Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bellevue Post Acute during CMS and state inspections, most recent first.
Infection surveillance was not completed for several months, with infections documented in records for residents with pneumonia and a positive Klebsiella pneumoniae result not appearing on the infection line listing. Staff also failed to sanitize vital sign equipment between resident uses, and an RN administered insulin from pens without wiping the rubber seals with alcohol swabs before attaching new needles, contrary to manufacturer instructions.
The facility failed to designate a qualified IP to oversee the infection prevention and control program. The policy required oversight by an infection prevention specialist or designee, but the Administrator stated there was no current IP and the DON was handling the program without certification. The DON confirmed they lacked specialized infection prevention training and certification and stated the facility should have a qualified IP.
Meals were served on trays in the dining room and left on the tables for multiple residents, with staff not offering to remove the trays. A resident stated the tray was in the way and a disturbance, and staff interviews showed inconsistent practice about whether trays should remain during meals. The issue affected the homelike environment and dining experience for residents.
A dietary service deficiency occurred when meal trays did not match the menu/meal tickets for multiple residents. Three residents were served half a banana instead of the mixed fruit cup listed on their tickets, and staff described ongoing issues, substitutes, and a menu change that was not communicated to nursing. The DON and Administrator stated that the menu/meal ticket was expected to match what residents received.
Food Handling and Storage Deficiencies: Staff D did not perform hand hygiene before entering the kitchen, before gloving, or after removing gloves while preparing pureed bread for a resident. Surveyors also found multiple food items in dry storage and the refrigerators that were unlabeled, undated, uncovered, or past their use-by/best-by dates, including sauces, croutons, pickles, cranberry sauce, pizza dough, raw chicken, and milk cartons. Staff acknowledged several items should have been labeled, covered, or discarded.
QAA committee records showed the committee met weekly and included multiple disciplines, but did not include the IP as a required member. QAPI minutes also did not show IP attendance. The DON stated the facility had not had an IP until one was recently hired, and the Administrator acknowledged that an IP was a required QAA committee member.
The facility did not consistently follow its antibiotic stewardship program or complete monthly surveillance, and antibiotic use was not formally tracked or reviewed in QAPI for several months. Records showed residents were placed on antibiotics during that period, but the infection line listing had no documentation of those uses. For one resident with hematuria and possible UTI, the chart did not show C&S results or that results were pending, yet an antibiotic was ordered for UTI.
CNA Annual Training Deficiencies: The facility failed to ensure multiple CNAs had the required annual in-service training, including the 12-hour minimum and training in abuse/neglect prevention and dementia management. Record review showed three CNAs had only partial training hours documented, and two of them lacked abuse/neglect and dementia training. The Staffing Coordinator and DON both stated CNAs were expected to have these training requirements.
A resident with orders for PT/OT and a PT plan of care specifying treatment twice weekly did not receive PT services for an 18‑day period. The resident reported not having PT for about two weeks, and review of therapy notes confirmed no PT during that time and no documentation of refusals or missed visits. The PT stated residents are to be seen per their treatment plan and that missed visits should be documented, but no such documentation existed. The rehab director acknowledged the gap in services was due to staffing shortages that prevented scheduling, and the administrator confirmed the expectation that residents receive therapy as ordered.
Failure to Provide SNF ABN Before Medicare Coverage Ended: The facility did not provide a SNF ABN to a resident before Medicare Part A skilled coverage ended. Record review showed the resident received skilled services under Medicare Part A, but the chart did not document the required notice before the last covered day. The DOSS confirmed the notice was not given, and the Administrator stated the notice was expected as required.
Incomplete Investigation of Alleged Neglect: A cognitively intact resident alleged neglect by a CNA, including being denied food and left soiled, and also reported delayed call light response and male CNAs standing in the doorway without helping. The facility’s investigation did not include interviews with the alleged staff member or other residents, and staff interviews showed the allegation was not thoroughly investigated as required by policy.
Failure to Provide Written Transfer/Discharge Notices: The facility did not provide written transfer/discharge notices for two residents who were transferred to the hospital. One resident had an unplanned discharge after a change in condition, and the EHR showed no documentation that the resident or representative received the required notice. Staff reported the facility had been using phone calls to notify representatives instead of providing the written notice with appeal rights and Ombudsman contact information.
Late SCSA MDS After Hospice Enrollment: A resident enrolled in hospice, but the SCSA MDS was not completed within the required timeframe. The RAI Manual required the assessment within 14 days of the hospice election date, yet the MDS was completed 27 days later. The MDS consultant and DON both stated the assessment was late.
