Avamere Transitional Care Of Puget Sound
Inspection history, citations, penalties and survey trends for this long-term care facility in Tacoma, Washington.
- Location
- 630 South Pearl Street, Tacoma, Washington 98465
- CMS Provider Number
- 505529
- Inspections on file
- 24
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 56
Citation history
Health deficiencies cited at Avamere Transitional Care Of Puget Sound during CMS and state inspections, most recent first.
A resident admitted with coccyx skin breakdown and moderate Braden risk was initially misclassified as having skin tears rather than Stage II PUs, and the skin integrity care plan lacked resident-centered interventions addressing specific risk factors such as repositioning, offloading, and moisture management. Nursing documentation over time was inconsistent, with notes alternately stating there were no wounds and describing excoriation and open areas, while weekly wound audits and evaluations were missed or incomplete. The WCC eventually identified a large unstageable coccyx PU that progressed to Stage IV, but WCC orders for twice-daily wound care, specific cleansers, and pressure-relieving devices were inaccurately transcribed on the TAR and not fully incorporated into the care plan. Weekly wound assessments were not consistently performed, and the care plan failed to document the presence and stage of the coccyx Stage IV PU or a new heel DTI, contributing to ongoing worsening of the resident’s pressure injuries.
A resident’s PU/PI status was inaccurately assessed and documented across multiple tools and time points, including the admission skin integrity database, daily skilled notes, CAA, and several MDS assessments and modifications. Initial documentation described coccyx wounds as skin tears and later MDS coding alternated between no PU/PI, unstageable PU/PI present on admit, and a Stage IV PU/PI not present on admit, without consistent supporting clinical detail such as stage, location, or measurements. The CAA lacked documented rationale for PU/PI-related care planning, and a new DTI on the heel identified by a WCC was not coded on the discharge MDS because the wound tracker form was not available to the MDS coordinator at the time of completion.
A resident with multiple medical conditions reported rough care by a CNA, resulting in bruising and distress. The incident was documented as a grievance but not reported as an abuse allegation, and there was no evidence of an investigation or required notifications. Staff interviews revealed inconsistent understanding of abuse reporting protocols, and the DNS could not provide documentation of follow-up actions.
A resident with dysphagia and a prescribed minced & moist texture diet was incorrectly served a regular texture hamburger, leading to coughing and hospital evaluation. Staff failed to verify dietary orders and care plans before serving the meal.
The facility failed to investigate an unexpected death and an abuse allegation. A resident with hypertension died unexpectedly after receiving medication against provider orders, and no investigation was conducted. Another resident reported inappropriate behavior by a staff member, but the incident was not logged or reported. The DON and Administrator acknowledged that such incidents should be investigated, but no actions were taken.
The facility failed to ensure accurate MDS assessments for two residents, leading to potential risks for unmet care needs. One resident, with heart conditions, reported pain and received medications, but the MDS inaccurately showed no pain or anticoagulant use. Another resident, with a leg contusion, had dressings applied, yet the MDS did not reflect this. Staff interviews confirmed these discrepancies.
The facility failed to create comprehensive care plans for four residents, leading to potential risks. A resident with anxiety related to toileting had no care plan addressing this issue, while another on narcotic pain medication lacked a pain management plan. A third resident had an indwelling catheter without an order or care plan, and a fourth resident's fear of falling during bed mobility was not addressed in their care plan. Staff interviews revealed communication gaps and inconsistencies in understanding residents' needs.
The facility failed to follow provider orders and ensure safe medication administration for several residents, leading to significant deficiencies in care. A resident with hypertension was given amlodipine despite low blood pressure, resulting in an unexpected death. Another resident experienced lightheadedness due to low blood pressure without proper monitoring or provider notification. Additional issues included improper administration of medications outside prescribed parameters and inadequate documentation of adverse effects and bowel care.
The facility failed to provide a working doorbell for handicap residents in the courtyard, leading to potential risks. A resident reported that the courtyard doors were too heavy to open, and the doorbell did not prompt staff response, leaving them stuck until a staff member came by. The Maintenance Director was aware of the issue but unsure of its duration.
The facility failed to provide nonpharmacological interventions (NPI) before administering PRN pain medications to two residents. One resident with hypertension received oxycodone and acetaminophen without NPI being offered, while another resident with a hip fracture received narcotic pain medication multiple times without NPI being documented. Staff interviews confirmed that the expectation to use NPI prior to PRN medications was not met.
The facility failed to properly store medications in both medication rooms and on two medication carts. Lorazepam, a controlled substance, was not secured in locked compartments in the medication rooms, and refrigerator temperatures were frequently out of range. Additionally, insulins on the medication carts lacked open or expiration dates, with one being expired. Staff interviews indicated a lack of awareness regarding proper procedures for securing medications and monitoring temperatures.
The facility failed to maintain an effective infection prevention and control program, lacking analysis of infection data and follow-up activities. Transmission-based precautions were not implemented properly, with staff observed entering rooms without required PPE. Enhanced Barrier Precautions were also not followed during wound care. Interviews confirmed that expected precautions were not consistently implemented.
The facility failed to ensure the infection prevention and control program was managed by a qualified individual. During the absence of the designated infection preventionist, there was confusion about who was responsible for infection control tasks. Staff B and Staff Z had not completed necessary training, and Staff CC, who was expected to cover, was not doing so. This placed residents, family members, and staff at risk.
The facility failed to educate four residents on the benefits and potential side effects of the COVID-19 vaccine before offering it. The residents declined the vaccine, and there was no documentation of education provided. Interviews with staff confirmed the lack of documentation and education, which was expected by the facility's administration.
