Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Ballard Center during CMS and state inspections, most recent first.
Late Completion of MDS Assessments: The facility failed to complete required MDS assessments on time for three residents. Two annual MDS assessments were completed late, and one admission MDS was also completed after the required timeframe. Staff, including the MDS coordinator and DON, acknowledged the assessments were not completed timely.
Surveyors found inaccurate MDS coding for multiple residents involving weights, PASRR, insulin injections, SMI, diagnoses, weight loss, opioid use, and BiPAP/CPAP status. Records showed mismatches between the MDS and the EHR, MAR, physician orders, and PASRR determinations, and staff acknowledged several of the assessments were not coded accurately.
The facility failed to keep IPCP policies reviewed annually, failed to ensure hand hygiene after PPE removal, failed to disinfect a shared BP cuff after use, and failed to follow EBP for a resident with an indwelling urinary catheter. A CNA entered a TBP room, removed PPE, and left without sanitizing hands; an RN stored a BP cuff without cleaning it; and a CNA provided high-contact care without a gown and with no EBP signage or PPE cart present.
A resident’s care plan was not revised to reflect current hearing device use. The plan still listed bilateral hearing aids, nightly charging, and a pocket talker, but the resident stated they did not use either device, and a CNA and RN also reported not seeing any hearing aids or pocket talker in use or in the room. The ADON and DON acknowledged the care plan should reflect the resident’s current status.
A resident signed consent to receive a pneumococcal vaccine, but the EHR did not show the vaccine was administered. The facility's policy stated residents would be offered pneumococcal vaccines and that they are given per the physician-approved vaccination protocol. During record review, the DON stated residents who signed consents would be vaccinated, but later could not find any record showing the resident received the pneumococcal vaccine.
The facility failed to complete thorough and timely investigations of alleged abuse and an unwitnessed fall. In one case, a cognitively intact resident’s alleged abuse by staff, reported by another resident, was not fully concluded until nearly a month later, and multiple resident interview forms lacked names and dates, listing only room numbers. In another case, a cognitively intact resident reported being called a derogatory name by a recreation staff member, and the investigation again used undated, unnamed interview forms. For a resident with a stroke, cognitive impairment, and total dependence for mobility who experienced an unwitnessed fall, the investigation did not include any staff interviews to determine circumstances before the fall. Nursing leadership acknowledged that interviews should be dated, identify residents by name, be completed within five working days, and that staff interviews are expected for fall investigations.
A resident without cognitive impairment reported that a recreation assistant called them a derogatory name, which the staff member claimed was a joke; the resident responded by calling the staff member a derogatory name in return. The facility’s investigation substantiated that the staff member had verbally abused the resident, but the incident was not entered on the required DSHS reporting log for the relevant period, despite the DON’s expectation that all incident investigations be logged within five days, resulting in a cited deficiency for failure to follow abuse reporting guidelines.
Three residents did not have timely or complete discharge care plans developed as required. For one resident, the discharge care plan was created only on the day of discharge, while two others had no documented discharge care plans at all. Staff interviews confirmed that the required care planning process was not followed, with both the Social Services and nursing departments acknowledging the deficiency.
Three residents who left the facility against medical advice did not receive complete discharge instructions, including discharge summaries or medication reconciliation. Documentation was missing or incomplete for each resident, and staff interviews revealed a lack of awareness about the requirement to provide these documents for AMA discharges.
A resident with a documented DNR order was given CPR after being found unresponsive, as staff did not verify the code status through the required documentation. Additionally, an LPN and a CNA were found to be working without current CPR certification, contrary to facility policy. Leadership confirmed that staff did not follow the expected process for verifying code status and that required CPR training was not up to date for all staff.
Two residents reported allegations of sexual abuse by staff, which were communicated to facility leadership but not reported to law enforcement as required by policy and guidelines. This failure to report placed the residents at risk and constituted a breach of abuse reporting requirements.
Two residents experienced ant infestations in their rooms, including one with ants found on a Foley catheter during hospital transfer and another with ants crawling on their body and bed. Housekeeping and visitors reported ant activity across multiple nursing units, and service requests documented repeated pest sightings, indicating the facility did not effectively implement its pest control policy.
A resident reported multiple concerns, including negligence and disrespectful language, to an outside agency. The facility failed to initiate a timely investigation, as required by their guidelines. Staff F submitted a report to the state agency but only conducted a care conference and completed grievance forms, without informing the Administrator or starting a formal investigation.
A facility failed to timely develop a care plan for a resident readmitted with lice. The resident was readmitted with orders for permethrin treatment, but the care plan was not initiated until 20 days later. This delay was confirmed by the Interim DON, acknowledging the care plan should have started upon readmission, increasing risk for further infestation.
A facility failed to maintain contact precautions for a resident with lice, as the required signage was removed from the resident's room. Despite ongoing symptoms and treatment orders, staff were not informed of the need for PPE. Interviews with staff, including an RN and Infection Preventionist, confirmed the oversight, highlighting a lapse in procedure adherence.
The facility did not conduct required reference checks for four staff members, including a CNA and RN Manager, before hiring them, violating its abuse policy. This oversight placed residents at risk for abuse and neglect, as the facility failed to adhere to its own procedures and legal requirements.
The facility failed to conduct annual performance evaluations for five CNAs, with some evaluations missing since 2015. This oversight, acknowledged by the DON and Administrator, risks resident care quality due to potential staff underqualification.
The facility failed to properly store medications in two medication carts, risking compromised or ineffective treatments for residents. Medication Cart 2 contained an opened vial of insulin past the discard date and a mix of creams and ointments for multiple residents, not properly separated. Medication Cart 3 also had improperly stored creams and ointments for different residents. Staff acknowledged some treatments were discontinued and needed discarding, and the DON emphasized the need for proper medication management.
The facility failed to provide residents with current food menus and alternatives that met their nutritional needs, including fresh fruits and vegetables. Several residents reported not receiving menus or being aware of alternative options like the Bistro menu. Staff acknowledged issues with menu distribution and communication, partly due to the resignation of the dietary manager. The facility's policy required nutrient analysis and menu posting, which was not consistently followed.
The facility failed to follow Contact Precautions for residents with infections, as staff frequently entered rooms without PPE, improperly disposed of PPE, and neglected hand hygiene protocols. These actions increased the risk of infection spread among residents and staff.
The facility failed to address grievances for two residents, one regarding a missing television remote control and the other concerning discharge planning to transfer closer to a family member. The grievances were not logged or resolved in a timely manner, leading to frustration and unmet care needs. The facility's grievance policy was not followed, resulting in unresolved issues impacting the residents' quality of life.
