Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of October 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.
A resident’s health coverage was changed from an HMO to a Federal Health Insurance Plan without clear documentation that the resident understood the risks and benefits of the change. Although a consent form stated the resident requested the change and understood the consequences, later cognitive testing suggested severe impairment, and staff interviews indicated the resident was confused and unable to explain the insurance change or their coverage.
Failure to complete audiology referrals for two residents. One resident had moderate hearing difficulty and impaired communication on the care plan, and another resident wanted a hearing test after speaking with the MD. Both had MD orders for audiology referrals, but the EHR did not show the referrals were initiated or completed, and staff could not find documentation that they had been done.
Failure to Provide Bed Hold and Transfer/Discharge Notices: The facility did not document providing bed hold notices for four residents who were transferred or discharged to the hospital, including one resident who was unresponsive at transfer. The facility also did not document a written transfer/discharge notice for one resident. Staff interviews and record review confirmed the notices were not found in the EHR, despite facility policy requiring written notice of bed-hold rights and appeal rights when a resident is transferred or discharged.
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.
Delayed Completion of Significant Change MDS Assessments: The facility failed to complete SCSA MDS assessments within required timeframes for 3 residents. One resident had an IDT-determined significant change and the MDS was completed 32 days late; another resident’s SCSA was completed 3 days late after readmission; and a third resident with a pressure wound had an SCSA completed 10 days late. Staff D and the DON acknowledged the assessments were not completed timely.
The facility failed to complete quarterly MDS assessments within the required timeframe for 3 residents. The MDS Coordinator confirmed that the assessments for 3 residents were not completed timely, and the DON stated that MDS assessments were expected to be completed on time per regulation.
Unsafe storage of smoking materials affected multiple residents with differing smoking plans, including residents who smoked independently and one who required supervision. Staff observed residents keeping cigarettes and lighters in pockets, bags, drawers, and bedside items instead of the smoking aide, smoking cart, or lockbox described in some care plans, while one resident was also observed smoking without the required supervision and another had no smoking care plan documented.
Incomplete Bed Rail Assessment, Consent, and Care Planning: The facility failed to fully assess and document bed rail use for 3 residents. Records showed bed rail evaluations that did not indicate rail use or addressed only one rail, yet observations found a resident with a right rail and two residents with rails on both sides in the raised position. EHR review did not show consent or care plans for bed rail use, and staff stated the residents should have had evaluations, consent, and care plans for the rails in use.
Incomplete and Outdated Daily Nurse Staffing Postings: The facility failed to post complete and current daily nurse staffing information. Observations showed the Daily Nurse Staffing Form had blank hours-worked fields and, on another occasion, displayed prior-day staffing information instead of the current form. The Scheduler stated the form should include scheduled and actual hours for each nursing category and be current, and the Administrator stated it was expected to be complete and posted at the beginning of the shift.
Controlled drugs were not properly tracked or secured in a medication room E-Kit. Surveyors found an unlocked medication refrigerator containing a removable emergency medication box with lorazepam vials and oral solution, a security seal taped to the side instead of securing the box, and no controlled drug logbook. An LPN and the DON stated the refrigerator should have been locked and the controlled drugs counted and logged.
Failure to Monitor Medication Effects and Follow Ordered Parameters: The facility did not monitor a resident on an antidepressant for adverse side effects or target behaviors, and staff did not follow ordered hold parameters for metoprolol and insulin for two other residents. Records showed metoprolol was given without required BP checks and at times when BP was below ordered limits, and insulin lispro was administered when blood sugar was below the hold parameter. Staff acknowledged the orders and monitoring expectations were not followed.
Medication Labeling and Storage Deficiencies: An LPN, RNs, and other staff observed multiple opened medications in medication carts and a medication room that were missing required open-date labels, including inhalers, insulin, oral solution bottles, and Tuberculin vials. Staff acknowledged the medications should have been labeled when opened, and the DON stated medications requiring an open date must be labeled at the time of opening.
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.
Unapproved bedside inhaler self-administration: A resident with chronic respiratory failure had inhalers at the bedside and used them without a documented physician order or completed self-administration approval. The record showed the resident was dependent on staff for medication administration and unable to use inhalant meds with proper procedure, yet staff observed the resident using albuterol inhalers at bedside. An RN stated the resident normally kept an inhaler at bedside and took it independently, while the DON stated a self-medication assessment and MD order were required.
A resident’s discharge MDS was completed but not transmitted to CMS within the required timeframe. The MDS Coordinator confirmed the assessment should have been submitted within 14 days of completion, and the DON stated that MDS assessments were expected to be submitted timely.