Failure to Accurately Assess, Care Plan, and Implement Wound Care for Pressure Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary treatment and services consistent with professional standards of practice to prevent the development and worsening of pressure ulcers/injuries for a resident admitted with coccyx skin breakdown and at moderate risk for pressure injury. On admission, the resident had two coccyx wounds documented as skin tears without detailed wound characteristics, and the Braden Scale score was 14, indicating moderate risk due to moisture, activity, mobility, and friction/shear issues. The initial skin integrity care plan identified actual skin impairment and included general interventions such as keeping skin clean and dry, using lotion, encouraging nutrition, weekly skin assessments, and monitoring/documenting wounds, but it did not include resident-centered interventions addressing specific Braden risk areas or pressure ulcer prevention measures such as repositioning, offloading, or moisture management tailored to the resident’s condition. In the weeks following admission, nursing documentation about the resident’s skin condition was inconsistent and incomplete. Progress notes alternated between stating that the resident had no wounds and describing a pressure ulcer with drainage and slough, excoriation of the buttocks, and open areas on the coccyx, without consistent measurements or staging. Weekly skin audits at times reported no irregularities despite other notes indicating significant skin issues. The contracted wound care clinician (WCC) did not evaluate the coccyx wounds until 14 days after admission, at which time the resident had a large unstageable coccyx pressure injury with extensive eschar. Although the WCC recommended specific treatments, including twice-daily dressing changes, an air mattress, and turning/repositioning every two hours, the care plan was only minimally updated to add an air mattress and did not document the unstageable pressure injury, pressure offloading, repositioning frequency, or other individualized interventions based on the Braden assessment. Over the subsequent weeks, the facility failed to consistently perform and document weekly wound evaluations and did not accurately transcribe or implement physician and WCC wound care orders. Treatment Administration Records showed that orders for twice-daily wound care were entered as once daily, and instructions to leave an acidic wound cleanser on the wound bed for 10 minutes were omitted. Weekly wound evaluations were missing for multiple weeks, and when the WCC documented worsening of the coccyx wound to Stage IV with increasing size and eschar, the care plan still was not updated to reflect the wound stage, detailed interventions, or additional pressure-relieving devices recommended by the WCC. The resident’s coccyx pressure injury continued to worsen in size and depth, and a new deep tissue injury developed on the right heel, despite WCC orders for heel protectors and offloading. The care plan eventually added general instructions to encourage repositioning and elevate heels with pressure-relieving boots, but it still did not document the presence or stage of the coccyx Stage IV pressure ulcer or the heel DTI. Interviews confirmed that wound orders were incorrectly transcribed, weekly wound evaluations were not routinely completed, and the initial coccyx wounds had been misidentified as skin tears rather than Stage II pressure ulcers, contributing to avoidable worsening of the resident’s pressure injuries.
Inaccurate MDS and Wound Documentation for Pressure Ulcers/Injuries
Penalty
Summary
The facility failed to ensure accurate assessment and documentation of a resident’s pressure ulcers/injuries (PU/PIs) from admission through discharge. On admission, the Nursing Database-Skin Integrity dated 12/04/2025 documented two coccyx wounds as skin tears, while the DON later stated the resident actually admitted with two Stage II PU/PIs on the coccyx, indicating the admission documentation was inaccurate. A daily skilled progress note on 12/08/2025 described a PU/PI with drainage and dead tissue but did not include the anatomical location, stage, or measurements. The 12/10/2025 admission MDS coded the resident as at risk for PU/PIs with no unhealed PU/PIs, and the 12/15/2025 PU/PI CAA did not document the rationale for care plan decisions, including complications, risk factors, or resident-centered care needs. Subsequent MDS assessments and modifications contained inconsistent and incomplete coding of the resident’s PU/PIs. A Significant Change MDS dated 01/22/2026 showed one Stage IV PU/PI present on admission, while a 12/10/2025 admission MDS modification dated 01/27/2026 coded one unstageable PU/PI on admission. A later admission MDS modification dated 02/11/2026, submitted after discharge, indicated one unhealed PU/PI but did not include the number or stage of the wound. The MDS coordinator reported there was no supporting documentation for a PU/PI on admission and that the earlier coding of an unstageable PU/PI present on admission was incorrect; the records were then modified to show a Stage IV PU/PI that was not present on admission and had developed at the facility. Additionally, a Wound Care Consultant form dated 02/05/2026 documented a new DTI on the right heel, but the discharge MDS dated 02/10/2026 did not code this DTI, which the MDS coordinator attributed to the wound tracker form not being available in the clinical record at the time of MDS completion.
Failure to Identify and Report Alleged Abuse
Penalty
Summary
The facility failed to identify and report an allegation of abuse involving one resident who was admitted for skilled nursing and rehabilitation following a recent hospitalization. The resident, who had a history of stroke, back surgery, and an implanted nerve stimulator, reported that a CNA was rough during personal care, including yanking the resident up and down and not listening to requests to stop. The resident described feeling like a 'rag doll' and reported bruising as a result of the rough care. The incident was reported by the resident to a provider the following morning, and subsequently discussed with the Director of Nursing Services (DNS). Despite the resident's report and a grievance form documenting the allegation of rough care, the facility did not log the incident as an abuse allegation in the incident logs. There was no documentation in the electronic health record of a provider note, skin assessment, or evaluation following the resident's report. The DNS documented that education would be provided to the CNA and updated the resident's care plan, but there was no evidence of an abuse investigation or required notifications to authorities as outlined in facility policy and state guidelines. Interviews with multiple staff members revealed inconsistent understanding and implementation of abuse reporting protocols. Some staff indicated they would notify supervisors or complete grievance forms, but were unclear about the process for suspending staff or notifying authorities. The DNS stated that further information would be gathered before suspending staff or notifying parties, and could not recall the staff member involved or provide documentation of the education provided. The administrator confirmed that either the administrator or DNS would decide next steps upon being notified of such incidents.
Failure to Serve Correct Therapeutic Diet
Penalty
Summary
The facility failed to ensure that the correct texture of food was served to a resident with a prescribed therapeutic diet. Resident 1, who was moderately cognitively impaired and had a diagnosis of dysphagia, was admitted to the facility with a physician's order for a minced & moist texture diet. Despite this, the resident was served a regular texture hamburger as an alternative meal, which was not in accordance with the prescribed diet. This incident occurred after the resident had been hospitalized for aspiration pneumonia, highlighting the importance of adhering to dietary orders. The incident report revealed that neither the kitchen staff nor the nursing staff verified the resident's dietary orders and care plan before serving the meal. As a result, the resident began coughing after consuming the hamburger, prompting staff to remove the meal and send the resident to the hospital for further evaluation. The failure to check the dietary orders and care plan led to the serving of an incorrect meal texture, which could have posed significant health risks to the resident.