The facility failed to investigate resident-to-resident altercations involving three residents, leading to risks of repeated incidents and unidentified abuse. A resident reported verbal assault, another experienced a physical threat, and a third reported unwanted physical contact, but these incidents were not properly documented or investigated. Staff failed to notify the appropriate authorities and did not follow the facility's policy for handling such altercations.
A resident's MDS assessment was inaccurately completed by the facility, as the MDS Coordinator signed off on key sections before the end of the observation period. This premature completion failed to capture the resident's condition accurately, potentially leading to unmet care needs. The Director of Nursing confirmed the expectation for accurate MDS completion according to the RAI Manual.
The facility failed to complete accurate PASARR evaluations for two residents with mental health conditions, leading to a lack of appropriate assessments for their care needs. One resident with bipolar disorder did not receive a timely Level II PASARR after a planned discharge was delayed, while another resident with anxiety and major depressive disorder had an incomplete PASARR process, lacking a necessary Level II evaluation.
The facility failed to update care plans for three residents, leading to potential risks. A resident's care plan was delayed, lacking involvement from the resident or their representative. Two residents with unsafe smoking behaviors and oxygen use did not have updated care plans, posing safety risks. Staff interviews confirmed the absence of necessary care plan revisions.
A LTC facility failed to follow physician orders for three residents, leading to medication administration errors. An LPN administered incorrect dosages of Sertraline to a resident due to outdated information. Another resident received a multivitamin with minerals instead of the prescribed type due to a misunderstanding about available stock. Additionally, the facility did not document vital signs before administering Hydralazine to a resident, as required by the medication's parameters.
A resident's discharge plan was not aligned with their expressed goal to transfer closer to family, despite their cognitive function being intact. The facility failed to update the discharge care plan and did not involve the resident or their representative in the planning process, leading to dissatisfaction and unresolved grievances.
The facility failed to provide necessary ADL assistance and nail care for two residents. One resident, requiring substantial assistance, was not helped out of bed or given showers as scheduled. Another resident with diabetes did not receive proper nail care, despite documentation indicating otherwise. Staff interviews confirmed these deficiencies, highlighting unmet care needs and documentation inaccuracies.
A facility failed to consistently provide ROM services for a resident with limited upper extremity ROM. The care plan required splint application and ROM exercises, but there was no documentation of these interventions being performed. Observations showed the resident was not wearing splints, and staff interviews revealed a lack of consistent implementation of the care plan.
A facility failed to follow its smoking policy and care plan for a resident with unsafe smoking habits, who was observed smoking without supervision and did not surrender smoking materials. The resident's care plan was not updated, and nicotine patches were refused. Additionally, another resident's bed side rails were found to be loose, with maintenance only performed upon request. Staff interviews revealed non-compliance with facility policies, posing risks to resident safety.
The facility failed to adhere to physician orders for oxygen therapy for two residents, leading to deficiencies in care. One resident received higher oxygen flow rates than prescribed, while another did not receive routine oxygen therapy as ordered. Staff interviews revealed non-compliance with verifying and adjusting oxygen flow rates and improper storage of oxygen equipment.
The facility failed to implement comprehensive care plans for four residents, leading to unmet care needs. A resident with lymphedema was not provided with compression stockings as per their care plan. Another resident experienced significant weight gain without proper notification to healthcare providers. A third resident's range of motion interventions were not documented or implemented, and a fourth resident's care plan lacked a discharge plan. Staff interviews confirmed these deficiencies.
The facility failed to follow care plans and notify providers for three residents, leading to unmet care needs. A resident with lymphedema did not receive prescribed compression therapy, another experienced significant weight gain without timely provider notification, and a third resident's constipation care plan was not followed, resulting in prolonged periods without bowel movements.
The facility's assessment failed to include plans for maximizing direct care staff recruitment and retention, as required by its policy. The Facility Assessment Tool, updated in August 2024, did not address this aspect, and both the Administrator and Interim Administrator acknowledged the oversight during interviews.
The facility failed to serve food at the proper temperature in two nursing units, with meals being significantly below required standards. Residents reported the food as cold and flavorless, leading to dissatisfaction and potential nutritional risks. Staff acknowledged the issue, noting that the containers used did not maintain warmth.
A malfunctioning boiler in the facility's kitchen led to a lack of consistent hot water for dishwashing, resulting in meals being served in plastic containers. Staff had to use a makeshift method to obtain hot water, which was inefficient and time-consuming. The issue began when the boiler was turned off due to a leak, and despite repair attempts, the problem persisted, affecting meal quality for residents.
Late Completion of MDS Assessments
Penalty
Summary
The facility failed to ensure annual MDS assessments were completed within 14 days of the ARD for 3 of 26 residents reviewed for comprehensive assessments. Resident 18’s annual MDS was completed on 10/27/2025 and was documented as six days late. Resident 100’s annual MDS was completed on 01/29/2026 and was documented as seven days late. Staff D, the MDS Coordinator, stated during interview and record review that the facility followed the RAI manual for MDS completion and acknowledged that both annual assessments were completed late and should have been completed within 14 days. The facility also failed to complete Resident 2’s admission MDS in a timely manner. Review of the face sheet showed Resident 2 was admitted to the facility on [DATE], and the admission MDS was completed on 01/05/2026, which was documented as 11 days late. During interview and joint record review, Staff D stated the RAI manual showed the admission MDS was to be completed on day 14 of admission and acknowledged that Resident 2’s MDS was not completed timely. Staff B, the DON, stated that the facility expected MDS assessments to be completed accurately and timely.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure that MDS assessments were completed accurately for 9 of 32 residents reviewed. Surveyors identified inaccuracies involving resident weights, PASRR status, insulin injections, SMI, active diagnoses, weight loss, opioid medication coding, and BiPAP use. The report states that these inaccurate assessments placed residents at risk for unidentified and/or unmet care needs and a diminished quality of life. For Resident 49, the annual MDS recorded a weight of 202.2 lbs, but the EHR showed the last documented weight was also 202.2 lbs and had been taken on 08/01/2024. Staff D stated that the facility used that weight for the annual MDS even though it was not obtained within 30 days of the ARD. For Resident 100 and Resident 14, the annual MDSs were marked No for Level II PASRR, while the records showed both residents had Level II PASRR determinations. Staff D acknowledged that the MDS for Resident 100 should have been marked Yes and stated Resident 14’s MDS was not marked accurately. For Resident 13, the quarterly MDS showed 7 injections and 0 insulin injections, but the MAR showed insulin injections were given on 6 days during the look-back period; Staff D stated the MDS should have reflected 6 injections and 6 insulin injections. For Resident 66, the annual MDS was not marked for SMI despite a diagnosis of Major Depressive Disorder and mental health visits, and Staff O stated it should have been marked. For Resident 19, the quarterly MDS did not code anxiety disorder even though the MAR showed medication for anxiety and a physician note documented the diagnosis. For Resident 3, the quarterly MDS marked No or unknown for significant weight loss even though weights showed a loss from 147.4 lbs to 132 lbs, which was calculated as 10.45% over 6 months. For Resident 10, the significant change MDS indicated opioid use and an indication noted, but the MAR showed no opioid during the look-back period. For Resident 71, the admission/5-day MDS coded CPAP use, while physician orders and the treatment record showed BiPAP use; Staff D stated the MDS was not marked accurately.