Inaccurate MDS coding affected two residents. One resident’s MDS undercounted injections, another resident’s MDS missed an injection, and one resident’s prognosis item was marked yes without physician documentation or a terminal illness certification supporting a life expectancy of less than 6 months. The MDS Coordinator and DON confirmed the assessments were inaccurate.
A resident admitted under a hospital-exemption Level 1 PASRR had SMI indicators, including mood disorder and anxiety, and diagnoses of psychosis and anxiety. The form stated that a Level 2 eval was not needed at that time, but if the resident remained beyond 30 days, Level 2 was required. The record showed no new Level 1 PASRR was completed after 30 days and no referral was sent to the PASRR Coordinator, despite staff stating that exempted cases should be sent on day 31 if the resident had not discharged.
Failure to notify the PASRR Coordinator after a significant change occurred for a resident admitted to hospice. The resident's Level 1 PASRR identified mood disorders and required a Level 2 eval, but the form was not documented as sent to the PASRR Coordinator when completed; staff later acknowledged it should have been sent timely.
A resident with CHF was ordered daily weights and provider notification for weight gains of 3 lbs in 24 hours or 5 lbs in a week while receiving furosemide for fluid retention. Staff identified multiple 24-hour weight gains above the ordered threshold, but the cardiologist was not notified and the record did not show reweighing or documentation of notification.
A resident received insulin Lispro doses from an opened pen after the 28-day beyond-use period had passed. Facility policy, the manufacturer instructions, and the pharmacy reference all required the pen to be discarded 28 days after first use, and the Charge Nurse, Pharmacist Consultant, and DON all confirmed it should not have been used after that date.
MRR recommendations were not completed accurately or in a timely manner for two residents. One resident with HTN had an amlodipine order with hold parameters, but the MAR documented BP and temperature instead of pulse, despite pharmacist review noting the error. Another resident with digoxin and alendronate had repeated pharmacist recommendations to obtain/document a digoxin level and discontinue alendronate, but follow-up was delayed and the medication changes were not addressed promptly.
Medication orders with parameters were not followed for two residents. One resident received insulin glargine and metoprolol when blood sugar and HR were outside ordered hold parameters. Another resident received PRN oxycodone without documented non-pharmacological interventions and was given doses outside the ordered pain-level ranges. Staff confirmed the orders should have been followed as written.
Expired insulin was found on the Team-One Second Floor medication cart during observation and record review. A resident’s insulin Lispro pen had been opened beyond the 28-day discard period stated in the facility policy, the pharmacy reference list, and the manufacturer’s instructions. The Charge Nurse and DON both confirmed the pen should have been discarded after the 28-day timeframe.
Failure to Offer Updated COVID-19 Vaccine to a Resident: The facility failed to ensure a resident was offered the most recent COVID-19 vaccine. The resident's EHR showed the last documented COVID-19 vaccine was in 2022, and there was no documentation that the resident was offered the updated 2025-2026 vaccine. During record review, the DON stated the resident was not offered the most recent COVID-19 vaccine.
A facility failed to keep the survey results binder complete by leaving out 4 complaint survey reports and their POCs that had resulted in citations. The Administrator confirmed the binder was expected to include annual surveys and complaints, and acknowledged the missing survey results should have been included.
A resident was discharged without receiving the required written notice of transfer/discharge, and neither the resident's representative nor the Office of the State Long Term Care Ombudsman were notified as mandated by facility policy and regulation. Staff interviews confirmed a lack of awareness and documentation regarding the notification process.
Surveyors found that the facility did not ensure an area was free from accident hazards and failed to provide adequate supervision to prevent accidents, resulting in a deficiency.
A resident reported feeling threatened by a staff member described as the head of nurses. Despite facility policy requiring immediate suspension of any accused staff pending investigation, the DON—who matched the initial description—was not suspended and instead conducted the follow-up interview, ultimately ruling themselves out as the alleged perpetrator. Staff interviews confirmed knowledge of the suspension policy, but it was not followed in this case.
A facility failed to notify law enforcement of suspected abuse involving a CNA and a resident. The resident reported feeling powerless and vulnerable after the CNA did not respect her request to stop touching her during a shower. Despite the facility's policy requiring such incidents to be reported, law enforcement was not contacted, as confirmed by interviews with the DON and Executive Administrator.
The facility did not post nurse staffing information on the second floor, as required by policy. Observations showed postings were only on the first floor, and interviews with staff and a resident confirmed the deficiency. Staff G admitted the posting was not in a prominent place accessible to all, and a resident suggested it should be posted on the second floor as well.