Failure to Investigate Unexpected Death and Abuse Allegation
Penalty
Summary
The facility failed to investigate an unexpected death and an allegation of abuse, leading to deficiencies in care. Resident 52, who had a diagnosis of essential hypertension, unexpectedly died at the facility. The resident was administered amlodipine despite having a low systolic blood pressure, which was against the provider's orders. The resident's condition deteriorated throughout the day, and despite being monitored, the resident became nonresponsive and died. The Director of Nursing Services and the Administrator acknowledged that unexpected deaths should be investigated to rule out abuse, neglect, or mistreatment, but no further investigation was conducted after reviewing the medical records. Resident 114, who was cognitively intact and admitted with multiple fractures of the pelvis, reported an incident involving a staff member to a Charge Nurse. The resident requested that the staff member not return to their room, but the staff member continued to act inappropriately. The incident was not recorded in the facility's incident log, and the Charge Nurse did not report the incident to anyone else. The Director of Nursing Services and the Administrator stated that allegations of abuse should be reported, investigated, and the alleged perpetrator suspended, but these actions were not taken.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Sets (MDS) accurately reflected the health status and care needs of two residents, leading to potential risks for unidentified and unmet care needs. Resident 107, admitted with congestive heart failure and atrial fibrillation, reported significant pain levels and received both tramadol and heparin sodium during the lookback period. However, the admission MDS inaccurately indicated no pain and no anticoagulant medication. Staff interviews revealed that the MDS Coordinator did not review records for reported pain, and the Director of Nursing Services acknowledged the inaccuracies in the MDS. Similarly, Resident 307, readmitted with heart failure and a leg contusion, was observed with a swollen leg and dressings applied by the facility's nurses. Despite this, the five-day MDS inaccurately showed no dressings. Staff interviews confirmed that the MDS should have reflected the dressing changes. These inaccuracies in the MDS assessments were identified through observations, interviews, and record reviews, highlighting a failure to accurately document residents' conditions.
Deficiencies in Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for four residents, leading to potential risks for these individuals. Resident 113, who was admitted with orthopedic surgery complications, expressed anxiety about being left alone in the bathroom, but this was not documented in their care plan. Despite the resident communicating their anxiety to therapy staff, this information was not relayed to nursing staff, resulting in a lack of appropriate interventions. Similarly, Resident 44, who was prescribed narcotic pain medication, did not have a care plan addressing pain management, contrary to the facility's expectations. Resident 108, admitted for post-surgical care, had an indwelling urinary catheter without a corresponding order or care plan, leaving the resident unaware of the catheter's purpose. Additionally, Resident 306, with diagnoses including anxiety and depression, expressed fear of falling during bed mobility, yet their care plan lacked instructions on managing this fear and the required assistance level. Staff interviews revealed inconsistencies in understanding the resident's needs, highlighting a gap in communication and care planning. These deficiencies indicate a failure to ensure that care plans are updated and communicated effectively among staff.
Medication Administration and Monitoring Deficiencies
Penalty
Summary
The facility failed to adhere to provider orders and ensure safe medication administration for several residents, leading to significant deficiencies in care. Resident 52, who had a diagnosis of essential hypertension, was administered amlodipine despite having a systolic blood pressure below the prescribed hold parameter. The resident's low blood pressure was not communicated to the provider in a timely manner, and the resident subsequently died unexpectedly. The Director of Nursing Services acknowledged that the medication should not have been given and that the provider should have been notified immediately of the resident's condition. Resident 8, with a history of chronic respiratory failure and heart conditions, experienced lightheadedness due to low blood pressure, yet there were no hold parameters for their metoprolol medication. Blood pressure readings were not consistently rechecked or documented, and the provider was not informed of low readings. Similarly, Resident 206 received metoprolol despite having a systolic blood pressure below the hold parameter, and Resident 44 was given medications with heart rates below the prescribed limits. These actions were contrary to the facility's expectations and policies. Additional deficiencies were noted with Resident 107, who was on anticoagulant therapy and developed bruising that was not documented or monitored as required. Resident 112, who was receiving morphine, experienced constipation that was not addressed according to the bowel care protocol. The facility failed to document interventions or follow the protocol for residents who had not had a bowel movement for several days. These failures in monitoring and communication placed residents at risk of adverse effects and diminished quality of life.
Non-Functioning Doorbells in Courtyard
Penalty
Summary
The facility failed to provide a working doorbell for handicap residents visiting the courtyard, which was identified as an accident hazard. During an interview, a resident stated that both ends of the courtyard had doors that were too heavy for them to open, and the button intended to call for assistance did not result in a staff response. This left residents stuck in the courtyard until a staff member happened to come by. Observations confirmed that the courtyard doors were heavy and that pressing the doorbells did not prompt a staff response. The Maintenance Director acknowledged awareness of the non-functioning doorbells but was unsure of how long they had been inoperative. This deficiency placed residents at risk for accidents, anxiety, feelings of entrapment, and a diminished quality of life, as the facility did not offer any handicap options for residents in the courtyard.