IPCP Review, Hand Hygiene, Equipment Disinfection, and EBP Failures
Penalty
Summary
The facility failed to ensure its Infection Prevention and Control Program (IPCP) policies and procedures were reviewed at least annually. Review of the IPCP, antibiotic stewardship, and water management program showed the policies were dated 09/18/2023 for the IPCP and antibiotic stewardship, and 06/24/2021 for the water management program, with no evidence that they had been reviewed annually as required. During interview and record review, the DON stated she was not sure when the policies were reviewed and said corporate completed the review. The facility also failed to ensure hand hygiene was performed after removal of PPE. During observation, a CNA performed hand hygiene, donned a gown and gloves, entered a TBP room with a breakfast tray, then exited after removing the gloves and gown without performing hand hygiene. In interview, the CNA stated they were expected to perform hand hygiene after removing PPE and acknowledged missing it. An LPN stated staff were expected to perform hand hygiene after removing PPE, and the DON also stated that staff were expected to do so. The facility further failed to ensure shared medical equipment was disinfected after resident use and failed to ensure proper EBP was followed for a resident with an indwelling urinary catheter. An RN used a digital blood pressure cuff on a resident, then placed it on the medication cart and stored it in a drawer without cleaning or disinfecting it. In another observation, a CNA provided incontinence care and changed bed linens for a resident with an indwelling urinary catheter without wearing a gown, and there was no EBP signage or PPE cart near the room. The CNA stated the resident required EBP and that a gown should have been worn during incontinent care; the DON stated that for residents on EBP, a sign would be posted, a PPE cart would be available, and gloves and gowns should be worn during high-contact care activities.
Care Plan Not Updated for Hearing Device Status
Penalty
Summary
The facility failed to ensure Resident 66’s comprehensive care plan was revised to accurately reflect changes related to hearing device use. The care plan, printed on 04/10/2026, identified impaired communication due to hard of hearing, but the interventions still listed use of bilateral hearing aids, nightly charging of hearing aids, and availability of a pocket talker, with no indication that these interventions had been updated to match the resident’s current status. The facility policy stated that care plans are to be reviewed and revised as information about the resident and the resident’s condition changes. During observation and interviews, Resident 66 was noted to have hearing difficulty and did not have hearing aids or a pocket talker. Resident 66 stated they had not used a pocket talker or worn hearing aids. Staff S, a CNA, and Staff E, an RN, both stated they did not see Resident 66 using hearing aids or a pocket talker, and Staff S looked in the room but did not find any hearing devices. Staff C, the ADON, stated care plans are reviewed during the IDT meeting and revised when residents’ care or status changes, and Staff B, the DON, stated the comprehensive care plan was expected to have been reviewed and revised to reflect Resident 66’s status.
Failure to Administer Pneumococcal Vaccine After Signed Consent
Penalty
Summary
The facility failed to ensure that pneumococcal vaccine was administered for one resident who had signed a Vaccine Informed Consent to receive the vaccine. The facility policy titled, Pneumococcal Vaccine, stated that all residents would be offered pneumococcal vaccines and that the vaccines are administered per the facility's physician-approved pneumococcal vaccination protocol. Review of the resident's EHR, including the immunization record, progress/clinical notes, and treatment record, did not show that the pneumococcal vaccine was given. During a joint record review, the DON stated that residents who signed consents for immunization would be administered their vaccines, but after further review stated that no record could be found showing the resident received the pneumococcal vaccine.
Incomplete and Untimely Abuse and Fall Incident Investigations
Penalty
Summary
The deficiency involves the facility’s failure to conduct thorough and timely investigations into alleged abuse and an unwitnessed fall, contrary to regulatory requirements and the facility’s own policies. The Nursing Home Guidelines (“Purple Book”) require that all alleged violations be thoroughly investigated, with results reported to the administrator and appropriate officials within five working days. The facility’s abuse policy also requires thorough investigations and interviews with other residents to whom the accused employee provides care or services. However, for multiple incidents involving three residents, investigations were either delayed beyond the five‑day requirement or lacked essential documentation such as interview dates, resident names, and staff interviews. For one resident with intact cognition, an incident investigation dated 02/16/2026 was initiated after another resident reported witnessing this resident being abused by a staff member. The investigation included an undated interview form in which the resident denied inappropriate touching and six additional interview forms that lacked resident names and dates, listing only room numbers. The summary and conclusion of this investigation were not completed until 03/17/2026, which was beyond the five working days allowed. The Assistant DON confirmed they did not conclude or summarize the investigation until almost a month after the allegation, and the DON stated that interviews should be dated and include resident names, and that investigations were expected to be completed within five working days. For another cognitively intact resident, an incident investigation dated 02/19/2026 documented that the resident complained a recreation staff member called them a derogatory name during a conversation, and that the staff member admitted to the communication issue, stating they were joking. The investigation concluded that the staff member did call the resident a derogatory name, and included five other interview forms that again lacked resident names and dates, listing only room numbers. The DON stated that all resident interviews should be dated and include resident names, noting that using only room numbers could make it difficult to identify who was interviewed if residents changed rooms or were discharged. In a separate unwitnessed fall incident for a resident with a stroke, cognitive impairment, and total dependence for transfers and mobility, the investigation documented that the roommate saw the resident get up from bed, move toward a chair, and stumble, with unclear documentation on where the resident landed or whether they hit their head. The investigation did not include any staff interviews. A RN, the LPN/Unit Manager who completed the investigation, and the DON all stated that staff interviews, particularly with the assigned nursing assistant and any staff who had contact with the resident prior to the fall, were expected and should have been included to complete the fall investigation.
Failure to Log Substantiated Verbal Abuse Incident on Facility Reporting Log
Penalty
Summary
The deficiency involves the facility’s failure to log an allegation of unprofessional conduct involving verbal abuse on the required reporting log. According to the Nursing Home Guidelines, The Purple Book, Sixth Edition, dated October 2015, allegations of staff-to-resident abuse must be entered on the facility’s Department of Social and Health Services reporting log within five days. Resident 3’s quarterly MDS assessment dated 02/10/2026 showed the resident had been readmitted on that date and did not have problems with memory or thinking. On 02/19/2026, an incident investigation form documented that Resident 3 complained a recreation assistant (Staff C) called them a derogatory name while they were speaking. Resident 3 reported that Staff C claimed the comment was made jokingly, but Resident 3 did not perceive it that way and responded by calling Staff C a derogatory name in retaliation. Further review of the incident investigation showed the allegation was substantiated when Staff C acknowledged calling Resident 3 a derogatory name. However, review of the facility’s incident log for the period 02/03/2026 to 02/28/2026 did not show that this substantiated verbal abuse incident from 02/19/2026 was entered on the log. During a joint record review and interview on 03/25/2026 at 4:50 PM, the Director of Nursing Services (Staff A) confirmed that the verbal abuse incident was not logged on the incident report log for that time frame and stated that all incident investigations were expected to be logged within five days of the incident. This failure to log the allegation and substantiated finding of verbal abuse was cited under WAC 388-97-0640(5)(a).