The facility failed to maintain food safety standards, with improper labeling and storage of food items, inconsistent hand hygiene and glove use by kitchen staff, and lack of hair coverings. Observations showed food past use-by dates, staff not washing hands after glove removal, and uncovered desserts being delivered to residents' rooms. Staff acknowledged these issues, which were against facility policies.
The facility did not include 2021 recertification and complaint survey results in the survey result binder and failed to post notices about the availability of these reports. This prevented residents and visitors from accessing important information. Two residents were unaware of the survey reports' availability, and observations confirmed the lack of postings. The Executive Director acknowledged the missing documents.
The facility failed to provide baseline care plans and written summaries to several residents within 48 hours of admission, as required by policy. Staff interviews and record reviews revealed that written summaries were not consistently provided, and in one case, a baseline care plan was missing entirely. This placed residents at risk for unmet care needs.
The facility failed to develop and implement comprehensive care plans for four residents, including those using assistive devices and self-administering medications. A resident with dementia used a tilt-in-space wheelchair without a care plan, while another had a Ventolin inhaler at their bedside without a self-administration plan. Additionally, a resident with dysphagia was left unsupervised during meals, contrary to their care plan, risking aspiration.
The facility failed to maintain a safe environment and provide adequate supervision, leading to potential hazards. Bubbling in the first-floor hallway carpet posed a tripping risk, while a resident with dysphagia was left unsupervised with food and fluids, contrary to their care plan. Staff acknowledged these issues, highlighting delays in addressing the carpet problem and the need for strict adherence to supervision protocols.
Expired medications and improperly labeled liquid medications were found in two medication carts at the facility. Observations revealed expired drugs such as Senna plus, Iron, Bisacodyl, Aspirin, Vitamin D3, Fish oil, Fexofenadine hydrochloride, and Melatonin. Additionally, Tylenol and Lactulose solutions lacked proper labeling. Staff acknowledged the oversight, and the DON confirmed the facility's expectations for medication management.
The facility failed to manage its resources effectively, resulting in hazardous carpet conditions in the hallways. Observations showed bubbling in the carpet, posing a risk to residents using mobility aids. Staff confirmed the issue, and the Executive Director acknowledged awareness but cited delays in corporate response to repair requests.
The facility failed to ensure proper hand hygiene and glove use by staff during resident care and meal delivery, as observed with an LPN and a scheduler. Additionally, Enhanced Barrier Precautions (EBP) were not implemented for residents with indwelling catheters, increasing infection risk. Observations showed catheter tubing touching the floor and staff not wearing gowns during high-contact care. Interviews revealed a lack of awareness and policy for EBP, leading to increased infection risk.
A facility failed to obtain informed consent before administering psychotropic medications to a resident with moderately impaired cognition. Despite the facility's policy requiring consent, the resident's EHR lacked documentation of consent for antidepressant and antianxiety medications. Staff confirmed that consent should have been obtained and documented.
Two residents were found with medications at their bedside without completed assessments or physician orders for self-administration. One resident had an incomplete assessment for a Ventolin inhaler and no order for a Stiolto Respimat inhaler, while another had home medications without any documented clearance. Staff confirmed that medications should not be at the bedside without proper assessment and orders.
A resident reported feeling threatened by the food served after complaining about it, but the facility failed to report this allegation of abuse to the State Agency as required. The resident, who was cognitively intact, described receiving 'throw away food' and 'goopy' food, which they considered a threat. The facility's administrator did not report the incident, believing it was unnecessary due to a lack of harm, but later acknowledged the need to report it.
A resident reported feeling threatened after receiving 'throw away food' following complaints about the facility's food. The administrator did not recognize this as an abuse allegation and failed to conduct a thorough investigation, placing the resident at risk for repeated incidents and unidentified abuse.
A facility failed to provide written notice of transfer to a resident, their representative, and the State LTC Ombudsman, as required by policy. Staff interviews revealed that verbal notifications were given instead, and the resident was omitted from the list sent to the Ombudsman. The Executive Director confirmed the oversight.
A facility failed to transmit a resident's assessment data to CMS within the required timeframe. The discharge MDS for a resident was not completed, resulting in an 87-day delay. An MDS RN acknowledged the oversight, and the DON confirmed the expectation for timely completion.
The facility inaccurately assessed two residents using the MDS tool. One resident with an indwelling catheter was incorrectly coded as occasionally incontinent, while another resident's discharge status was wrongly recorded as discharged to an acute hospital instead of an Assisted Living Facility. These errors were identified during record reviews and interviews with the MDS RN and DON.