PASRR Level II Reports Not Obtained for Two Residents: The facility failed to obtain PASRR Level II reports for two residents who had mental health diagnoses and PASRR notices stating they met NF level of care and may benefit from specialized behavioral health services. The EHR did not contain the Level II reports for either resident, and the SS director stated the reports were not in the clinical record and should have been requested after 30 days.
PASARR screening was not completed or accurately documented for two residents. One resident admitted under an exempted hospital discharge stayed past 30 days, but no new Level I PASARR was completed. Another resident had PTSD documented in the chart, but PTSD was not marked on two Level I PASARRs. The Social Services Director and Administrator acknowledged the omissions.
A resident with MDD had a significant change in condition after developing a pressure wound and a SCSA was completed, but the facility did not notify the PASRR Coordinator or complete a new Level I PASRR. The SS Director stated she believed a new PASRR was only needed for a change in mental condition, while the Administrator stated staff were expected to complete a new Level I PASRR and notify the PASRR Coordinator when a significant change occurred.
Failure to include psychotropic and PTSD care plans: The facility did not develop comprehensive care plans for two residents. One resident was receiving Mirtazapine, and the MDS indicated psychotropic use should be addressed, but no care plan was found. Another resident had PTSD documented in the record and MDS, yet the comprehensive care plan did not address PTSD. Staff confirmed the missing care plans.
Failure to Provide Ongoing Activities for a Resident: A resident with documented leisure interests and an activity care plan for weekly support was found spending time in bed watching TV, while stating staff did not offer activities or invite them to participate. Record review showed no evidence of participation or refusal for the resident's preferred activities during the reviewed periods, and the Activity Director could not provide documentation to support that activities were offered or completed.
A resident with baseline cognitive intactness and type 2 DM with ketoacidosis had an unwitnessed fall, then developed worsening weakness, confusion, tachycardia, dehydration, lethargy, and severe hyperglycemia. Neuro checks were not completed for the full required period, and despite the resident stating she wanted to go to the hospital and later receiving an order for ER transfer, staff did not document calling EMS to send her out before she died.
Respiratory care was not provided in accordance with accepted standards for two residents. One resident with respiratory failure and sleep apnea had a BiPAP mask and O2 nasal cannula left out of bags, with the cannula undated and touching personal items and the wheelchair. Another resident with chronic respiratory failure had an AIRVO 2 water bag left in place beyond the ordered change interval, despite the physician order and posted device instructions. Staff acknowledged the equipment should have been stored or changed as required.
A resident with ESRD receiving hemodialysis three times weekly had missing pre- and post-dialysis weight documentation on multiple occasions, despite a physician order requiring weights before and after dialysis. The resident’s care plan and active orders also did not include dialysis transportation details, even though staff confirmed the resident used a transport service to get to and from dialysis.
Hand Hygiene Not Performed Between Glove Changes During Food Service: An Asst Dietary Mgr cut up baked fish, removed soiled gloves, and put on new gloves without hand hygiene, and a Dietary Aide picked up a condiment from the floor, removed gloves, and donned new gloves without hand hygiene. The facility policy required safe food handling and proper hygiene, and both staff later stated they should have washed their hands before putting on new gloves; the Dietary Mgr, DON, and Administrator said they expected hand hygiene in these situations.
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.
Failure to Verify Resident Understanding Before Insurance Plan Change
Penalty
Summary
The facility failed to ensure that a resident who had the capability to make the decision was fully informed and understood the risks and benefits associated with a change in health care coverage. Resident 1 was admitted on an HMO plan, and the primary payor status later changed to a Federal Health Insurance Plan. A Consent for Healthcare Insurance Enrollment & Disenrollment Form dated 05/31/2026 showed Resident 1 requested assistance to disenroll from the HMO and enroll in the Federal Health Insurance Plan, and the form stated the resident understood the possible loss of the ability to re-enroll in the original plan and that the decision was their choice. The same form also stated that an assessment of cognitive function supported the resident’s ability to understand the information contained in the information sheet. However, the record also included a BCAT-SF dated 06/03/2026 showing a score of 15, which was suggestive of dementia and severe cognitive impairment. In interviews, Resident 1 could not answer questions about medical needs, care, or insurance coverage, and staff described the resident as confused most of the time and only alert to name. The Business Office Manager, Regional Social Services Director, and Administrator stated the insurance change should have been initiated by the resident, but no documentation could be found in the EHR showing that Resident 1 requested the change.
