Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avamere Rehabilitation At Ridgemont during CMS and state inspections, most recent first.
The facility failed to submit required 5‑day follow‑up reports of investigation results to the State Agency Hotline for two separate abuse/neglect allegations. In one case, a resident with heart failure and diabetes, who needed staff help with some ADLs and had no cognitive impairment, reported that a NA told the resident to stop stuttering and slammed the resident’s refrigerator door hard enough to open the freezer. In the other case, a resident with dementia, a UTI, moderate cognitive impairment, and dependence in ADLs had bruising on the thigh shaped like a handprint, prompting family concerns about staff treatment. Although both allegations were initially reported to the State Agency, the RN/DON acknowledged that she did not submit the required 5‑day follow‑up reports for either incident.
Psychotropic medication management was deficient for multiple residents with dementia, anxiety, depression, and related diagnoses. Records showed inconsistent or unclear indications and target behaviors for antidepressants, antipsychotics, and an antihistamine used for behavior, blank or missing behavior monitors, no documented side effect monitoring for trazodone and other meds, an inadequately supported GDR review for quetiapine, and PRN anticonvulsant/anxiety doses given without documentation that non-drug interventions were attempted first.
Missing Transfer and Bed Hold Notices: The facility did not document providing transfer notices or written bed hold notices for 3 residents who were sent to the hospital. The EHR showed no evidence that these notices were given during multiple transfers, including transfers for residents who were cognitively intact, and the DON stated the notices should have been completed.
The facility failed to follow bowel care orders and its bowel protocol for two residents who went multiple days without a BM, including missed escalation steps and no documented abdominal assessments. It also failed to replace a tube-feeding syringe and graduated container every 24 hours for a resident with pancreatic cancer, and failed to document NPIs before PRN pain meds for two residents with severe cognitive impairment/dementia.
Expired and undated medications were found in the 300 Hall med cart and med room during observation with an LPN. An opened glargine insulin pen, an opened atropine eye drop bottle, an expired ondansetron card, and an opened Humulin R insulin pen were identified, and the LPN confirmed they were past discard dates or missing open dates.
Aide staff were observed transporting linen and resident clothing in uncovered wheeled carts through multiple hallways and between rooms without consistent hand hygiene. A Laundry Aide handled hangers and other items while moving from room to room, and the ES Supervisor and DON stated carts should be covered and staff should sanitize between room entries when delivering personals and linen.
A resident with a history of stroke and kidney disease had an indwelling urinary catheter that was not reassessed for removal after coming off hospice care. Despite repeated concerns from family and documentation by the provider requesting urology follow-up, there was no evidence of timely communication with urology. The resident later developed hematuria and a catheter-associated UTI, requiring hospitalization and IV antibiotics.
A resident with multiple health issues underwent a left toe amputation and was discharged with specific wound care instructions. The facility failed to follow these instructions, as there was no documentation of dressing changes or assessments, leading to the wound dehiscing and becoming necrotic. Despite a follow-up visit indicating cellulitis and prescribing antibiotics, the facility did not monitor the wound, resulting in a necrotic and infected surgical site.
The facility failed to maintain a homelike environment on the 200 hall due to a carpet in disrepair, with cuts covered by duct tape. A resident and staff expressed dissatisfaction, and the Maintenance Director explained that the issue persisted for years due to administrative changes delaying carpet replacement.
A resident's need for assistive vision devices was neglected, as their glasses were not within reach and were broken. Despite the care plan indicating the necessity of glasses for reading, staff failed to ensure the glasses were in good repair and accessible, impacting the resident's ability to perform daily activities independently.
The facility failed to follow the bowel management protocol for five residents, resulting in extended periods without bowel movements. Despite the protocol requiring specific interventions after three days without a bowel movement, the staff did not administer the necessary medications, as confirmed by the DNS. This oversight affected residents with histories of constipation, placing them at risk for discomfort and other complications.