Failure to Provide Nonpharmacological Interventions Before PRN Pain Medications
Penalty
Summary
The facility failed to provide nonpharmacological interventions (NPI) before administering as-needed (PRN) pain medications to two residents, leading to a deficiency in medication management. Resident 44, who was admitted with a diagnosis of essential hypertension, had orders for oxycodone and acetaminophen to be administered as needed. However, there were no orders for NPI, and the medication administration record showed that Resident 44 received oxycodone four times and acetaminophen three times without any NPI being offered. Interviews with staff confirmed that the expectation was to use NPI prior to administering PRN pain medications, but this was not done for Resident 44. Similarly, Resident 1, admitted with a diagnosis of a fall with a hip fracture, received narcotic pain medication 33 times over a specified period. Documentation showed that NPI was not offered prior to administration for 22 of these instances. Staff interviews revealed that nursing staff should have offered and documented NPI in the medical record, but this was not included in Resident 1's orders. The Director of Nursing Services confirmed that the expectation was to offer NPI before administering narcotic medications, which was not met in this case.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage of medications in both the north and south medication rooms and on two medication carts. In the south medication room, an emergency kit containing Lorazepam, a controlled substance, was not secured in a locked compartment. Similarly, in the north medication room, the refrigerator containing an emergency kit with Lorazepam was not locked, and the medication was not secured. Additionally, the temperature logs for the south medication room showed that the refrigerator temperatures were frequently out of the required range, with instances of both freezing and excessively high temperatures recorded throughout July 2024. On the medication carts, multiple instances of improper labeling were observed. In the south high medication cart, two multi-dose insulins lacked open or expiration dates. Similarly, the south low medication cart contained two multi-dose insulins without open or expiration dates, and one insulin was expired. Staff interviews revealed a lack of awareness and understanding regarding the proper procedures for securing controlled substances and monitoring refrigerator temperatures, contributing to the deficiencies in medication storage and labeling.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of analysis of infection control data, identification of trends, and follow-up activities for the months of April, May, and June 2024. The facility's policy, revised in October 2018, required the infection prevention and control program to be coordinated by an infection preventionist and to follow guidelines from the CDC. However, the facility did not document any analysis or interventions based on infection surveillance data, nor did they map current organisms or infections. Additionally, the facility did not implement transmission-based precautions (TBP) effectively. Observations revealed that rooms with Aerosol Generating Procedure (AGP) precautions had open doors and lacked necessary personal protective equipment (PPE) such as N95 masks. Staff members were observed entering rooms without wearing the required PPE, despite signs indicating the need for gowns, gloves, and masks. Interviews with staff, including the Resident Care Manager and Director of Nursing Services, confirmed that the expected precautions were not followed. The facility also failed to adhere to Enhanced Barrier Precautions (EBP) for residents with multidrug-resistant organisms (MDROs). During wound care for a resident, staff did not wear a gown as required by the CDC guidelines. Interviews with the Director of Nursing Services and the Administrator highlighted the expectation for staff to follow posted precautions, but these were not consistently implemented. The infection preventionist's responsibilities, including tracking and mapping infections and ensuring precautions were in place, were not fulfilled, contributing to the deficiencies observed.
Inadequate Infection Control Oversight
Penalty
Summary
The facility failed to ensure that the infection prevention and control program (IPCP) was managed by a qualified individual with the necessary time and training to effectively oversee the program. This deficiency was identified during interviews and record reviews, revealing that the designated infection preventionist, Staff Z, was on vacation, and there was confusion about who was responsible for infection control tasks in their absence. Staff CC, a Registered Nurse/Resident Care Manager, was expected to cover for Staff Z but stated they were not currently doing so. Additionally, Staff B, who was not aware of their responsibility for infection control tasks, was only managing the antibiotic line list. The report highlights that neither Staff B nor Staff Z had completed infection control training, which is crucial for the effective management of the IPCP. The facility's policy required the infection preventionist to track vaccines, conduct rounds, ensure proper isolation precautions, review electronic health records for new infections, and provide staff education, among other duties. The lack of a qualified and trained infection preventionist to oversee these tasks placed residents, family members, and staff at risk of contracting communicable diseases and experiencing a decreased quality of life.
Failure to Educate Residents on COVID-19 Vaccine
Penalty
Summary
The facility failed to provide education on the benefits and potential side effects of the COVID-19 vaccination to four residents before offering the vaccine. This deficiency was identified during a review of the electronic health records (EHR) for Residents 14, 15, 20, and 34, who all declined the COVID-19 vaccine on various dates in 2024. There was no documentation found indicating that these residents or their representatives received the necessary education prior to being offered the vaccine. Interviews with facility staff further confirmed the deficiency. Staff Z, the Interim Infection Preventionist, acknowledged that residents should have been educated on the benefits and potential side effects of the COVID-19 vaccines when they were offered, but was unable to locate documentation for the four residents in question. Additionally, Staff A, the Administrator, stated that it was their expectation that all residents receive education on the risks and benefits when offered the COVID-19 vaccines. This lack of documentation and education placed residents at risk of not being able to make informed decisions regarding their medical care.
Latest citations in Washington
A resident with cerebral palsy and a court-appointed guardian experienced multiple episodes of nausea, vomiting, loose stools, abdominal discomfort, fatigue, and later refusal of meals and medications, leading to changes in the care plan including close monitoring, lab testing, and IV fluid administration. Despite a facility policy recognizing court-appointed guardians as resident representatives with decision-making authority, staff did not document any notification to the guardian during these changes in condition or treatment decisions. The guardian reported not being contacted when the resident stopped eating or developed stomach issues and felt the facility did not respect the guardianship, while the DON acknowledged there were multiple missed opportunities to notify the guardian of the resident’s change from baseline.
A resident with depression, anxiety, moderate cognitive impairment, and urinary incontinence, care-planned for q2h checks and assistance with toileting, was found by a visitor to be soaking wet, unusually agitated, and reporting they had been told to wait to be changed and referred to with a derogatory remark. The visitor filed a written grievance alleging abuse/neglect related to delayed incontinence care and removal of the resident’s tablet as a consequence. Although an incident report noted that the matter was reported to the state and that the resident was not soaking wet, a CNA who actually changed the resident later reported the resident’s brief, pants, wheelchair, and socks were soaked and that the resident was acting timid and repeatedly saying they had to sit for five minutes, but this CNA was never interviewed. The DON acknowledged not investigating the resident’s behavior or interviewing this CNA, and the grievance official acknowledged the facility did not fully investigate or communicate findings and resolution to the complainant, resulting in a failure to follow the facility’s grievance policy.
A resident with dementia, respiratory failure, and heart failure developed new shortness of breath with an O2 sat of 90%, and a physician ordered transfer to the ED for tx and eval. An RN completed an SBAR, notified the MD and family, and reported to the oncoming nurse that the resident needed ED transfer and that paramedics should be contacted, then left the facility. Instead of calling 911 for this emergent respiratory distress, staff arranged non-emergent transport through a contracted ambulance service, resulting in the resident remaining at the facility for several hours without pickup until the dispatcher later instructed staff to call 911. The DON stated that 911 is expected to be used for emergent conditions and the contracted service only for non-emergent transport.