Failure to Complete Audiology Referrals
Penalty
Summary
The facility failed to ensure physician orders for audiology referrals were followed for 2 residents reviewed for hearing devices. Resident 2’s quarterly MDS dated 07/03/2026 showed moderate difficulty hearing, and the care plan dated 07/10/2026 identified impaired communication related to being hard of hearing. A physician order dated 04/03/2026 documented a referral to audiology, but review of the EHR did not show that the referral was initiated or completed. Resident 3’s quarterly MDS showed intact thinking and memory. During an interview on 07/07/2026, Collateral Contact 1 stated Resident 3 wanted a hearing test to determine whether they were hard of hearing and had already spoken with the doctor, but nothing had happened to get the resident tested. A physician order dated 04/03/2026 also showed a referral to audiology, and further review of the EHR did not show that the referral was initiated or completed. Staff F stated the facility coordinated referrals for residents to be seen by providers, and Staff B and Staff A stated they could not find documentation that the audiology referrals for Resident 2 and Resident 3 had been completed.
Failure to Provide Bed Hold and Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide bed hold notices for 4 of 4 residents reviewed for discharge process. Facility policy stated that residents and/or their representatives are to receive written information about bed-hold policies in advance of transfer and again at the time of transfer, or within 24 hours if the transfer is an emergency. For Residents 1, 2, 3, and 4, record review showed each was transferred or discharged to a short-term general hospital, but there was no documentation in the EHR that a bed hold notice was provided to the resident and/or their representative. Resident 1 was unresponsive when transferred to the hospital, and the discharge MDS documented discharge to a short-term general hospital. Resident 2 was transferred to the hospital, and Resident 3 was sent to the ER for evaluation and treatment and later discharged to a short-term general hospital. Resident 4 was transferred to the hospital for evaluation and also discharged to a short-term general hospital. Interviews with the residents and staff confirmed that no bed hold notice could be found in the records for these residents, and staff stated that the notices should have been provided. The facility also failed to provide a written transfer/discharge notice to Resident 4 and/or the resident's representative when the resident was transferred to the hospital. Facility policy stated that upon notice of transfer or discharge, the resident is to be provided a statement of the right to appeal the transfer or discharge, including appeal contact information, instructions for completing and submitting an appeal form, assistance with the appeal process, and the facility bed-hold policy. Record review showed no documentation that Resident 4 received a transfer/discharge notice, and staff from social services, medical records, and administration stated that the notice should have been completed and provided.
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.
Delayed Completion of Significant Change MDS Assessments
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) MDS for 3 of 6 residents reviewed for SCSA timing requirements. The RAI Manual states that an SCSA is a comprehensive assessment that must be completed when the IDT determines a resident meets significant change criteria, and the completion date must be no later than 14 days after that determination. The facility policy titled MDS Completion and Submission Timeframes also states assessments are to be completed and submitted according to current federal and state timeframes. For one resident, the IDT determined on 10/03/2025 that an SCSA was needed, but the SCSA MDS completion date was 11/18/2025, which was 32 days late. For another resident, nursing progress notes showed the resident was readmitted and an SCSA was scheduled for 01/21/2026, but the SCSA MDS was completed on 02/04/2026, three days late. For a third resident, a nursing progress note documented a pressure wound to the right heel and indicated the resident would benefit from a significant change in condition MDS, with the ARD set for 10/06/2025; the SCSA MDS was completed on 10/27/2025, 10 days late. Staff D and Staff B acknowledged that these SCSA MDS assessments were not completed timely.
Late Quarterly MDS Assessments
Penalty
Summary
The facility failed to complete quarterly MDS assessments within 14 days of the ARD for 3 of 21 residents reviewed. Resident 14’s quarterly MDS had a completion date of 01/27/2026 and was documented as one day late. Resident 10’s quarterly MDS had a completion date of 01/27/2026 and was documented as eight days late. Resident 7’s quarterly MDS had a completion date of 01/27/2026 and was documented as four days late. During interviews and joint record reviews, the MDS Coordinator stated that the facility followed the RAI Manual for MDS completion and confirmed that each of the three quarterly MDS assessments was not completed timely. The DON also stated that the facility expected Resident 14 and Resident 10’s quarterly MDS assessments to have been completed timely, and later stated that MDS assessments were expected to be completed on time per regulation.