A facility failed to conduct a required Level II PASARR evaluation for a resident with bipolar disorder, as indicated by a positive Level I PASARR. The oversight occurred despite updated guidance from the Department of Social and Health Services, which staff were aware of but did not implement, placing the resident at risk of not receiving appropriate care.
The facility failed to conduct care conferences for two residents within the required seven days of admission, as per their policy. Both residents confirmed the absence of these conferences, and staff interviews corroborated the oversight. This deficiency placed the residents at risk of not having input on their care goals and unmet needs.
The facility failed to ensure proper medication administration and monitoring, as a nurse did not prime an insulin pen before dosing, and medications were left unattended for a resident. Additionally, vital signs were not consistently checked before administering blood pressure medication to a resident with hypertension, despite specific parameters for withholding the medication. Staff confirmed these practices were against facility expectations.
A resident with diabetes and muscle weakness did not receive necessary nail care or assistance with wheelchair transfers. Observations showed long, untrimmed nails with debris, and no documentation of scheduled care. Staff interviews confirmed the lack of scheduled nail care and assistance, despite the resident's expressed need and care plan requirements.
A facility failed to administer PRN Torsemide for a resident with significant weight gain and did not follow the bowel management protocol for another resident. Despite having orders for diuretic medication and bowel management, the staff did not take appropriate actions, leading to unmet care needs. Interviews revealed a lack of adherence to protocols and physician orders, placing residents at risk of medical complications.
A facility failed to provide consistent restorative services for a resident with limited ROM, as required by their care plan. Documentation showed missing records for active ROM exercises and ambulation training, and interviews revealed that the responsible CNA was often reassigned to other duties, leading to neglect of the restorative program. The DON confirmed the lack of documentation and acknowledged that the program was not carried out, placing the resident at risk for unmet care needs.
A facility failed to properly label, date, and store a nebulizer treatment set and tubing for a resident with COPD, who was prescribed Albuterol Sulfate Nebulization Solution. Observations showed the equipment was left on a chair without proper labeling or storage, contrary to facility policy. A nurse confirmed the equipment should have been labeled and bagged, and the DON stated it should be changed weekly and stored properly.
Infection Surveillance and Equipment/Insulin Pen Sanitization Failures
Penalty
Summary
The facility failed to provide appropriate infection surveillance for July 2025 through November 2025. Review of the infection line listing for July 2025 through December 2025 showed no documentation of infections from July 2025 through November 2025. However, record review showed that Resident 78 had a chest x-ray result given to the physician with antibiotic orders for pneumonia on 07/03/2025, and Resident 64 had laboratory results positive for Klebsiella pneumoniae on 07/30/2025. The DON stated there was no surveillance plan for identifying, tracking, or monitoring infections prior to December 2025, but acknowledged there had been infections during that period and that they should have been included on the infection line listing. The facility also failed to ensure proper sanitization of vital sign equipment and failed to clean insulin pens before administration. Observation showed a CNA took vital signs for multiple residents using the same vital sign equipment and did not sanitize or disinfect the equipment between resident uses. The CNA stated they were supposed to sanitize the equipment between residents and that not doing so was a mistake. In addition, an RN prepared Resident 4's insulin aspart and insulin glargine pens by removing the caps and attaching new needles without wiping the rubber seals with alcohol swabs first. The RN stated the seals should have been cleaned before connecting the needles, and the Charge Nurse and DON both stated staff should have followed the manufacturer's instructions to wipe the pen seals with alcohol swabs before use.
Lack of Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified staff person to serve as an Infection Preventionist to oversee the infection prevention and control program. The facility policy titled, Infection Prevention and Control Program, stated that the program is coordinated and overseen by an infection prevention specialist (infection preventionist), or designee. During an interview, the Administrator stated that the facility did not currently have an IP and that the DON was responsible but was not certified. The DON later stated that they were responsible for the facility's infection prevention and control program, did not have specialized training in infection prevention and control, and were not certified. The DON also stated that the facility should have a qualified IP. The Administrator later stated that there should have been a certified IP responsible for the facility's infection prevention and control program.
