight loss of over 20% in 60 days. The facility did not document any follow-up actions or reassessments for this weight loss, and the Registered Dietitian was unavailable for an extended period, leaving nutritional assessments incomplete. Resident 62, who was cognitively intact and had diagnoses of heart failure and kidney disease, was on a fluid restriction of 1800 ml per day. The facility did not reconcile the fluid intake recorded during meals with the intake recorded on the MAR, leading to the resident exceeding the fluid restriction on multiple occasions. There was no documentation indicating that staff identified this non-adherence or provided necessary education to the resident about the risks and benefits of adhering to the fluid restriction. Additionally, there was no evidence of physician notification regarding the resident's fluid intake exceeding the prescribed limit. These deficiencies in monitoring and documentation placed both residents at risk for serious health complications, including fluid volume overload, electrolyte imbalances, and significant weight loss. The facility's failure to implement and evaluate nutritional interventions and fluid restrictions compromised the residents' quality of life and health outcomes.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 54 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sequim
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sequim Bay Post Acute | 0.5 mi | ★★★★★ | 21 | 0 |
| Olympic View Post Acute | 14.5 mi | ★★★★★ | 17 | 0 |
| Life Care Center Of Port Townsend | 15.9 mi | ★★★★★ | 10 | 0 |
| Regency Coupeville Rehab And Nursing Center | 22.2 mi | ★★★★★ | 6 | 0 |
| Martha And Mary Health Service | 31.5 mi | ★★★★★ | 16 | 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.