Unsafe Storage of Smoking Materials
Penalty
Summary
The facility failed to ensure smoking materials were safely stored for 8 of 10 residents reviewed for smoking. The deficiency involved Residents 66, 54, 63, 61, 75, 13, 2, and 85, whose smoking evaluations and care plans varied between independent smoking, supervised smoking, and storage with the smoking aide, smoking cart, or lockbox. Facility policy stated that the interdisciplinary team would develop an individualized plan for safe storage and use of smoking materials. Resident 66’s care plan stated smoking materials would be maintained with the smoking aide, but the resident was observed keeping cigarettes and lighters in a bag in the drawer and later had a cigarette in the bag and a lighter on the bedside table. Resident 54’s care plan also stated smoking materials were kept with the smoking aide, but the resident’s room smelled of cigarette smoke and an unlit half-smoked cigarette was found in a cup in the room, while the resident stated they had smoked in the room and showed a lighter. Resident 63’s care plan stated smoking materials were securely maintained in the smoking cart and at the nurses’ station, but the resident kept a lighter in a pocket and stated they could not use the lockbox because it had no key. Staff later stated these residents kept smoking materials with them and that the care plans were not implemented and/or updated to reflect their status. Resident 61’s smoking care plan did not show how to safely store smoking materials, and the resident stated they kept smoking materials in their pocket and had never used the lockbox. Resident 75’s smoking evaluation showed supervision was required for safety, but the resident was observed smoking in the designated area without staff supervision and removed a cigarette and lighter from a shoulder bag. Resident 13 was documented as independent with smoking, but the care plan still directed staff to maintain smoking materials with the smoking aide and monitor compliance; the resident kept cigarettes and a lighter in their pocket. Resident 2 was independent with smoking, but the comprehensive care plan did not include a smoking care plan, and the resident kept cigarettes and a lighter in a zippered bag. Resident 85’s care plan directed that smoking materials be securely maintained in the smoking cart, but the resident kept cigarettes and a lighter in a jacket pocket and stated they were waiting for a lockbox.
Incomplete Bed Rail Assessment, Consent, and Care Planning
Penalty
Summary
The facility failed to comprehensively assess and evaluate the need for bed rails for 3 residents who were reviewed for bed rail use. The facility policy stated that alternative approaches should be attempted before bed rails are used, and that if bed rails are used, the facility would ensure correct installation, use, and maintenance, complete a bed rail assessment, obtain informed consent, and obtain a physician’s order for the specific bed rail. The deficiency was identified during observation, interview, and record review involving Residents 9, 74, and 103. For Resident 9, a bed rail evaluation dated 01/26/2026 stated that mobility bars were not indicated and recommended no rails. However, the EHR did not show consent for the right-side bed rail, and the care plan did not include bed rail use. During observations on 04/07/2026, 04/09/2026, and 04/15/2026, Resident 9 had a right bed rail in the raised position and stated they used it. Staff BB and Staff CC also observed the right bed rail in use and stated the resident used it, with Staff CC stating it had been present since readmission. Staff C and Staff B both stated the resident should have had an evaluation, consent, and care plan for the right-side bed rail. For Resident 74, a bed rail evaluation dated 02/11/2026 stated that bed rail/transfer bar use was not indicated and recommended no rails. The EHR did not show consent for bed rail use, and the care plan did not include bed rail use. Observations on 04/07/2026, 04/09/2026, and 04/15/2026 showed bed rails attached on both sides of the bed in the raised position, and the resident stated they used them. Staff BB and Staff CC stated the resident used the bed rails and had them since admission. For Resident 103, a bed rail evaluation dated 02/22/2025 addressed only a left upper bed rail, yet observations on 04/07/2026 and 04/15/2026 showed bed rails on both sides of the bed in the raised position, and the resident stated they used them. Staff C and Staff B stated Resident 103 should have had an evaluation for both bed rails.
Incomplete and Outdated Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to ensure the posted daily nurse staffing information included the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care for 9 of 10 days reviewed, and it also failed to post current nurse staffing information for 1 of 8 days reviewed. Observation on 04/07/2026 at 8:06 AM showed a Daily Nurse Staffing Form for 04/07/2026 with the number of staff and scheduled hours completed, but the hours worked column was blank. Additional observations on 04/09/2026 at 8:25 AM, 10:30 AM, and 3:00 PM, and on 04/10/2026 at 8:00 AM showed a Daily Nurse Staffing Form dated 04/08/2026 rather than current staffing information. On 04/10/2026 at 1:22 PM, the hours worked column on the Daily Nurse Staffing Form was still blank. Staff G, the Scheduler, stated they were responsible for the form, that it should be completed for each nursing category with scheduled and actual hours worked, and that the form should be current. Staff G stated they filled out hours worked at the end of the shift, left forms on weekends and updated them on Monday, and did not update the form on 04/09/2026 because they were out of the facility. Staff A, the Administrator, stated the Daily Nurse Staffing Form was expected to be complete, include actual hours, be current, and be posted at the beginning of the shift.