The facility failed to properly assess, maintain, and monitor IV access devices for three residents, leading to incomplete IV orders and lack of documentation for necessary procedures such as site monitoring, dressing changes, and flushes. This oversight placed the residents at risk for potential negative health outcomes.
The facility failed to provide prescribed therapeutic diets to several residents, with dietary staff not following portion sizes and food substitutions as ordered by physicians. Observations showed unmeasured preparation of pureed foods and incorrect serving sizes, with the facility also lacking certain menu items. The Food Service Director confirmed these errors, which affected residents on various therapeutic diets, including those with renal and limited carbohydrate needs.
The facility failed to provide residents with access to their personal funds during evenings and weekends, affecting 11 residents. A resident had to open another bank account due to this issue. Staff, including an LPN and a Resident Care Manager, were unaware of the withdrawal process during non-banking hours. The Business Office Manager acknowledged the inadequacy of current signage regarding banking hours.
The facility failed to provide written notice of transfer or discharge to two residents and did not notify the state Ombudsman, as required. One resident was severely cognitively impaired and the other was cognitively intact. Staff interviews confirmed the absence of necessary documentation, placing residents at risk for inappropriate transfers and lack of information regarding their rights.
The facility failed to conduct timely care conferences and maintain accurate care plans for residents. A resident had not had a care conference in over a year, despite being cognitively intact and valuing family involvement. Additionally, care plans for residents with IV access, CPAP therapy, and impaired range of motion lacked necessary details and updates, as confirmed by the DNS.
The facility failed to assist two residents with activities of daily living, specifically oral care and shaving. One resident was not helped with brushing teeth or shaving despite family requests, and another resident was observed with unwanted facial hair due to lack of assistance. Staff acknowledged the oversight.
The facility failed to ensure proper CPAP management for two residents with obstructive sleep apnea. One resident had no active CPAP order, and the previous order was discontinued without documentation. Observations showed undated distilled water for the CPAP machine and no staff instructions for maintenance. Another resident's care plan lacked details on CPAP/BiPAP use, pressure settings, and cleaning instructions. The DNS acknowledged the incomplete orders and the need for clarification.
Failure to Submit Required 5‑Day Follow‑Up Reports for Abuse/Neglect Allegations
Penalty
Summary
The facility failed to ensure that the results of abuse and neglect investigations were reported to the State Agency Hotline within 5 working days for two residents. For the first resident, who had heart failure, diabetes mellitus, no cognitive impairment, and required staff assistance with some ADLs, an incident report dated 03/16/2026 documented that a nursing assistant stood at the end of the resident’s bed, told the resident to stop stuttering, and then slammed the resident’s refrigerator door so hard that the freezer opened. This allegation was reported to the State Agency on the same date, but there was no evidence that a 5‑day follow‑up report of the investigation results was submitted as required. For the second resident, who had dementia, a urinary tract infection, moderate cognitive impairment, and was dependent on staff for ADLs, an incident report dated 04/01/2026 documented that the resident’s family expressed concerns about the resident’s treatment by an unnamed staff member. The allegation statement noted bruising on the resident’s thigh shaped like a handprint. This allegation was reported to the State Agency on the date of the incident report, but again, no evidence was provided showing that a 5‑day follow‑up report of the investigation results was submitted. In an interview, the RN/DNS acknowledged that she did not submit the required 5‑day follow‑up reports for either allegation, despite the requirement under WAC 388-97-0640(5)(a).