Failure to Develop and Implement Timely Discharge Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans addressing discharge needs for three out of five residents reviewed for discharge care planning. According to the facility's policy, a comprehensive care plan, including discharge planning, should be developed within seven days of completing the comprehensive MDS assessment. However, for one resident, the discharge care plan was initiated only on the day of discharge, and for two other residents, no discharge care plan was documented prior to or at the time of discharge. Review of the electronic health records confirmed the absence or late completion of these required care plans. Interviews with facility staff revealed that the interdisciplinary team was responsible for care plans based on medical needs, while the Social Services Department handled discharge care plans. The Social Services Director stated that discharge care plans were to be completed within 72 hours of admission, but acknowledged that for the residents in question, this was not done in a timely manner or at all. The Director of Nursing Services confirmed that discharge care plans should have been completed within seven days after the admission MDS assessment, but this requirement was not met for the affected residents.
Failure to Provide Discharge Summaries and Medication Reconciliation for Residents Leaving AMA
Penalty
Summary
The facility failed to provide appropriate discharge instructions, including a discharge summary or recapitulation of stay, for three residents who left the facility against medical advice (AMA). For each of these residents, documentation was incomplete or missing regarding their medical status, medication reconciliation, and other essential discharge information at the time of their departure. The facility's policy required that AMA discharges be processed in accordance with the resident's or representative's request for a safe and appropriate discharge, with applicable documentation completed, but this was not followed. One resident with diagnoses including type II diabetes, protein-calorie malnutrition, and dysphagia left the facility AMA without documentation of a discharge summary or medication reconciliation. The discharge plan documentation for this resident was incomplete, lacking information on home/community status, follow-up care, skin condition, diet, infections, assistance needs, therapy services, and medication changes. Another resident with type II diabetes and atrial fibrillation also left AMA, and similarly, there was no documentation of attempts to provide a discharge summary or medication reconciliation. The discharge plan documentation for this resident was also incomplete in several key areas. A third resident, with a history of falls and a healing fracture, left the facility AMA to a shelter, and there was no evidence of a completed discharge summary or discussion of medication reconciliation prior to discharge. Interviews with staff revealed a lack of awareness regarding the requirement to provide discharge summaries for residents leaving AMA, and record reviews confirmed the absence of completed discharge documentation for all three residents involved.
Failure to Honor Advance Directive and Maintain Staff CPR Certification
Penalty
Summary
The facility failed to verify and follow the code status for a resident and did not ensure that licensed nursing staff maintained current CPR certification. One resident, who had a documented advance directive and physician order for Do Not Resuscitate (DNR), was found unresponsive, without a pulse or breathing. Despite the resident's clear DNR status, staff initiated CPR and continued until paramedics arrived and took over, performing multiple rounds of CPR. Staff interviews revealed that the completed POLST form indicating the resident's DNR status was not available at the time of the emergency, and staff did not verify the code status through physician orders in the electronic health record before starting resuscitation efforts. Further review showed that the facility's policies required staff to inform residents of their right to execute advance directives and to maintain copies in the medical record. The policies also stated that CPR-certified staff would be available at all times and that licensed nursing staff must maintain current CPR certification. However, two staff members, an LPN and a CNA, were found to be working without current CPR certification. One staff member admitted their certification had lapsed, and another stated they had not received recent CPR training, with their last training occurring years prior. Interviews with facility leadership confirmed that staff were expected to verify code status using the POLST form or physician orders during emergencies, but in this case, the required documentation was not accessible, and the staff did not follow the expected verification process. The lack of current CPR certification among staff and the failure to honor the resident's advance directive were directly observed and confirmed by staff and leadership during the investigation.
Failure to Report Alleged Sexual Abuse to Law Enforcement
Penalty
Summary
The facility failed to report allegations of sexual abuse involving two residents to law enforcement, as required by both facility policy and state guidelines. One resident, who had intact cognition and required assistance with care, reported to a therapist that two male staff members engaged in inappropriate touching and made sexually suggestive comments during nighttime care. This allegation was communicated to the Director of Rehabilitation, who then informed the Administrator. In a separate incident, another resident with impaired cognition and in need of care assistance reported to a physical therapist that a staff member was sexually inappropriate during a bathroom visit. This allegation was also reported to the Administrator. Despite being made aware of both allegations, the Administrator did not report either incident to law enforcement. Interviews with facility staff, including the Director of Nursing Services, confirmed that the facility's policy and the referenced guidelines required immediate reporting of such allegations to law enforcement. The failure to report these incidents constituted a breach of the facility's abuse reporting policy and placed the residents at risk for further harm.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program as required by its own policy, resulting in multiple incidents involving ants in resident care areas. For one resident with paralysis and a Foley catheter, emergency medical transport staff observed ants on the catheter during a hospital transfer. Nursing progress notes confirmed the resident was located in the 200 nursing unit at the time. Another resident was found by a visitor to have ants crawling on their body and in their bed, with the visitor reporting similar observations to staff on two separate occasions. Service request forms documented additional ant sightings on the 400 and 500 nursing units, including ants on a call button cord and in resident rooms. Housekeeping staff reported seeing ants in the 200, 300, 400, and 500 nursing units and communicated these findings to both maintenance and the facility administrator. The administrator acknowledged that the current pest control service might be insufficient to address the ongoing ant problem. The facility's pest control policy, last revised in May 2008, requires an ongoing program to keep the building free of insects and rodents, but the documented incidents and staff interviews indicate that this policy was not effectively implemented.
Failure to Investigate Allegation of Neglect
Penalty
Summary
The facility failed to timely initiate and investigate an allegation of neglect for one resident, which placed the resident at risk for potential unidentified neglect and lack of protection from abuse or neglect. The facility's guidelines and policy require that all alleged incidents of abuse, neglect, and other related issues be thoroughly investigated and reported to the appropriate agencies. However, in this case, the facility did not adhere to these guidelines. The resident, who was cognitively intact, reported multiple concerns, including negligence, falls, and disrespectful language, to an outside agency. This information was communicated to the facility by the agency, but the necessary investigation was not initiated. Staff F, responsible for social services, received the report from the outside agency and submitted it to the state agency's online incident reporting line. However, Staff F only conducted a care conference with the resident and completed grievance forms, believing this was sufficient. The Director of Nursing Services at the time was informed, but the Administrator was not. Staff B, who was not present during the incident, acknowledged that an allegation of neglect should have been thoroughly investigated. Staff G, the Regional Nurse Consultant, confirmed that no investigation folder was found, and Staff A, the Administrator, stated that they were not informed of the allegation or involved in any investigation.