A resident with anoxic brain injury, dysarthria, and documented lack of decisional capacity alleged physical abuse and expressed fear of their identified representative, yet social services only reported the allegation to the state and did not complete an incident report, revise the care plan, or implement protective interventions. The same representative continued to be treated as the resident’s decision-maker and visited frequently, with staff noting suspicious odors of foreign substances and concerns about possible illicit substance use. Psychiatry later documented concern that the representative was providing illicit substances, and the resident was subsequently hospitalized for altered mental status and overdose, after which the representative was banned. Key staff, including the DON, unit manager, and administrator/abuse coordinator, were unaware of the initial abuse allegation, and social services did not timely explore or clarify legal decision-making authority or alternative representation for the resident.
A resident with severe cognitive impairment, osteoarthritis, and spinal spondylosis, care planned for 2-person Hoyer transfers, was being moved by two CNAs using a mechanical lift when one corner loop of the sling became disengaged, causing the resident to fall about four feet, strike the floor and the lift, and sustain head abrasion, multiple rib fractures, and lumbar vertebral fractures. Facility policy required staff to verify secure sling attachment, examine hooks, clips, fasteners, and strap stability, and ensure the sling bar was sound before lifting, but during this transfer the sling loop detached despite staff believing it was properly fastened and hearing it click into place; post-incident assessment showed the loop had come loose, the sling appeared in good condition, and a CNA later reported thinking one of the round metal disks on the lift might have been slightly loose, while maintenance logs documented no prior concerns with the lifts or slings.
The facility failed to revise and individualize care plans to reflect current needs and preferences for multiple residents, including one cognitively intact resident with hemiplegia, hemiparesis, and mononeuropathy who had bilateral shoulder surgery and could not tolerate BP measurements on the upper arms but preferred forearm readings. Despite repeatedly informing staff, this preference was not documented in the care plan or Kardex, and direct care staff and the RN/UM were unaware of it. Another cognitively intact resident with hemiplegia, contractures, and weakness reported they were supposed to get out of bed for two hours daily, but some NACs did not know this, even though the MAR/TAR contained an order to document times up and back to bed. The surveyors concluded that care plans were not accurately revised for several residents, placing them at risk for unidentified and unmet care needs and diminished quality of life.
Surveyors found that two residents with hemiplegia, hemiparesis, weakness, and contractures did not receive restorative nursing services, including ROM exercises and splint/brace or orthotic assistance, after therapy discharge. Although PT and OT discharge summaries documented established restorative ROM and transfer programs, recommended PROM to affected extremities, and recommended splint/brace use and assistance with orthotic wear, these recommendations were not entered as restorative referrals in the EHR. As a result, the residents’ care plans and records showed no restorative programs, and both residents reported that therapy and restorative exercises had stopped, while the DON, rehab director, and MDS coordinator confirmed they were unaware of and had not implemented the recommended restorative services.
A resident with cancer, cognitive impairment, and declining strength experienced multiple unwitnessed falls, most occurring while attempting to toilet or move toward the bathroom, culminating in a fractured ankle requiring ED treatment. Although assessments identified fall and incontinence risks and the facility’s policy required individualized interventions, the comprehensive care plan lacked a toileting plan and did not include several interventions that were discussed in incident investigations, such as consistent wheelchair placement and frequent rounding for bathroom assistance. Staff reported relying on verbal reminders and education to use the call light, despite acknowledging the resident’s impulsivity and failure to call for help, and the resident’s bed remained furthest from the bathroom while repeated bathroom-related falls occurred without the trend being recognized or addressed in the care plan.
A resident with a history of acute urinary retention and acute kidney injury had a Foley catheter deemed permanent by the hospital, with instructions that it not be removed in the SNF. At a later urology visit, the catheter was removed, and the resident returned with no new orders documented. Facility staff did not document bladder assessments, post-void residuals, or urine output, and CNA documentation showed the resident did not void that evening. Over the next day, the resident had vomiting, poor intake, altered level of consciousness, tachycardia, hypotension, and no documented wet briefs. A bladder scan eventually showed more than 2000–2500 mL of retained urine, and a new catheter drained a large volume. The resident and a roommate reported moaning, crying out in pain, and repeatedly alerting staff that the resident was not urinating and that the catheter was not draining, while nurses documented catheter care when no catheter was in place and later had to flush and replace the catheter due to continued complaints.
Surveyors found that nurses and nurse aides did not consistently administer medications according to professional standards and facility policy. Multiple residents reported that agency nurses were slow with medications, did not fully follow instructions, and often gave routine meds late. Observations showed an LPN administering expired Humalog/Lispro insulin well past the scheduled time, an LPN giving several scheduled meds (including Tizanidine) late and all at once, and an RN attempting to give sliding-scale insulin nearly two hours late, which a resident refused after already eating. Another resident received Methocarbamol two hours late after questioning the RN, and a resident on scheduled Tramadol had doses given without timely documentation, with a discrepancy between the narcotic count and pills remaining. These events demonstrated failures in timely administration, use of non-expired medications, and immediate, accurate MAR and narcotic documentation.
Failure to Notify Court-Appointed Guardian of Resident’s Clinical Changes
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s court-appointed guardian of significant clinical changes and care decisions, contrary to its own policy and state requirements. The facility’s policy on Resident Representatives, revised 02/2021, states that a resident representative includes a court-appointed guardian or conservator and that the facility treats the representative’s decisions as those of the resident to the extent delegated or required by the court. Resident 1, admitted with cerebral palsy, had a Superior Court guardianship letter dated 02/07/2025 indicating a guardian of person and conservator of the estate with full authority, identifying Collateral Contact 1 (CC1) as the guardian. Despite this, multiple clinical events and changes in condition were documented without any corresponding documentation that CC1 was notified. Progress notes and provider notes show that Resident 1 experienced an episode of nausea and vomiting, frequent loose stools, abdominal discomfort, bloating, worsening fatigue, generalized weakness, and later refusal of meals and medications over at least a 24-hour period, with observations that the resident appeared frailer, more fatigued, and had no energy or interest to talk. The provider developed care plans including close monitoring for deterioration, sending stool to the lab, and later initiating IV fluids for rehydration, with a plan to call family/POA for discussion. However, there was no documentation that the guardian was notified at any of these points, including when IV fluids were started. CC1 reported that they were not contacted when the resident stopped eating or developed stomach issues, and expressed that the facility did not respect their guardianship and that involvement in care planning took too long. The DON confirmed on record review that there were many opportunities to notify the guardian when the resident’s condition changed from baseline and that there was no evidence staff did so.