Psychotropic medications lacked clear indications, behavior monitoring, GDR documentation, and PRN non-drug intervention records
Penalty
Summary
The facility failed to ensure psychotropic medications had adequate indications for use, that the specific target behaviors for each medication were identified and monitored, that gradual dose reductions were properly assessed and documented, that non-drug interventions were identified and attempted before PRN psychotropic use, and that staff monitored for adverse side effects for three residents reviewed. The report states these failures affected the facility’s ability to assess medication effectiveness, ongoing need, and adverse side effects. For one resident with moderate cognitive impairment, dementia, anxiety disorder, and psychotic disorder, the record showed multiple psychotropic orders including citalopram, mirtazapine, quetiapine, and hydroxyzine, but the documented indications were inconsistent across orders, care plans, TARs, and psychotropic reviews. The target behaviors listed for quetiapine differed between the care plan and the behavior monitor, the antidepressant behavior monitors were blank for several months, and the records did not identify distinct target behaviors for citalopram and mirtazapine. A quetiapine GDR was implemented after a psychotropic review, but the documentation of the GDR period showed no behaviors on the behavior monitor and only one nursing note describing increased anxiety and frustration related to call light response time; the DNS acknowledged that this was not sufficient to determine the GDR had failed. For a second resident with anxiety disorder, depressive disorder, unspecified dementia, and severe cognitive impairment, the record showed trazodone ordered at bedtime for insomnia, but there was no side effect monitoring documented for that medication. For a third resident with severe dementia with agitation and anxiety disorder, the record showed antidepressant, antipsychotic, and anticonvulsant/anxiety medications, but there were no behavior monitor orders specific to what each medication was treating, no adverse side effect monitoring orders for the medications, and no consent found for the antidepressant. The resident’s PRN anticonvulsant/anxiety medication was administered multiple times over several days, but the PRN order did not include an NPI monitor to show that non-pharmacologic interventions were attempted before administration, and staff could not find documentation of such interventions for several of the doses reviewed.
Missing Transfer and Bed Hold Notices
Penalty
Summary
The facility failed to provide a transfer notice and written bed hold notice at the time of hospital transfer for 3 of 3 sampled residents reviewed for hospitalization: Resident 24, Resident 73, and Resident 2. Resident 24 was admitted to the facility, was documented on the 5 Day MDS as cognitively intact, and was transferred to the hospital and later returned, but the EHR contained no documentation that a transfer notice or bed hold notice was provided at the time of transfer. Resident 73 was admitted to the facility and documented on the admission MDS as cognitively intact. Resident 73 had one hospital transfer with return to the facility and a second transfer from which the resident did not return, and the EHR had no documentation that a transfer notice or bed hold notice was provided for either transfer. Resident 2 was admitted to the facility and documented on the Quarterly MDS as cognitively intact, and the EHR showed multiple hospitalizations over the past year, with no documentation that a transfer notice or bed hold notice was provided for any of the listed transfers.
Bowel Care, Tube Feeding Syringe, and PRN Pain Medication Documentation Failures
Penalty
Summary
The facility failed to provide bowel care in accordance with physician orders and its bowel protocol for two residents. One resident with a diagnosis of constipation and intact cognition had no bowel movement for five days in August 2025. The resident had orders for scheduled and as-needed bowel medications, including Milk of Magnesia, polyethylene glycol, bisacodyl suppository, and mineral oil enema. The record showed the resident refused Milk of Magnesia on one day, and staff later stated the refusal should have been reapproached, documented in a progress note, and followed by an abdominal assessment and provider notification, but those actions were not documented. Another resident had bowel care orders for Milk of Magnesia if no bowel movement for three days, followed by a Dulcolax suppository if ineffective, then a Fleet mineral oil enema if needed, along with Dulcolax tablets as needed. The resident went six days without a bowel movement. The record showed Dulcolax tablets were given once, but when there were no results and the resident continued without a bowel movement, no further as-needed bowel medications were administered. There was also no abdominal assessment documented during that period. The DNS stated the resident did not receive bowel care in accordance with the physician orders and facility bowel protocol. The facility also failed to replace a tube-feeding syringe and graduated container every 24 hours for one resident with pancreatic cancer and aftercare following surgery on the digestive system. Staff observed a syringe dated several days earlier at the resident’s bedside, and an LPN stated it should be changed every day. In addition, the facility failed to document non-pharmacological interventions before PRN pain medication for two residents. One resident with severe cognitive impairment received tramadol multiple times with no documented interventions such as repositioning, relaxation, diversional activities, food or beverage, or a blanket/sweater. Another resident with severe dementia and agitation received PRN opioid pain medication on two occasions without any documented non-pharmacological interventions.