Delayed Care Plan for Lice Infestation
Penalty
Summary
The facility failed to develop a timely care plan for a resident who was readmitted with a lice infestation. The resident was readmitted on 03/04/2025 with orders for permethrin treatment for lice, but the care plan addressing the lice and necessary contact precautions was not initiated until 03/24/2025, 20 days after readmission. This delay in care planning was confirmed during an interview with the Interim Director of Nursing Services, who acknowledged that the care plan should have been started upon the resident's readmission. This oversight placed residents, staff, and visitors at increased risk for further infestation and unmet care needs.
Failure to Maintain Contact Precautions for Resident with Lice
Penalty
Summary
The facility failed to ensure that contact precautions signage was placed on the outside of a resident's room, who was being treated for lice infestation. The absence of this signage meant that staff and visitors were not informed of the need to wear personal protective equipment (PPE) such as gowns and gloves before entering the resident's room. This oversight was identified during a joint observation and interview with a registered nurse, who acknowledged the missing sign and the ongoing symptoms of lice infestation in the resident. The resident, who was cognitively intact, had been treated for lice at a hospital and readmitted to the facility with orders for further treatment. Despite this, the contact precautions sign was removed, and the resident continued to experience symptoms such as persistent itching. Interviews with various staff members, including an ARNP and the Infection Preventionist, confirmed that the resident should still be on contact precautions. The Interim Director of Nursing Services was unaware of why the sign was removed, indicating a lapse in communication or procedure adherence within the facility.
Failure to Conduct Reference Checks for New Hires
Penalty
Summary
The facility failed to implement its abuse policy and procedure by not conducting reference checks for four out of five staff members reviewed, which included a Certified Nursing Assistant, a Weekend Registered Nurse Manager, a Nursing Assistant Registered, and a Smoking Aide. The facility's policy, titled 'Abuse Prohibition Policy and Procedure,' mandates screening potential hires for a history of abuse, neglect, or mistreatment, including obtaining information from previous employers. However, the employee records for these staff members did not show that reference checks were conducted prior to their hire dates. Interviews with facility staff revealed that reference checks were not completed for these employees, despite the facility having a process in place since January 2023. The Administrator acknowledged that reference checks were expected as part of the hiring process and should have been completed. The failure to conduct these checks placed residents at risk for abuse, neglect, exploitation, and misappropriation of property, as the facility did not adhere to its own policy and state and federal requirements.
Failure to Conduct Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to complete the required annual performance evaluations for five Certified Nursing Assistants (CNAs), identified as Staff M, N, O, P, and Q. The facility's policy mandates that each employee's job performance be reviewed and evaluated at least annually. However, upon review of the personnel files, it was found that Staff M's last evaluation was in 2015, Staff N's in 2015, and Staff P's in 2022. No evaluations were found for Staff O and Q. Interviews with the Director of Nursing and the Senior President of Operations revealed a lack of awareness and oversight regarding the completion of these evaluations. The absence of current performance evaluations for these CNAs placed residents at risk of receiving care from potentially underqualified staff. The Director of Nursing and the Administrator both acknowledged the expectation for timely evaluations, yet the records provided by Human Resources confirmed the evaluations were either missing or outdated. This deficiency highlights a significant lapse in the facility's adherence to its own policies and regulatory requirements, potentially impacting the quality of care provided to residents.
Improper Storage of Medications in Medication Carts
Penalty
Summary
The facility failed to appropriately store drugs and biologics for two of the three medication carts reviewed, which placed residents at risk for receiving compromised or ineffective medications. During an observation and interview, it was found that Medication Cart 2 contained an opened vial of Humulin insulin that was dated 40 days from the date it was opened, exceeding the facility's policy of discarding multi-dose vials within 28 days. Additionally, the bottom drawer of the cart contained a box with various creams, ointments, and powders for multiple residents that were not properly stored or separated by resident. This included opened bottles and tubes of medications such as nystatin powder, triamcinolone, bacitracin, and Aspercream, some of which were unlabeled or intended for house supply. Similarly, Medication Cart 3 was found to have a box in the last drawer containing various creams, ointments, and powders for different residents, which were also not properly stored or separated. This included opened tubes and bottles of medications like triple antibiotic ointment, Halobetasol, nystatin, bacitracin, and clotrimazole cream. Staff members acknowledged that some of these treatments were discontinued and needed to be discarded. The Director of Nursing stated that discontinued medications should be sent back to the pharmacy and that expired or discontinued medications should be removed from the medication cart immediately. Treatment creams should not be mixed and should be separated in the medication cart.
Deficiency in Menu Provision and Nutritional Needs
Penalty
Summary
The facility failed to ensure that residents received current food menus and alternative menus that met their nutritional needs, including daily fresh fruits and vegetables. This deficiency was observed in five out of six residents reviewed for dining services. The facility's menus did not consistently offer fresh fruits and vegetables, and residents were not always provided with menus or informed of their food choices. The facility's policy required menus to be posted in resident care areas and to include nutrient analysis to meet nutritional needs, but this was not consistently followed. Several residents reported not receiving food menus or being aware of the Bistro menu, which offered alternative meal options. For instance, Resident 14 stated they did not receive a food menu and had to physically check the posted menu to know their meal options. They also reported not receiving fresh fruits or vegetables. Similarly, Resident 309 had an outdated menu and was unaware of the Bistro menu. Resident 89 mentioned inconsistency in receiving menus and noted that the fruit provided was mostly canned. Resident 55 also reported not receiving fresh fruits or vegetables. The facility's staff acknowledged issues with menu distribution and communication of available food options. Staff CC, the Regional Dietary Manager, mentioned that the menus were preloaded and based on resident preferences, but only a small percentage of residents returned filled menus. Staff OO, the Recreation Assistant, noted that the dietary manager had resigned, leading to a lapse in menu distribution. Staff PP, the Dietitian, confirmed that fresh fruits were available but not always served daily. The facility administrator, Staff A, expressed the expectation that residents should be aware of their meal choices and have access to fresh fruit daily.