Failure to Thoroughly Investigate and Resolve Resident Grievance Regarding Incontinence Care and Staff Conduct
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and resolve a grievance alleging neglect and disrespect toward a resident, as required by its grievance policy. The resident had depression, anxiety, moderate cognitive impairment, occasional urinary incontinence, and required moderate assistance with toileting, with a care plan directing staff to check the resident every two hours, ask about toileting needs, and ensure they were clean and dry. A collateral contact reported arriving to visit the resident and finding them soaking wet and agitated, with behavior that was not typical for the resident. The collateral contact documented in a written grievance that the resident’s tablet was off, the resident appeared upset, and the resident reported being told they had to wait five minutes to be changed and that staff would change their “nasty *ss” in five minutes, leading the collateral contact to believe the resident had been given a consequence of no tablet and sitting in wet clothes, which they characterized as abuse/neglect and requested immediate removal of the responsible staff and a report filed. The facility documented receipt of the grievance and created an incident report indicating the matter was reported to the state agency, and that the unit manager interviewed the collateral contact and the resident, with the resident described as confused and denying being soaking wet. The incident report stated that a different nursing assistant was assigned to assist with the brief change and that the unit manager believed the resident was not soaking wet, and that the resident and collateral contact were satisfied when they left the room. However, a CNA who actually changed the resident reported that the resident’s brief was soaked through their pants onto the wheelchair and their socks were soaked, and that the resident was timid, repeatedly saying they had to sit for five minutes, and not acting like themselves; this CNA stated they were never interviewed or asked about the grievance or the resident’s condition. The DON acknowledged not interviewing this CNA or investigating the resident’s behavior and why they were upset, and the unit manager did not recall whether the collateral contact was present during follow-up and did not believe they followed up with the collateral contact regarding the grievance. The administrator, identified as the Grievance Official, stated the facility should have thoroughly investigated the grievance and discussed findings and resolution with the collateral contact, indicating the grievance process was not fully carried out in accordance with policy and WAC 388-97-0460.
Failure to Obtain Timely Emergency Transport for Resident in Respiratory Distress
Penalty
Summary
The deficiency involves the facility’s failure to obtain timely emergency medical services for a resident experiencing new-onset respiratory distress. The resident had dementia, respiratory failure, and heart failure, with severe cognitive impairment and a need for substantial assistance with activities of daily living. On the day the resident was sent to the hospital, a collateral contact observed the resident having difficulty breathing, appearing unable to get enough air, and looking as if they were sleeping or unconscious, and reported this to staff with a request to contact the doctor. An SBAR Communication Form documented that the resident was experiencing shortness of breath that had not occurred before, with an oxygen saturation of 90%. The physician was notified and ordered the resident sent to the emergency department for treatment and evaluation, and the collateral contact was notified shortly thereafter. Progress notes later documented that, despite the order for emergency department transfer, the resident was still awaiting pickup by Olympic transportation several hours later, with no estimated time of arrival. At approximately 3:30 AM, the dispatcher informed the facility that they could not provide transportation and instructed that 911 be called; only then was 911 contacted and the resident transported to the hospital via ambulance for respiratory distress. The RN caring for the resident stated they completed the SBAR, notified the physician and family, and at the end of their shift reported to the oncoming nurse that the resident needed to be sent to the emergency department for respiratory distress and that paramedics should be contacted, then left assuming 911 would be called. The DON stated that staff are expected to contact 911 for emergent conditions such as shortness of breath or respiratory distress, and that Olympic Ambulance is used only for non-emergent transport.
Failure to Provide Social Service Advocacy After Abuse Allegation and Questionable Representative
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate medically-related social services and advocacy for a resident following an allegation of abuse and concerns about the resident’s representative. The resident had an anoxic brain injury, dysarthria, moderate cognitive impairment, and was dependent on staff for activities of daily living. A hospital palliative care note documented that the resident lacked decisional capacity, had no DPOA, that the legal next of kin (CC4) did not want to be part of care decisions, and that care decisions were being deferred to another contact (CC5). CC5 accompanied the resident on admission, signed admission forms, and was listed as the primary contact in the medical record profile. On a date in February, during communication therapy, the resident reported that CC5 had done something to them, pounded their hands on their chest, recalled being hit in the back of the head by an unknown person, and stated they were sometimes afraid of CC5. A social services staff member reported this allegation to the state agency but did not complete a facility incident report, did not initiate care plan changes or interventions, and took no further action. CC5 continued to be treated as the resident’s representative, and progress notes documented CC5 at the bedside on multiple dates, including an entry noting the room smelled like foreign substances and that CC5 was seen waking the resident and then asking the nurse to administer pain medications. A psychiatry note later documented concern that CC5 was providing the resident with illicit substances and stated it would be prudent for the resident to identify a POA. Subsequently, the resident was found unresponsive, transported to the hospital, and later readmitted after altered mental status and overdose, with a provider note stating that CC5 posed a significant danger to the resident and was banned from visiting. After readmission, staff attempted to contact CC4 for consent to treat but initially reached someone who stated they were not CC4. The social service director acknowledged that, beyond reporting the initial allegation, no additional interventions were implemented, that CC5 continued to be used as the resident’s representative after the allegation, and that they had not explored legal authority for decision making following the abuse allegation or concerns about substances. The social service assistant reported they did not speak with the resident about the hospital stay or CC5 and did not complete an incident report or care plan changes after the allegation. The unit manager and DON were unaware of the initial abuse allegation, and the administrator, who served as abuse coordinator, also stated they were unaware of the allegation and that an investigation should have been initiated and a representative for the resident investigated at a minimum.