Controlled Drugs Not Properly Locked or Logged
Penalty
Summary
The facility failed to ensure a system was in place for tracking and accounting of controlled drugs and failed to store controlled drugs in a locked, permanently affixed compartment in 1 of 2 medication rooms, specifically the medication room's E-Kit. During observation and interview, the second medication refrigerator in the medication room was found to be unlocked, and a clear removable emergency medication box was stored inside it. The E-Kit's security seal was taped to the side of the box rather than being applied to secure the contents. Inside the E-Kit, surveyors observed two 2 mg vials of lorazepam injectable solution and two 30 mL bottles of lorazepam oral solution. There was no controlled drug logbook in the E-Kit. Staff stated the E-Kit had been delivered by the facility's new pharmacy provider and that they had not seen the controlled drug logbook. The DON later stated that controlled drugs must be counted, logged in the controlled drug book, and stored in a locked box, and acknowledged being unaware that the E-Kit with controlled drugs had been delivered by the new pharmacy provider.
Failure to Monitor Medication Effects and Follow Ordered Parameters
Penalty
Summary
The facility failed to ensure that residents’ drug regimens were free from unnecessary drugs by not monitoring for adverse side effects and target behaviors and by not following physician orders with medication parameters for 3 of 6 residents reviewed. The report identified Resident 30 as having an order for nortriptyline at bedtime, but the January 2026 through April 2026 MAR and TAR did not show monitoring for adverse side effects or target behaviors related to antidepressant use. Staff C and Staff B both stated that residents on antidepressants were expected to be monitored, and both acknowledged that Resident 30 was not being monitored as expected. Resident 30 also had an order for metoprolol twice daily with instructions to hold the medication if systolic blood pressure was less than 100 and pulse was less than 60. The January through April 2026 MARs showed the medication was scheduled for 8:00 AM and 4:00 PM, but the blood pressure and pulse were not recorded in the MAR before administration. Staff C stated the MAR should have included spaces to record blood pressure and pulse, and Staff B stated staff were expected to follow the physician’s orders with parameters. Resident 13 had an order for insulin lispro in the evening to be held if blood sugar was less than 150, but the March 2026 MAR showed insulin was administered when blood sugar was 100, 100, and 134. Resident 7 had an order for metoprolol twice daily with instructions to hold it if systolic blood pressure was less than 110 or diastolic pressure was less than 60, yet the March and April 2026 records showed doses given without blood pressure monitoring and/or when readings were below the ordered parameters, including administration at 105/46 and 106/65 on 04/05/2026. Staff V, Staff C, and Staff B each stated that staff were expected to check blood pressure and follow the physician’s parameters before giving the medication.
Medication Labeling and Storage Deficiencies
Penalty
Summary
Drugs and biologicals were not properly labeled and stored in accordance with accepted professional principles in 3 of 3 medication carts and 1 of 2 medication rooms reviewed. During observation and interview, an opened Albuterol Sulfate inhaler in Medication Cart 3 had a sticker for the date opened, but the date field was blank. In Medication Cart 4, an opened Combivent Respimat inhaler was stored without an open date. In Medication Cart 2, Resident 53's insulin glargine pen, two amantadine hydrochloride oral solution bottles, and one opened Spiriva Respimat inhaler all had blank or unlabeled stickers and were not marked with open dates. Staff stated these medications should have been labeled when opened. In medication room [ROOM NUMBER], an opened Tuberculin vial in the refrigerator was labeled with an open date of 02/17/2026, and staff stated it had been opened on that date. A later observation found two additional opened, unlabeled Tuberculin vials stored in the second refrigerator, and staff stated they had been opened but not labeled. The DON stated staff were expected to label medications with an open date, that medications requiring an open date must be labeled at the time of opening, and that Tuberculin vials should be labeled with the open date and discarded within 30 days of opening.
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.