Infection Control Lapses in Contact Precaution Practices
Penalty
Summary
The facility failed to adhere to Contact Precautions for four residents, leading to potential infection risks. Resident 51 had a wound infection requiring Contact Precautions, but there was no hazardous waste container in the room, leading staff to improperly dispose of PPE. Staff M, a CNA, admitted to taking the soiled gown to the utility room without bagging it due to the absence of a designated disposal bin. Staff MM, an RN, confirmed the lack of a disposal container and intended to find one, while the Infection Preventionist and Director of Nursing both emphasized the expectation for PPE disposal within the room. Resident 27 and Resident 64 were also on Contact Precautions due to wounds and MDROs, respectively. However, multiple staff members, including CNAs and RNs, entered their rooms without wearing the required PPE. Staff members admitted to not following the posted precaution signs, with some believing that brief room entry or lack of direct contact with residents exempted them from PPE use. This misunderstanding led to actions such as taking contaminated items out of precaution rooms, further increasing the risk of infection spread. Resident 93, with multiple wounds and a history of MDRO infection, was on Contact Precautions, yet staff failed to consistently wear PPE when entering the room. Staff X, a Maintenance Assistant, entered without PPE and touched various surfaces, while Staff LL, a CNA, also entered without proper attire. The facility's policies on hand hygiene and glove use were not followed by several staff members, including Staff DD, who handled medication without gloves, and Staff II, who did not sanitize an insulin pen before use. These lapses in infection control practices were acknowledged by staff and management, highlighting a systemic issue in adherence to established protocols.
Failure to Address Grievances for Missing Items and Discharge Planning
Penalty
Summary
The facility failed to properly address and resolve grievances for two residents, leading to frustration and unmet care needs. Resident 44, who was cognitively intact, reported a missing television remote control to a staff member, but the grievance was not logged or resolved, and the resident was not reimbursed for the replacement. The staff member responsible for handling the grievance was new and unaware of the reimbursement process, resulting in the grievance not being properly addressed. Resident 36, also cognitively intact, expressed a desire to transfer to another facility closer to a family member, CC2, but experienced issues with the facility not returning phone calls to CC2 regarding discharge planning. A grievance was filed by CC2 in December, but it was not addressed in a timely manner, and the resident's discharge care plan did not reflect their goal of transferring closer to CC2. The staff member responsible for addressing the grievance did not receive it until several weeks after it was filed, and there was no documentation of communication between social services and CC2 during the relevant period. The facility's grievance policy requires grievances to be logged, investigated, and resolved promptly, with notification to the person filing the grievance within 72 hours. However, in both cases, the grievances were not logged or resolved in a timely manner, and the facility's expectations for handling grievances were not met. The failure to address these grievances resulted in unresolved issues for the residents, impacting their quality of life.
Failure to Investigate Resident Altercations
Penalty
Summary
The facility failed to thoroughly investigate resident-to-resident altercations involving three residents, which placed them at risk for repeated incidents and unidentified abuse. Resident 44 reported being verbally assaulted by another resident, Resident 95, but the incident was not documented in the nursing progress notes or assessed for a change of condition. Staff S, who was involved in the incident, did not notify the Administrator or Director of Nursing and did not document the incident as a resident-to-resident altercation, as they believed altercations were only physical. Resident 55 experienced an incident where their roommate, Resident 39, threw a fork at them, but this was not documented in the nursing progress notes, grievance log, or incident log for August 2024. Although Resident 39 was transferred to another room, the altercation was not investigated until October 2024, and the appropriate authorities were not notified at the time of the incident. Staff EE and Staff T confirmed that the altercation was not documented or reported as required. Resident 46 reported an unwanted physical interaction with their previous roommate, Resident 95, which was considered sexual abuse. However, the investigation into this allegation was incomplete, lacking staff and additional resident interviews, and did not include a summary ruling out abuse. Staff A, the abuse coordinator, acknowledged the deficiency in the investigation process and the lack of documentation to support a thorough investigation.
Inaccurate MDS Assessment for a Resident
Penalty
Summary
The facility failed to accurately assess a resident, identified as Resident 36, using the Minimum Data Set (MDS) assessment tool. The deficiency was found in the completion of the Significant Change in Status Assessment (SCSA) for the resident, specifically in Sections L (Oral/Dental Status), N (Medications), O (Special Treatments, Procedures, and Programs), P (Restraints and Alarms), and Q (Participation in Assessment and Goal Setting). The MDS Coordinator, Staff D, signed off on these sections before the end of the observation period, which was from 10/15/2024 to 10/21/2024, thus failing to capture the resident's condition accurately during the entire look-back period. During interviews, Staff D acknowledged that the assessments were completed prematurely, and the Director of Nursing, Staff B, confirmed that the facility's expectation was for the MDS to be completed accurately according to the RAI Manual. This premature completion of the assessment placed the resident at risk for unidentified and/or unmet care needs, potentially affecting their quality of life. The report highlights the importance of adhering to the specified observation period to ensure accurate resident assessments.
Failure to Complete Accurate PASARR Evaluations
Penalty
Summary
The facility failed to ensure accurate Preadmission Screening and Resident Reviews (PASARR) for two residents, which is essential to determine if individuals with Serious Mental Illness (SMI) or Intellectual/Developmental Disabilities (ID/DD) are appropriately placed in nursing homes. Resident 103, diagnosed with bipolar disorder, was admitted with a Level I PASARR indicating an exempted hospital discharge. However, due to an inability to discharge the resident as planned, a Level II PASARR evaluation was required but not completed within the stipulated 30 days. The Social Services Director acknowledged the oversight and stated that the Level II PASARR would be sent out after the deficiency was identified. Resident 22, with diagnoses including anxiety and major depressive disorder, had a Level I PASARR indicating SMI indicators for mood and anxiety disorders, yet no Level II evaluation was conducted. The Social Services Director admitted that a Level II PASARR should have been initiated and attempted to rectify the situation by submitting a new Level I PASARR. However, the updated form was not found in the records, and the PASARR evaluator did not have a copy either. The Interim Administrator confirmed the expectation for timely PASARR reviews and submissions, highlighting the failure to correct and submit the necessary evaluations for Resident 22.