Expired and Undated Medications Found in Medication Storage Areas
Penalty
Summary
Drugs and biologicals in the facility were not labeled and dated in accordance with accepted professional standards of practice, and expired medications were not discarded in the 300 Hall medication room and on the 300 Hall medication cart. During observation with an LPN, Resident 37’s glargine insulin pen was found opened and undated, Resident 62’s atropine eye drops had an open date of 08/22/2024, and Resident 4’s ondansetron card was expired with a discard date of 08/25/2025. In the 300 Hall medication room, Resident 80’s Humulin R insulin pen was also found opened and undated. The LPN confirmed the medications were opened and undated or past their discard dates and needed to be disposed of.
Infection Control Lapses During Linen and Clothing Transport
Penalty
Summary
Provide and implement an infection prevention and control program was cited after staff were observed failing to maintain infection control practices while transporting linen and delivering resident clothing in multiple hallways. On 09/07/2025, a Laundry Aide was observed delivering personal clothes down the 100 hallway from an uncovered rolling basket cart with clothes layered inside it. The aide touched hangers in one room, removed them from the room, and hung them on the cart, then moved between rooms without performing hand hygiene before entering or after exiting rooms while assisting a resident in finding clothes, removing hangers, and taking a blanket into another room. On 09/09/2025 and 09/11/2025, a Laundry Aide was observed transporting towels, clothing protectors, draw sheets, and resident clothing in uncovered wheeled baskets down the 300 hallway, the TC hallway, and to the clean linen closet connecting TC, the 300 rooms, and the 100 and 200 rooms. The Environmental Services Supervisor stated the linen should have been covered with a sheet and that staff should hand sanitize between rooms when delivering personal items. The DON also stated there should be a sheet placed over the cart as staff transported and delivered personals and linen in the hallways.
Failure to Assess Catheter Removal and Coordinate Urology Follow-Up
Penalty
Summary
The facility failed to ensure that a resident with an indwelling urinary catheter was properly assessed for catheter removal and that timely coordination with urology occurred. The resident, who was admitted with a history of stroke and kidney disease and was severely cognitively impaired and dependent for activities of daily living, had an indwelling catheter placed during a hospital stay due to severe diaper rash. After discharge, the resident was placed on hospice, and the catheter remained in place. When the resident was no longer on hospice, there was no documentation that the facility reassessed the need for the catheter or consulted with urology regarding its continued use. Collateral contacts, including a family member, repeatedly expressed concerns to facility staff about the resident's catheter, specifically noting frequent red urine and the presence of sludge in the catheter bag. Despite these ongoing concerns and repeated documentation by the medical provider requesting clarification and follow-up with urology, there was no evidence in the medical records of communication or follow-up with the urology office until several months later. The care plan continued to list the indwelling catheter for obstructive uropathy, but no action was taken to reassess or attempt removal. Eventually, after the family contacted the urology office directly, an appointment was scheduled, and the urologist requested a catheter change and urinalysis prior to the visit. When the catheter was changed, the resident was found to have red urine and was sent to the emergency room, where a catheter-associated urinary tract infection was diagnosed and treated with intravenous antibiotics. The facility's Director of Nursing confirmed that there was no documentation of assessment for catheter removal or timely urology consultation after the resident came off hospice.