Unapproved bedside inhaler self-administration
Penalty
Summary
The facility failed to ensure Resident 25 was evaluated and had a physician order for self-administration of medication before inhalers were kept and used at the bedside. Resident 25 was admitted with chronic respiratory failure with hypoxia. The facility’s policy stated residents may self-administer medications only if the interdisciplinary team determines it is clinically appropriate and safe, and if not safe, nursing staff administer the medications. The record review showed a Medication Self-Administration Evaluation dated 01/29/2026 stating Resident 25 was unable to administer inhalant medications with proper procedure and was dependent on staff for all cares and medication administration. The physician order reviewed on 04/10/2026 did not show an order for self-administration of medication, and the electronic health record did not show that Resident 25 could keep medication at the bedside. Observations showed Resident 25 receiving nebulization and having an albuterol inhaler with a red chamber at the bedside table on 04/10/2026. On 04/13/2026, Resident 25 was observed using an inhaler with a blue chamber and stated they did not know how much puff to take and just did it many times. Both inhalers were labeled albuterol-sulfate HFA and did not show Resident 25’s name. Resident 25 stated the red inhaler was from home. Staff E, RN, observed both inhalers and stated Resident 25 normally had an inhaler at bedside and took it by themselves, then discarded the red inhaler as empty. Staff E later stated Resident 25 brought inhalers on admission, that they had told Resident 25 they could not have inhalers at the bedside, and that they had called the provider but did not remember documenting it. Staff E also stated Resident 25’s red inhaler was the rescue inhaler and did not know where the blue inhaler came from. The DON stated residents should be assessed for self-medication before being allowed to keep medications at the bedside and that there should be a doctor’s order.
Failure to Timely Transmit Discharge MDS
Penalty
Summary
The facility failed to transmit Resident 94’s discharge MDS to CMS within the required timeframe. The discharge MDS was completed on 11/07/2025, but it was not submitted/transmitted to CMS. The report states that the facility’s policy required resident assessments to be conducted and submitted in accordance with current federal and state submission timeframes, and the RAI Manual required a discharge non-comprehensive MDS to be completed no later than 14 days after the ARD and submitted within 14 days of the completion date. During an interview and joint record review on 04/15/2026, the MDS Coordinator stated that the discharge assessment should have been submitted/transmitted within 14 days from completion and identified that Resident 94’s discharge MDS should have been submitted by 11/21/2025. In a later interview on 04/16/2026, the DON stated that MDS assessments were expected to be submitted/transmitted timely.
PASRR Level II Reports Not Obtained for Two Residents
Penalty
Summary
The facility failed to ensure that PASRR Level II reports were obtained for 2 of 10 residents reviewed for PASRR coordination. Resident 6 had diagnoses including schizophrenia and PTSD, and a PASRR Notice of Determination dated 05/13/2025 stated that the resident had a mental health diagnosis, met nursing facility level of care requirements due to current mental health needs, and may benefit from specialized behavioral health services. The notice also stated that the full PASRR Level II report would be sent to the nursing facility and become part of the medical record within 30 days, but the EHR did not contain the Level II report. Resident 30 had diagnoses including depression and anxiety disorder, and a PASRR Notice of Determination dated 04/02/2025 stated that the resident had a mental health diagnosis, met nursing facility level of care requirements due to current mental health needs, and may benefit from specialized behavioral health services. The EHR did not contain the Level II PASRR report for this resident either. During interview and record review, the Social Services Director stated there was no Level II PASRR report in the clinical record for either resident and that the reports should have been requested after 30 days of receiving the notices of determination. The Administrator stated staff were expected to follow the PASRR policy and to follow up to obtain the Level II PASRR reports for both residents.
PASARR Screening Not Completed or Accurately Documented
Penalty
Summary
The facility failed to ensure a new Level I PASARR was completed for a resident admitted under an exempted hospital discharge who remained in the facility beyond 30 days. The resident’s Level I PASARR dated 08/12/2025 marked PTSD, mood disorders, and anxiety in Section IA, and Section IV indicated no Level 2 evaluation was needed at that time because of exempted hospital discharge. Review of the electronic record showed no new Level I PASARR was completed after the resident exceeded 30 days in the facility, and no Level I PASARR was sent to the PASRR Coordinator. During interview, the Social Services Director stated they were supposed to send out a new PASARR Level I before residents exceeded 30 days and confirmed this resident stayed longer than 30 days, but no new Level I PASARR was completed. The facility also failed to accurately complete Level I PASARRs for a resident with PTSD. The resident’s admission record listed PTSD, and the trauma questionnaire and physician history and physical notes also documented PTSD, but Level I PASARRs dated 10/02/2025 and 02/18/2026 did not mark PTSD. During interview and record review, the Social Services Director stated they were not sure whether the resident had PTSD, then acknowledged that PTSD should have been marked and a new Level I PASARR completed. The Administrator stated staff were expected to review PASARRs on admission and complete a Level I PASARR if required, and agreed that a new Level I PASARR should have been completed for both residents.