Injury from Mechanical Lift Sling Detachment During Transfer
Penalty
Summary
The facility failed to ensure a safe mechanical lift transfer when a resident was being moved with a Hoyer lift and sling, resulting in a fall and injury. Facility policy for using a mechanical lifting machine required staff to securely attach sling straps to the sling bar according to manufacturer’s instructions, double-check the security of the sling attachment before lifting, examine all hooks, clips, or fasteners, check strap stability, and ensure the sling bar was securely attached and sound. Despite these requirements, during a transfer for dinner, two CNAs placed the sling under the resident, attached the loops at each corner of the sling to the lift, and raised the resident off the bed into the space between the bed and wheelchair when the bottom left corner of the sling became disengaged from the lift. The resident involved had multiple diagnoses including osteoarthritis, cervical and thoracic spondylosis, and Alzheimer’s disease, with the Minimum Data Set documenting severely impaired cognitive skills for daily decision-making. The resident’s care plan required the assistance of two staff during Hoyer lift transfers. During the transfer, the resident fell approximately four feet, landing on her buttocks, bouncing, and then falling backward and striking her head on the leg of the Hoyer lift. Hospital records documented that the resident sustained an abrasion to the back of the head, fractures of the 6th, 7th, 8th, and 10th ribs, and fractures of the 1st and 2nd lumbar vertebra. Staff interviews and observations showed that staff believed the sling loops had been securely fastened and reported hearing the loops click into place before lifting. One CNA stated that they had barely lifted the resident off the bed when the bottom left loop became disconnected and the resident fell. Another CNA reported being shocked and unable to figure out what had happened. A nurse who assessed the resident and then examined the equipment after the fall noted that one of the loops of the sling had become disengaged but stated the sling appeared to be in good condition. During a later demonstration, a CNA indicated she thought one of the round metal disks on the lift might have been a little loose. Maintenance logs for Hoyer slings and lifts for the preceding months documented no concerns with the slings or lifts, and the DON acknowledged expecting a citation due to the resident’s injury from the fall.
Failure to Revise Care Plans to Reflect Resident Needs and Preferences
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize comprehensive care plans to reflect residents’ current needs and preferences, as required by its own care planning policy. For one resident with hemiplegia, hemiparesis following cerebrovascular disease, and mononeuropathy of the upper limb, the admission MDS showed intact cognition and upper extremity impairment. This resident reported having bilateral shoulder surgery and an inability to tolerate blood pressure measurements on the upper arms due to pain, and stated a preference for BP measurements on the forearms. The resident reported having informed multiple nursing staff of this preference, but staff continued to place the cuff on the upper arms. Review of the resident’s care plan and Kardex showed no interventions or instructions regarding forearm BP cuff placement. A NAC confirmed they were unaware of the preference until the resident told them directly and that this instruction was not documented in the Kardex. The RN/Unit Manager, who stated they were responsible for revising and reviewing care plans when there were changes, also confirmed they were not aware of the resident’s preference and that it should have been updated in the care plan. Another resident, readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, contracture of the left hand, and weakness, was cognitively intact and required maximum assistance for bed mobility per a quarterly MDS. This resident stated they were supposed to get out of bed for two hours every day, but some NACs were not aware of this care requirement. Review of the resident’s March 2026 MAR/TAR showed an order to document the time the resident got up and the time they returned to bed daily. The report states that, overall, the facility failed to revise care plans accurately to reflect residents’ needs for three of four residents reviewed for care plan revision, placing them at risk for unidentified and unmet care needs and a diminished quality of life.
Failure to Implement Restorative Nursing and Splint/Brace Programs After Therapy Discharge
Penalty
Summary
The deficiency involves the facility’s failure to provide restorative nursing services, including range of motion (ROM) exercises and splint/brace assistance, to maintain or prevent decline in mobility and contractures for two residents with significant motor impairments. The facility’s undated Restorative Nursing Services policy stated that residents would receive restorative care as needed to achieve and maintain optimal functioning and that residents may initiate a restorative program upon discharge from rehabilitative care. Despite this, surveyors found that residents with documented hemiplegia, hemiparesis, weakness, and contractures were not placed on restorative programs and had no restorative interventions documented in their electronic health records (EHRs). Resident 1 was admitted with hemiplegia and hemiparesis following cerebrovascular disease, a left lower leg fracture, and weakness, and the admission MDS showed intact cognition, moderate assistance needs for bed mobility and transfers, and one-sided upper and lower extremity impairment. During observation, the resident was seen lying in bed with a bent inward left forearm and hand and reported no longer receiving therapy or nursing-assisted exercises. The care plan initiated in January showed no restorative services, and the care plan history and EHR contained no restorative nursing interventions. However, the PT discharge summary from February documented that restorative ROM and transfer programs had been established and trained, including PROM to the left upper and lower extremities and stand-by assist with transfers, and the OT discharge summary recommended a splint/brace to prevent contracture. The OT stated that the splint/brace was not tried due to lack of time before insurance was discontinued, and both the Director of Rehab and the MDS coordinator confirmed there was no restorative referral in the EHR and they were unaware of the recommendations. Resident 2 was readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, a left-hand contracture, and weakness, and the quarterly MDS showed intact cognition, maximum assistance needs for bed mobility, total assistance for transfers, bilateral upper and lower extremity impairment, and no therapy or restorative programs. The resident reported that therapy had been discontinued months earlier and that no restorative staff were assisting with exercises. The care plan and EHR showed no restorative services. OT evaluation documented left upper extremity ROM impairment, a left-hand contracture, and prior use of a left orthotic to manage flexion tone, and the OT discharge summary recommended restorative care and assistance with donning/doffing the orthotic. The PT discharge summary recommended restorative programs if Medicaid Part B services did not continue. The Director of Rehab confirmed therapy was discontinued and that restorative nursing programs were recommended, but both the Director of Rehab and the MDS coordinator stated there were no restorative referrals in the EHR after readmission, and the MDS coordinator confirmed the resident had no restorative programs since readmission.