Failure to Monitor and Assess Surgical Wound
Penalty
Summary
The facility failed to provide appropriate wound care for a resident who had undergone a left toe amputation. The resident was admitted with multiple health issues, including diabetes, heart, and kidney disease, and required assistance with daily activities. Post-surgery, the resident was discharged with instructions to change the dressing every other day and to monitor for signs of infection. However, the facility did not follow these instructions, as there was no documentation of dressing changes or assessments of the surgical site from the time the initial dressing order expired until the resident's condition worsened. The resident's surgical site was not assessed or monitored adequately, leading to the incision dehiscing, becoming necrotic, and showing signs of infection. Despite the surgeon's follow-up visit indicating residual cellulitis and prescribing an antibiotic, the facility staff did not document any dressing changes or assessments. The resident's condition was only noted nine days after the surgeon's visit, at which point the wound was found to be necrotic with purulent drainage and a foul odor. Staff interviews revealed that there was an expectation for new dressing orders after the follow-up appointment, but no action was taken when the resident returned without paperwork. The Director of Nursing acknowledged the lack of documentation and monitoring, stating that the surgical incision should have been followed by the Resident Care Manager until healed. The failure to obtain clarification for treatment and timely assessment of the wound placed the resident at risk for medical complications and decreased quality of life.
Failure to Maintain a Homelike Environment Due to Carpet Disrepair
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment on the 200 hall, as evidenced by the poor condition of the hallway carpet. Observations revealed a 30-foot-long vertical cut down the middle of the hallway carpet, along with multiple horizontal cuts, all of which were covered with duct tape. This condition had persisted for several years, as confirmed by a staff member who expressed dissatisfaction with the state of the carpet. Resident 65 also expressed discontent, describing the carpet as "disgusting" and "insulting," and noted that it did not contribute to a homelike environment. The Maintenance Director, Staff D, explained that the carpet had been bunching up for over two years, creating potential tripping hazards. In an attempt to address the issue, Staff D cut the carpet to stretch it and then covered the cuts with duct tape. Despite obtaining bids for carpet replacement, the project was delayed due to frequent changes in administration, requiring new bids each time. Staff D acknowledged informing the state survey team about the planned replacement for several years, but no work order had been issued, and the process had not progressed beyond obtaining bids.
Failure to Assist Resident with Vision Needs
Penalty
Summary
The facility failed to ensure that a resident who required assistive devices for vision was assisted with the application of their glasses. The resident, identified as Resident 10, was admitted to the facility and had a care plan indicating the need to wear glasses during waking hours and at night for reading. However, observations on multiple occasions revealed that the resident's glasses were not within reach or sight, and were in disrepair with only one lens intact. The resident expressed unawareness of the glasses' location and confirmed they were broken, stating that staff were aware but had not taken action. Staff C, a Resident Care Manager, confirmed the resident's glasses were not accessible and found additional pairs of glasses, each missing a lens. Staff C admitted to not being informed about the broken glasses and acknowledged that facility staff should have identified the issue during daily cleaning. This oversight precluded the resident from independently reading the activity calendar and menus, potentially affecting their quality of life.
Failure to Adhere to Bowel Management Protocol
Penalty
Summary
The facility failed to provide necessary bowel management care for five residents, as per the Avamere Living Bowel Care Protocol. This protocol required the administration of milk of magnesia after three consecutive days without a bowel movement, followed by a bisacodyl suppository if there was no result, and then a fleets enema if needed. However, the facility staff did not adhere to these orders, resulting in residents experiencing extended periods without bowel movements. For instance, Resident 65 went 11 days and 4 days without a bowel movement in July and August 2024, respectively, without receiving the prescribed bowel medications. Similarly, Resident 32 and Resident 10 experienced 4-day and 5-day periods without bowel movements, respectively, without receiving the necessary interventions. Resident 25 and Resident 13 also did not receive the required bowel care as per the protocol. Resident 25 went 4 days without a bowel movement in June 2024, and Resident 13 went 4 days without a bowel movement in August 2024, yet the bowel protocol was not implemented timely. The Director of Nursing Services confirmed that the staff did not provide the as-needed bowel care as ordered for these residents. This lack of adherence to the bowel management protocol placed the residents at risk for discomfort and other complications associated with constipation.