Failure to Update Care Plans for Smoking and Oxygen Use
Penalty
Summary
The facility failed to develop and revise comprehensive care plans for three residents, leading to potential risks for unmet care needs and negative outcomes. Resident 36's care plan was not completed within the required seven days following a Significant Change in Status Assessment (SCSA). Despite the resident's intact cognitive function, the care plan addressing various health concerns was delayed, and there was no documented involvement of the resident or their representative in the care planning process. Interviews revealed that the resident and their representative were not adequately informed or involved in the care planning. Resident 87, who was admitted with generalized muscle weakness and a history of falls, was identified as having unsafe smoking behaviors and was using oxygen therapy. However, the resident's care plan was not updated to address these smoking behaviors or the use of oxygen, which posed a significant safety risk. Staff interviews confirmed the absence of a care plan for these issues, despite the known hazards of smoking while using oxygen. Resident 91 was also involved in unsafe smoking behaviors, as observed by staff. Although a smoking evaluation was conducted, the resident's care plan was not revised to reflect these behaviors or the resident's refusal of nicotine patches for smoking cessation. The lack of timely updates to the care plan following the identification of these behaviors was acknowledged by staff, indicating a failure to adequately address and document the resident's needs and risks associated with smoking.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to adhere to physician orders and professional standards in medication administration for three residents, leading to potential medication errors and compromised care. For Resident 42, the Licensed Practical Nurse (LPN) did not verify the current medication order for Sertraline, resulting in the administration of an incorrect dosage. The LPN was observed preparing a 100 mg dose of Sertraline without confirming the updated order, which had changed from 125 mg to 100 mg daily. This oversight was due to the LPN's haste and reliance on outdated medication packaging, rather than checking the Medication Administration Record (MAR). Resident 43 experienced a similar issue with the administration of a multivitamin. The LPN administered a multivitamin with minerals instead of the prescribed multivitamin without minerals, due to a misunderstanding about the facility's available stock. The LPN admitted to not verifying the order against the available supply and relied on incorrect information from a coworker. The Director of Nursing (DON) later confirmed that the two types of multivitamins were not interchangeable and that the order should have been clarified. For Resident 46, the facility failed to follow the prescribed parameters for administering Hydralazine, a blood pressure medication. The MAR indicated that the medication should be withheld if the resident's systolic blood pressure was below 110 or their heart rate was below 60. However, the facility did not document vital signs before administering the evening dose of Hydralazine, as required. The Registered Nurse and DON both acknowledged the lack of documentation and the necessity of checking vital signs before each dose, highlighting a lapse in following medication administration protocols.
Failure in Resident-Centered Discharge Planning
Penalty
Summary
The facility failed to ensure an effective resident-centered discharge plan for one resident, identified as Resident 36, who was reviewed for discharge planning. The deficiency was identified through interviews and record reviews, revealing that the discharge care plan did not align with the resident's needs or the expressed goals of the resident's representative. Despite Resident 36's cognitive function being intact and their expressed desire to transfer to another facility closer to a family member, the discharge care plan was not updated to reflect this goal. Resident 36 had submitted a grievance expressing dissatisfaction with the facility's discharge planning process, stating that they were unhappy at the facility and wanted to be closer to a family member. The grievance was assigned to a social services assistant, who acknowledged the resident's desire to transfer but did not update the discharge care plan accordingly. Additionally, the resident and their family member reported issues with communication, as the facility did not return phone calls or involve them in the discharge planning process. Interviews with facility staff, including the social services assistant and the director of nursing, confirmed that the discharge care plan should have been updated to reflect the resident's stated goal. The facility's process for discharge planning was not followed, as the resident and their representative were not included in care conferences, and the discharge care plan did not include interventions to support the resident's goal of transferring to another facility closer to family.
Failure to Provide Necessary ADL Assistance and Nail Care
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADL) for two residents, leading to unmet care needs. Resident 8, who required substantial assistance with transfers and bathing, was observed to have remained in bed for several days without being offered the opportunity to get out of bed. Despite the expectation that residents be offered daily opportunities to get out of bed, staff interviews revealed that Resident 8 had not been assisted out of bed since returning from the hospital. Additionally, there was no documentation of Resident 8 receiving a shower from early December to early January, despite being scheduled for weekly showers. Resident 65, who had diabetes and required regular nail care, was found to have long, curving fingernails with brown discoloration, indicating a lack of proper nail care. Although the Medication Administration Record (MAR) indicated that nail care was provided, observations and interviews confirmed that Resident 65's nails had not been trimmed as required. Staff acknowledged that the MAR should not have been signed if the care was not performed. The facility's policy on ADLs, revised in March 2018, mandates that residents unable to perform ADLs independently receive necessary services to maintain hygiene and mobility. However, the facility's failure to adhere to this policy for Residents 8 and 65 resulted in deficiencies related to unmet care needs and documentation inaccuracies.
Failure to Provide Consistent ROM Services for a Resident
Penalty
Summary
The facility failed to consistently provide services to maintain or improve the range of motion (ROM) for Resident 17, who had limited ROM in their upper extremity. The resident's care plan, revised in April 2020, included interventions such as applying a right rigid resting splint for 3-4 hours and performing passive ROM (PROM) to the right upper extremity and active ROM (AROM) to the left upper extremity. However, there was no documentation in the resident's electronic health record indicating that these interventions were carried out. Observations on two separate occasions showed that Resident 17 was not wearing any splints. Interviews with staff revealed a lack of consistent implementation of the care plan. A Certified Nursing Assistant (CNA) acknowledged that they did not perform any ROM exercises for Resident 17 and noted that the resident had not been wearing splints recently. A Registered Nurse confirmed that nursing was responsible for applying splints but could not confirm consistent application. The Director of Nursing (DON) admitted that there was no restorative program in place and expected CNAs to perform exercises recommended by therapy. The DON also confirmed the absence of documentation for the application of splints and ROM exercises, indicating a failure to meet the resident's care needs as outlined in their care plan.
Deficiencies in Smoking Policy and Bed Safety Maintenance
Penalty
Summary
The facility failed to implement and follow its smoking assessment and care plan for Resident 91, who was not listed on the facility's smoking audit despite having a history of unsafe smoking habits. Resident 91 was observed smoking in the facility's entrance lot and did not surrender smoking materials to staff upon re-entering the facility. The resident's care plan was not updated to reflect smoking behaviors identified in a smoking evaluation, which indicated the need for supervised smoking due to unsafe habits. Additionally, the resident refused nicotine patches prescribed for smoking cessation, and there was no documentation of where the resident stored smoking materials, posing a potential hazard. The facility also failed to ensure that side rails were secured and maintained for Resident 34. Observations revealed that the side rails on Resident 34's bed were loose, and a registered nurse acknowledged the need for maintenance. The maintenance assistant confirmed that side rails were only checked if listed in a work order, and upon inspection, noted that the side rails were loose and required additional washers to tighten them. This lack of maintenance could lead to potential hazards associated with resident entrapment. Interviews with staff revealed a lack of adherence to facility policies regarding smoking materials and bed safety. Staff acknowledged the need for care plan updates and proper storage of smoking materials, as well as the requirement for side rails to be maintained and functioning properly. The deficiencies in both smoking policy implementation and bed safety maintenance placed residents at risk of harm.