Failure to Complete New PASRR After Significant Change
Penalty
Summary
The facility failed to notify the State PASRR Coordinator and complete a new Level I PASRR after a resident with a diagnosis of major depressive disorder had a significant change in condition. The facility’s PASRR Completion Policy stated that it would follow state-specific guidelines, and the Level I PASRR form stated that when a resident experiences a significant change in condition, the nursing facility must complete a new PASRR Level I and make referrals to the appropriate entities. Resident 7’s record showed a Significant Change Assessment dated 10/06/2025. A nursing progress note dated 10/03/2025 documented that the resident developed a pressure wound to the right heel and would benefit from a significant change in condition MDS, which was scheduled for 10/06/2025. During record review and interview, the Social Services Director stated that a new Level I PASRR was not completed and that she thought it was only needed when residents had a change in mental condition. The Administrator stated that staff were expected to complete a new Level I PASRR for residents with a significant change in condition and notify the PASRR Coordinator.
Failure to Include Psychotropic and PTSD Care Plans
Penalty
Summary
The facility failed to develop and/or implement comprehensive care plans for 2 of 26 residents reviewed. The facility policy stated that an individualized comprehensive care plan with measurable objectives and timetables should be developed for each resident to meet medical, physical, mental, and psychosocial needs. For Resident 1, the admission MDS showed antidepressant use during the assessment period, and the care area assessment indicated that psychotropic drug use would be addressed in the care plan. The February, March, and April 2026 MARs showed the resident was receiving Mirtazapine, but the comprehensive care plan printed on 04/13/2026 did not include a care plan for the resident's psychotropic medication use. Staff C stated that a care plan would be developed for a resident placed on an antidepressant, and later stated that no care plan had been initiated for Resident 1's antidepressant medication; Staff B also stated that a care plan was expected for psychotropic medication use. For Resident 19, the admission record showed a diagnosis of PTSD, the quarterly MDS marked PTSD, and a progress note dated 03/23/2026 documented the diagnosis. The resident stated they had been diagnosed with PTSD and received doctor visits and medications related to it. However, the comprehensive care plan printed on 04/10/2026 did not include a plan of care for PTSD. During joint record review and interviews, Staff C and Staff B both confirmed that Resident 19 did not have a care plan addressing PTSD, and Staff B stated that the resident should have had a PTSD care plan.
Failure to Provide Ongoing Activities for a Resident
Penalty
Summary
Provide activities to meet all resident's needs. The facility failed to provide ongoing activities and programs for Resident 91, who had an activity care plan identifying interests that included building club, reading materials, stamp collection, going outside, gardening, and attending religious services and veteran events. The resident's recreation comprehensive assessment stated that it was important to have the opportunity to engage in daily routines that were meaningful relative to their preferences. The activity care plan, printed on 04/10/2026, directed staff to assist the resident to activities at least once a week. Record review showed no evidence that Resident 91 participated in or refused preferred activities during 02/22/2026 through 02/28/2026 and 03/19/2026 through 03/30/2026. On 04/09/2026 and again on 04/10/2026, the resident was observed lying in bed watching TV and stated that staff did not provide or offer activities, that they did not go out of their room, and that nobody had really invited or talked to them about activities. The Activity Director stated the resident was seen once a week and offered Lego sets because they liked model building, but could not provide documentation of the resident's activities. The Activity Assistant stated activity participation was documented on lunch attendance census forms and transferred to the monthly participation record, but those records also showed no evidence of participation or refusal during the reviewed periods.
Failure to complete neuro checks and follow transfer orders after unwitnessed fall and change in condition
Penalty
Summary
The facility failed to coordinate care and communicate with medical providers in a timely manner for a resident who had an unwitnessed fall and then experienced a significant change in condition. Resident 106 was cognitively intact at baseline and had an active diagnosis of type 2 diabetes mellitus with ketoacidosis without coma. After the unwitnessed fall, the resident reported striking the right side of the head lightly and discomfort in the right armpit. Pain medication was given and neuro checks were initiated, but the neurological assessment flow sheet was completed only on the first two days and was blank for the last two days reviewed. Following the fall, the resident developed worsening symptoms including weakness, nausea, no appetite, confusion, tachycardia, dehydration, lethargy, and poor oral intake. Blood glucose readings were documented as HI, above 600, then 467 and 454, and the resident received multiple one-time STAT insulin orders and IV hydration. A psych evaluation documented that the resident reported a recent fall, did not feel well, had poor appetite, and stated she was very sick and wanted to go to the hospital. Despite this, the record did not show that emergency services were contacted at that time. On the day the resident died, the physician documented that the resident was lethargic, minimally arousable, confused, and needed urgent evaluation in the ER. A physician order was entered to send the resident to the ER for further evaluation and treatment related to the change in condition, but the record did not show that emergency services were called to transfer the resident out as ordered. The resident was documented as having passed away around 10:00 AM, and staff later documented that the family and provider were notified and the funeral home picked up the body.