Failure to Monitor and Maintain IV Access Devices
Penalty
Summary
The facility failed to ensure proper assessment, maintenance, and monitoring of intravenous (IV) access devices for three residents receiving IV therapy. The facility's policies required routine monitoring of IV insertion sites, flush orders, weekly changes of IV dressings and needleless injection caps, and measurements of IV catheters' external length and residents' arm circumferences. However, these protocols were not followed, placing the residents at risk for potential negative health outcomes. Resident 16, who was admitted with a diagnosis of osteomyelitis and had a midline IV for antibiotic therapy, did not have documented IV maintenance and monitoring orders. The facility staff failed to monitor the IV site for infection, perform weekly dressing changes, measure the midline external length and arm circumference, and conduct midline flushes. Similarly, Resident 48, admitted with a wound infection and a midline IV for Daptomycin, lacked a comprehensive care plan addressing the IV access. The staff did not document monitoring of the IV site, perform weekly dressing changes, measure the midline external length and arm circumference, or conduct midline flushes. Resident 74, admitted with a PICC line, also had incomplete IV orders without monitoring and maintenance instructions. The Director of Nursing Services acknowledged that the IV orders for all three residents were incomplete and should have included the necessary maintenance and monitoring orders as per the facility's policy. The failure to identify and clarify incomplete IV orders contributed to the deficiency.
Failure to Provide Prescribed Therapeutic Diets
Penalty
Summary
The facility failed to ensure that residents received foods in the appropriate form and nutritive content as prescribed by a physician, affecting five of the 36 sampled residents. Observations revealed that dietary staff did not follow the prescribed diet orders, which included specific portion sizes and food substitutions for residents on therapeutic diets. For instance, residents on a regular diet were to receive a #8 scoop of apple crisp, while those on soft bite-sized, minced and moist, and pureed diets were to receive different scoop sizes. However, the dietary staff served a #16 scoop of peach crisp to all residents, regardless of their dietary requirements. During meal preparation, Staff L, a cook, was observed not measuring ingredients while preparing pureed foods, which is against the facility's protocol to maintain nutritional content and appropriate texture. The Food Service Director confirmed that staff were expected to follow written recipes and measure ingredients accurately. Additionally, the facility was out of several menu items, such as butter, garlic green beans, and apple crisp, and failed to prepare spiral pasta for residents on renal diets, leading to further deviations from prescribed diets. The lunch tray line observations showed multiple instances where residents did not receive their prescribed diets. For example, a resident on a limited carbohydrate diet did not receive extra sauce or gravy, and another on a renal diet was served milk instead of lemonade. The Food Service Director acknowledged these errors and confirmed that the dietary computer system's list of diets was accurate, indicating that the deviations were due to staff errors rather than incorrect dietary information.
Lack of Access to Personal Funds During Non-Banking Hours
Penalty
Summary
The facility failed to ensure that residents had ready access to their personal funds or resident trust accounts during evenings and weekends. This deficiency affected 11 out of 11 residents reviewed for personal funds accounts. A resident reported having to open another bank account with a family member's help because they could not access their funds on weekends. Staff members, including an LPN, a Resident Care Manager, and a Receptionist, were unaware of the process for residents to withdraw money from their accounts during weekends or after hours. The Business Office Manager acknowledged that the current signage indicating banking hours was inadequate, as it did not provide a solution for when activities staff were unavailable to assist residents with withdrawals outside of regular hours.
Failure to Notify Residents and Ombudsman of Transfers
Penalty
Summary
The facility failed to provide the required written notice detailing the reasons for discharge or transfer to two residents, as well as failing to notify the state Ombudsman office. This deficiency was identified during a review of two residents who were hospitalized. Resident 27, who was severely cognitively impaired, was hospitalized for several days, yet there was no documentation of a transfer notice or Ombudsman notification in their Electronic Health Record (EHR). Similarly, Resident 75, who was cognitively intact, was also hospitalized without any documentation of a transfer notice or Ombudsman notification in their EHR. Interviews with facility staff revealed that the required notifications were not completed. Staff C, the Resident Care Manager, confirmed the absence of the necessary documentation for both residents. Staff N, the Social Services Director, acknowledged responsibility for Ombudsman notifications and provided a list of transferred residents for the relevant months, which did not include Residents 27 and 75. This oversight placed the residents at risk for inappropriate transfers and a lack of information regarding their rights and options related to bed-holds.