Deficiencies in Oxygen Therapy Management for Two Residents
Penalty
Summary
The facility failed to provide respiratory care in accordance with accepted professional standards for two residents, leading to deficiencies in oxygen therapy management. Resident 22, who was cognitively intact and diagnosed with chronic obstructive pulmonary disease, was observed receiving oxygen at higher flow rates than prescribed. Despite physician orders for two to three liters per minute, observations showed Resident 22 receiving four and a half to five liters per minute. Staff interviews revealed a lack of adherence to checking and adjusting the oxygen flow as per the physician's orders, with staff admitting to not verifying the flow rate during their shifts. Resident 87, admitted with generalized muscle weakness and chronic pain syndrome, had a physician's order for oxygen therapy at two liters per minute every day and evening. However, observations indicated that the oxygen therapy was not administered as ordered, and there was no documentation of oxygen saturation readings since October 2024. Staff interviews confirmed that the oxygen therapy was not given routinely, contrary to the physician's order, and there was no instruction to administer it based on oxygen saturation levels. Additionally, the nasal cannula was improperly stored, being placed on personal belongings instead of in a bag. The facility's failure to follow physician orders for oxygen therapy and properly store oxygen equipment placed the residents at risk for respiratory infections and related complications. Staff interviews highlighted a lack of compliance with the facility's policy on oxygen administration, which requires verification of physician orders and proper storage of equipment. The Director of Nursing and other staff acknowledged the discrepancies and the expectation for staff to follow the physician's orders as written.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for four residents, leading to unmet care needs and potential complications. Resident 39, diagnosed with lymphedema, had a care plan that included the use of compression stockings to manage edema. However, multiple observations revealed that the resident was not wearing the stockings, and staff acknowledged their responsibility in failing to implement this aspect of the care plan. Resident 89 experienced a significant weight gain, indicating a nutritional risk. The care plan required notifying the dietitian and physician of such changes, but there was no documentation of this notification before the resident was sent to the emergency room for anasarca evaluation. Staff interviews confirmed that the weight gain was not reported to the nurse practitioner or physician as expected. Resident 17's care plan included interventions for limited range of motion, such as the use of splints and exercises. Observations and record reviews showed no documentation of these interventions being carried out, and staff interviews confirmed the lack of implementation. Additionally, Resident 99's comprehensive care plan lacked a discharge plan, which staff attributed to uncertainty about the resident's discharge destination. The Director of Nursing stated that discharge planning should begin at admission, but this was not reflected in the care plan.
Failure to Follow Care Plans and Notify Providers
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards for three residents, leading to unmet care needs and potential complications. Resident 39, diagnosed with lymphedema, had orders for compression therapy to manage swelling in the lower extremities. However, multiple observations revealed that the resident was not wearing the prescribed compression Tubigrip, despite documentation indicating otherwise. Staff interviews confirmed that the compression therapy was not administered as ordered, and documentation was inaccurately completed, failing to reflect the actual care provided. Resident 89 experienced a significant weight gain of 26.2 pounds within a week, which was not reported to the medical provider in a timely manner. The resident expressed concerns about their condition and requested to be sent to the hospital, but staff did not notify the provider until after the resident's representative called 911. The provider was only informed of the weight gain and associated edema during a routine visit, highlighting a lapse in communication and failure to follow the facility's weight management policy. Resident 46's care plan for constipation was not followed, as the resident went several days without a bowel movement without receiving the prescribed PRN medications. Documentation of bowel movements was inconsistent, and staff interviews revealed that the bowel protocol was not initiated as required. The lack of documentation and failure to administer necessary medications resulted in prolonged periods without bowel movements, contrary to the resident's care plan and facility policy.
Facility Assessment Lacks Staff Recruitment and Retention Plan
Penalty
Summary
The facility failed to update its facility assessment to include plans for maximizing direct care staff recruitment and retention, which is necessary to competently care for residents during both day-to-day operations and emergencies. The facility's policy, dated December 2023, mandates an annual assessment to determine the resources needed to meet resident needs. However, the Facility Assessment Tool, last updated on August 14, 2024, did not address strategies for staff recruitment and retention. During interviews, both the Administrator and Interim Administrator acknowledged the omission, with Staff A admitting it was missed and Staff C confirming it should have been included.
Food Temperature and Palatability Deficiency
Penalty
Summary
The facility failed to ensure that food was served at the proper temperature for residents in two nursing units, specifically the 500 and 200 Units. During observations, it was noted that the temperatures of the meals served were significantly below the required standards. For instance, a chicken patty was served at 100 degrees Fahrenheit, whereas it should have been at least 135 degrees Fahrenheit. Similarly, other food items like stuffing and Brussel sprouts were also served at temperatures below the required 135 degrees Fahrenheit. Cold items such as banana pudding and milk were also not maintained at the appropriate cold temperature of 40 degrees Fahrenheit, being served at 58 and 57 degrees Fahrenheit, respectively. Staff members acknowledged the temperature discrepancies and noted that the plastic containers used for serving did not help in maintaining the food's warmth. Multiple residents expressed dissatisfaction with the food, describing it as cold, flavorless, and inedible. Residents without cognitive impairments reported that the food was consistently served cold and lacked taste, leading some to avoid eating the meals provided by the facility. Complaints about the food's temperature and palatability were frequent, with residents even resorting to leaving notes for the dietary staff. The Director of Nursing Services stated that the expectation was to serve food at the correct temperatures, which was not being met, thus placing residents at risk for decreased nutritional intake and a diminished quality of life.
Boiler Malfunction Affects Kitchen Operations
Penalty
Summary
The facility failed to maintain a functioning boiler that consistently supplied hot water to the kitchen sink, which is essential for dishwashing. This deficiency was observed during a survey on December 12, 2024, when it was noted that the kitchen staff had to use a makeshift method to obtain hot water. A small white sink with a white tube taped to the faucet was used to fill large pans with hot water, which were then transported to larger sinks for washing pots, pans, and meal trays. This process was time-consuming and inefficient, leading to the use of plastic food containers for serving meals to residents. The issue began on December 3, 2024, when the boiler stopped working, and the problem persisted despite attempts to repair it. Interviews with staff revealed that the boiler had been turned off by the city on December 3, 2024, due to a leak, and it was tagged to prevent use. Although a repair technician was on-site on December 4 and 5, 2024, and again on December 8, 2024, the boiler continued to malfunction, affecting the kitchen's operations and the quality of meals served to residents. The maintenance staff was aware of the situation and expressed concerns about the boiler's reliability. The facility administrator acknowledged the issue and expressed dissatisfaction with the delay in resolving the problem.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,202 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Seattle
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Broadview Center | 1.8 mi | ★★★★★ | 16 | 1 |
| Hearthstone, The | 2.3 mi | — | 0 | 0 |
| Columbia Lutheran Home | 2.6 mi | ★★★★★ | 1 | 0 |
| Avamere Rehabilitation Of Shoreline | 3.7 mi | ★★★★★ | 12 | 0 |
| Cascades Of St Anne | 3.8 mi | ★★★★★ | 42 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Ballard Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.