Failure to Implement Effective Fall and Toileting Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision, identify fall trends, and implement progressive, resident-centered interventions for a resident with multiple falls and declining strength. The facility’s own Falls and Fall Risk Management policy required staff to identify interventions related to residents’ specific risks and causes to prevent falls and minimize complications. The resident’s Care Area Assessment identified cancer-related risks for pain, falls, and ADL decline, and stated that falls and urinary incontinence would be addressed in the care plan with an objective of improvement and risk minimization. However, the comprehensive care plan did not include a urinary or ADL care plan and contained no toileting plan, despite the resident’s identified risks and prior fall history. Over a series of falls, the resident repeatedly fell while attempting to toilet or move toward the bathroom, yet the facility did not recognize or address this pattern in its investigations or care planning. The resident had multiple unwitnessed falls: next to the bed while getting up to use the restroom, in the bathroom while standing to use the toilet, and near or in the bathroom on several occasions. Incident investigations and post-fall assessments documented environmental factors such as clutter, items on the floor, water on the floor, and issues with footwear, as well as the resident’s increasing weakness, impulsivity, poor safety awareness, and poor insight into limitations. Interventions documented in investigations and risk reviews included encouraging use of the front-wheeled walker, keeping the wheelchair and walker accessible, ensuring proper footwear and non-skid socks, and providing resident education on safe transfers, ambulation, and assistive device use. However, several of these planned interventions, including placement of the wheelchair and frequent rounding/toileting assistance, were not added to or reflected in the care plan as stated. Staff interviews further showed that the resident frequently fell while trying to go to the bathroom and that staff relied on verbal education and reminders to use the call light, even though the resident often did not use it. Staff acknowledged the resident’s impulsivity and tendency to get up independently despite instructions, and one staff member stated that nursing assistants were verbally instructed to offer bathroom assistance, but this intervention was not documented in the care plan. The resident’s bed remained the one furthest from the bathroom throughout the stay, and none of the facility’s investigations identified the trend of bathroom-related falls or addressed toileting options in the care plan. Ultimately, the resident sustained a left ankle fracture after another bathroom-related fall, requiring transfer to the emergency department for evaluation and treatment, and later records documented additional fractures and a decline in condition. The surveyors concluded that the facility’s failures placed residents at risk of repeated falls and injuries.
Failure to Monitor Urinary Retention After Foley Removal Leading to Prolonged Pain
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and monitor a resident for complications associated with an indwelling urinary catheter and urinary retention, particularly after catheter removal. The resident had a history of acute kidney injury due to urinary retention, which improved after Foley catheter placement in the hospital. Hospital discharge documentation indicated the catheter was placed for acute urinary retention, was deemed permanent, and included instructions that, given the resident’s significant retention and acute renal failure, staff at the skilled nursing facility should not attempt Foley removal. The facility’s catheter care plan directed staff to empty the catheter as needed and record output in milliliters, but review of the last 30 days of documentation showed continence was not rated due to the indwelling catheter and there was no documented urinary output in milliliters on the treatment administration records. The resident had a scheduled urology appointment at which the urinary catheter was discontinued. Upon return from this appointment, nursing documentation initially indicated no new orders, and an alert note later stated the catheter was discontinued and staff were monitoring for retention or pain. However, there was no documented bladder assessment or urinary output following catheter removal. Nursing assistant documentation showed that the resident did not void on the evening shift that same day. Despite the catheter having been removed, the treatment administration record showed staff continued to document provision of catheter care on subsequent shifts when no catheter was in place. Over the next day, the resident experienced vomiting, decreased oral intake, and an altered level of consciousness, with vital signs showing tachycardia and low blood pressure, and staff documented decreased urine output. A bladder scan performed later revealed more than 2000–2500 milliliters of urine in the bladder, and an indwelling catheter was reinserted, initially draining a large volume of urine. The provider note indicated the resident had not eaten since the prior night, was unable to hold down fluids, and staff were unsure whether the resident had urinated in incontinence briefs, with no wet briefs reported since the resident’s return from the hospital after catheter removal. The provider expressed concern that the documented early-morning wet brief might not be accurate given the large bladder volume on scan and stated this should require further investigation. Subsequent notes described the resident moaning and complaining of pain, with limited urine output in the catheter bag and staff flushing and then replacing the catheter due to continued complaints. Interviews with the resident, the roommate, and staff indicated the resident was crying out and moaning in pain, the roommate repeatedly alerted staff that the resident was not urinating and that the catheter was not draining, and staff had to seek assistance to replace the catheter. Facility leadership and clinical staff later acknowledged that typical practice after catheter removal would include contacting the provider, placing the resident on alert, performing post-void residuals with bladder scans, and documenting monitoring, which was not done in this case.
Medication Administration Delays, Documentation Errors, and Use of Expired Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient nursing staff with appropriate competencies and skill sets to administer medications according to professional standards of practice, facility policy, and prescriber orders. The facility’s medication administration policy required medications to be given as prescribed, in accordance with manufacturers’ specifications and good nursing principles, with no expired medications used, and doses administered within 60 minutes of the scheduled time and documented immediately after administration. Multiple residents reported that agency nurses often gave medications late, did not read full instructions, or were slow in bringing medications, and that routinely scheduled medications were not consistently provided without residents having to ask. Surveyors observed several specific medication administration failures. For a resident with diabetes, an LPN drew up and administered Humalog/Lispro insulin from a multi-dose vial that had been opened and dated “02/16” with no year, making it expired per policy, and administered the dose nearly 1 hour and 45 minutes after it was due. Another resident with care plan instructions to receive medications as ordered had multiple scheduled medications (Gabapentin, Oxybutynin, Baclofen, and Tizanidine) that were ordered at specific times throughout the day; the LPN was observed administering all four together and acknowledged that at least one (Tizanidine) was late, while the resident reported that receiving them together at that time was typical and not at their request. For another diabetic resident, an RN checked blood sugar and prepared sliding scale Humalog/Lispro insulin almost two hours after the scheduled time; the resident refused the insulin, stating they had already finished lunch. Additional deficiencies were identified with other residents’ pain and scheduled medications. One resident with a pain care plan and an order for Methocarbamol four times daily at set times approached the cart requesting Methocarbamol and Tylenol; the RN initially stated the Methocarbamol had already been given, but then administered it two hours after it was due when the resident pointed out the scheduled timing. For another resident with a risk for pain care plan and Tramadol ordered three times daily at specific times, an LPN retrieved a PRN pain medication while the electronic record showed no 8:00 AM medications documented; the LPN stated they had given them but had not yet documented. Later, an RN prepared the 2:00 PM Tramadol dose, and review of the narcotic count showed a discrepancy between the number of pills documented and the number remaining in the card. The RN stated they had given the 8:00 AM Tramadol but had not signed it out, then signed out both the 8:00 AM and 2:00 PM doses at that time. Residents interviewed consistently reported that medications were sometimes or frequently late, that agency nurses did not always follow instructions, and that they often had to request medications that were routinely scheduled.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