Deficiencies in Care Conferences and Care Plan Accuracy
Penalty
Summary
The facility failed to conduct care conferences and maintain accurate and comprehensive care plans for several residents, leading to deficiencies in care. Resident 13, who was cognitively intact and valued family involvement in care discussions, had not had a care conference since August 2023, despite the expectation for quarterly meetings. Staff K, the Social Services Coordinator, acknowledged the lapse without providing a reason, and Staff B, the Director of Nursing Services, confirmed the expectation for quarterly conferences, noting an attempt to contact the family in March 2024 without further follow-up. Additionally, the facility did not develop or update care plans to reflect the specific needs of Residents 16, 48, 63, and 8. Resident 48 and Resident 16, both with IV access, lacked care plans detailing the type and location of their IVs and necessary interventions. Resident 63, who required CPAP therapy, had a care plan that failed to specify the type of machine, settings, and maintenance instructions. Resident 8, with impaired range of motion, had a care plan that did not specify the frequency or details of the required exercises. Staff B confirmed these omissions, indicating a failure to ensure care plans were comprehensive and up-to-date.
Failure to Assist Residents with ADLs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for two residents, specifically in the areas of oral care and shaving. Resident 63, who was admitted to the facility and assessed as dependent on staff for oral hygiene, was not assisted with brushing his teeth after breakfast or shaving daily, despite his family's repeated requests. Observations confirmed that Resident 63 had facial hair, and both the resident and his family member reported that oral care was not being provided as expected. Staff J, a Certified Nursing Assistant, admitted to not assisting with these tasks as often as desired. Similarly, Resident 10 was observed with unwanted facial hair on multiple occasions, indicating a lack of assistance with shaving. When asked, Resident 10 expressed a preference for not having facial hair but lacked the means to remove it. Staff C, the Resident Care Manager, acknowledged that staff should have been assisting Resident 10 with shaving but had not done so recently. These deficiencies were noted under the reference WAC 388-97-1060 (2)(c).
Inadequate CPAP Management for Residents
Penalty
Summary
The facility failed to provide non-invasive mechanical ventilation via CPAP machines in accordance with accepted professional standards for two residents. Resident 25, who was cognitively intact and had diagnoses of chronic lung disease and obstructive sleep apnea, required CPAP therapy. However, there was no active CPAP order in place, and the previous order had been discontinued without documentation of a new order. Observations revealed an undated and partially used container of distilled water for the CPAP machine, and there were no instructions for staff regarding the maintenance or application of the CPAP machine. The Director of Nursing Services confirmed the absence of an order and acknowledged the need for dating opened distilled water containers. Resident 63, diagnosed with obstructive sleep apnea, also required CPAP therapy. The care plan did not specify whether a CPAP or BiPAP was used, nor did it include pressure settings or cleaning instructions. Existing orders lacked details on prescribed pressure settings, cleaning solutions, and instructions for checking or refilling the humidifier reservoir. The Director of Nursing Services admitted that the CPAP orders were incomplete and that facility nurses failed to identify and clarify the incomplete order set.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Port Orchard
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Center Of Port Orchard | 0 mi | ★★★★★ | 20 | 0 |
| Washington Veteran Home-retsil | 2.8 mi | ★★★★★ | 19 | 0 |
| Port Washington Post Acute | 3.2 mi | ★★★★★ | 15 | 0 |
| Belmont Terrace | 4.6 mi | ★★★★★ | 22 | 0 |
| Bremerton Trails Post Acute | 4.8 mi | ★★★★★ | 55 | 0 |
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