Respiratory equipment not stored or maintained per orders
Penalty
Summary
The facility failed to provide respiratory services in accordance with accepted professional standards of practice for 2 residents reviewed for respiratory care. The deficiency involved improper storage of a BiPAP mask and O2 nasal cannula when not in use, failure to label/date O2 tubing, and failure to change an AIRVO 2 water bag as ordered. The report cited facility policies for CPAP/BiPAP support and cleaning and for oxygen and nebulizer tubing, which were intended to guide infection prevention associated with respiratory therapy tasks and equipment. Resident 71 was admitted with diagnoses including acute and chronic respiratory failure and sleep apnea. The resident’s record showed orders for a BiPAP machine and O2, including weekly O2 tubing changes. Observations on multiple occasions showed the BiPAP mask on the floor or on top of the dresser and not stored in a bag, and the O2 nasal cannula tubing was undated and not stored in a bag, at times touching the resident’s personal items, wheelchair backrest, and other belongings. The resident stated they used O2 all the time and BiPAP at night, and staff assisted with putting the BiPAP on and off. Staff later stated the BiPAP mask and O2 tubing should have been stored in a bag when not in use and the tubing should have been labeled and dated when last changed. Resident 25 was admitted with chronic respiratory failure with hypoxia and had an order for an AIRVO 2 heated humidified airflow device, with the water bag to be changed every 30 days along with the tubing. Observations showed the AIRVO 2 machine at the bedside and the water bag dated 1/29/26 on multiple dates. Staff stated the bag had been refilled with distilled water and acknowledged the physician’s order to change it every 30 days. The AIRVO 2 instructions posted in the room stated the water bag should be replaced or changed every 60 days, and staff stated the bag had not been replaced since the resident was admitted. The DON and ADON stated staff were expected to follow the physician’s order, and the water bag should have been changed.
Dialysis weights not consistently monitored and transportation information missing from care plan
Penalty
Summary
The facility failed to consistently monitor pre-dialysis and post-dialysis weights for a resident with end stage renal disease who received hemodialysis three times a week. Resident 19 had a physician order requiring pre- and post-dialysis weights to be taken and documented every Monday, Wednesday, and Friday, but the record showed missing pre-dialysis weights on 01/02/2026, 01/12/2026, 02/06/2026, and 03/06/2026, and missing post-dialysis weights on 01/07/2026, 02/06/2026, 04/06/2026, 04/08/2026, and 04/10/2026. Staff V and Staff B both acknowledged that the resident’s weights should have been monitored before and after dialysis in accordance with the physician order. The facility also did not include the resident’s dialysis transportation information in the care plan. The facility policy stated that transportation to and from the dialysis provider would be arranged and that the care plan would be updated as needed, but review of the resident’s comprehensive care plan and active physician orders did not show the transport service or pickup information. Resident 19 stated that transportation to dialysis was provided by a transport service, and Staff V confirmed the resident rode that service, but the information was not documented in the care plan.
Hand Hygiene Not Performed Between Glove Changes During Food Service
Penalty
Summary
The facility failed to perform hand hygiene before putting on new gloves for 2 of 6 staff reviewed for food services. During observation on 04/10/2026 at 12:29 PM, Staff Z, the Assistant Dietary Manager, cut up baked fish while holding it in place with a gloved hand, then removed and discarded the soiled gloves and put on new gloves without performing hand hygiene between glove changes. During observation on 04/10/2026 at 12:34 PM, Staff AA, a Dietary Aid, picked up a whipped spread sealed condiment from the ground and discarded it in the trash, then removed and discarded the gloves and put on new gloves without hand hygiene between glove changes. The facility policy titled, Food Preparation and Service, revised in November 2022, stated that food and nutrition services employees prepare, distribute, and serve food in a manner that complies with safe food handling practices and that food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness. In interviews, Staff Z and Staff AA both stated they should have performed hand hygiene before donning new gloves after touching a food item or dirty surface. Staff Y, the Dietary Manager, Staff B, the DON, and Staff A, the Administrator, each stated they would expect staff to perform hand hygiene and put on new gloves after touching a food item or picking up an item off the floor.
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.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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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 | ★★★★★ | 6 | 0 |
| Hearthstone, The | 2.3 mi | — | 0 | 0 |
| Columbia Lutheran Home | 2.6 mi | ★★★★★ | 1 | 0 |
| Avamere Rehabilitation Of Shoreline | 3.7 mi | ★★★★★ | 15 | 0 |
| Cascades Of St Anne | 3.8 mi | ★★★★★ | 42 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.