Meals Served on Trays in Dining Room
Penalty
Summary
The facility failed to provide a homelike environment when residents in the First Floor Dining Room were served meals on trays and the trays were left on the tables during dining. During observation, a CNA served Resident 78 a tray, removed the cover from the plate, and left the tray on the table. The CNA then served Resident 11 and Resident 64 in the same manner, and neither CNA offered to remove the trays. Additional observation showed multiple residents eating their meals on trays in the dining room, including Residents 36, 57, 64, 78, 21, 43, 80, 39, 11, 67, 30, 44, 41, and 59. A later observation showed another group of residents eating lunch on trays in the First Floor Dining Room, including Residents 13, 8, 57, 64, 18, 10, 21, 43, 80, 39, 11, 68, 67, 30, 41, 32, 44, and 59. Resident 13 stated that having the tray bothered them, that it was in the way and a disturbance, and that staff did not offer to remove it. In interview, a CNA stated that residents were served meals on trays in the dining room and that trays would only be removed if residents did not like them, while the Charge Nurse stated staff would leave the tray when residents were served in the dining room before later stating staff were expected to remove the tray. The Administrator stated residents were expected to be able to eat safely in the dining room and to make it as homelike as reasonable.
Menu and Meal Ticket Mismatch for Multiple Residents
Penalty
Summary
The facility failed to ensure that menus and meal tickets were followed for 3 of 8 residents reviewed for food services. The report states that the facility’s policy required food and nutrition staff to inspect trays to ensure the correct meal was provided and to report incorrect meals so a new tray could be issued. During observations and interviews, Resident 35 stated that dietary staff did not follow the menu/meal ticket and that they were supposed to receive fruit but did not get any. The resident’s meal ticket showed a mixed fruit cup, but the breakfast tray observed did not contain a mixed fruit cup and instead had half of a banana. Staff M confirmed that the banana was not a fruit cup and stated there had been a lot of issues with residents not receiving items listed on their meal tickets. Resident 27 was observed at breakfast receiving half of a banana even though the meal ticket showed a mixed fruit cup, and the resident stated that they were being given substitutes. Resident 32 was also observed with half of a banana on the tray when the meal ticket showed a mixed fruit cup, and Staff W stated it was not a mixed fruit cup and was likely a miscommunication with the kitchen. Staff D stated that the menu had been changed because the fruit was going bad and admitted that nursing was not notified. Staff A stated that the expectation was for dietary staff to follow the menu and for the meal ticket to match what residents received.
Food Handling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure food was handled in accordance with professional food safety standards for staff hand hygiene, dry storage, and refrigerated food storage. During observation, Staff D, the Director of Food Services, entered the kitchen, went to the office to answer the phone, then went into the walk-in refrigerator, brought out a bowl, and went to a preparation station to make pureed bread for a resident. Staff D did not perform hand hygiene when entering the kitchen, before putting on gloves, or after removing gloves. Staff D later stated hand hygiene should have been performed before entering the kitchen and before and after glove use, and the DON stated dietary staff were expected to perform hand hygiene before and after entering the kitchen and before and after glove use. In the dry storage room, surveyors observed an opened container of vanilla extract with no opened date or use-by/expiration date, an unlabeled plastic bag of croutons with no open or use-by date, and an opened container of Kikkoman Sweet and Sour Sauce with a best-by date of 09/26/2025. Staff L, Cook, stated that food items past the use-by or best-by date should be thrown away and that opened items needed to be labeled with the ingredient name and open and use-by date. Staff L also stated the vanilla extract should have had an open date, the croutons should have been labeled and dated once opened, and the sweet and sour sauce should have been discarded. In the walk-in refrigerator, surveyors observed a container of Sweet Baby Ray's Korean Barbeque and Wing Sauce with a best-by date of 11/27/2025 and a plastic bag labeled pepperoni with a use-by date of 12/31/2025; Staff L stated both should have been discarded. On a later observation, the refrigerator contained cranberry sauce with a preparation date of 12/13/2025 and no use-by date, dill pickles dated 07/01/2025 with no use-by/expiration date, three unlabeled and uncovered round pizza doughs, and one unlabeled and uncovered raw chicken on a sheet pan. Staff D stated the pickles and cranberry sauce should have been discarded and that the pizza dough and raw chicken should have been covered and labeled when removed from the freezer. In the first-floor food refrigerator, six unopened half-pints of 2% milk had a best-by date of 01/06/2026; Staff C was unsure whether they could still be served, while Staff D and the Administrator stated they should not be used past that date and should have been removed.
QAA Committee Lacked Required Infection Preventionist Member
Penalty
Summary
The facility failed to maintain a Quality Assessment and Assurance (QAA) committee that included the Infection Preventionist (IP) and to conduct required QAPI and QAA activities. Review of the facility’s QAA committee information showed the committee met weekly and included the Administrator, DON, Medical Director, Social Services Director, Case Manager, Therapy Consultant, Charge Nurse, MDS Director, Registered Dietitian, and Dietary Director, but did not show that an IP was included. Review of the facility’s QAPI agenda/minutes showed a QAPI meeting was held, but the minutes did not show that an IP attended. The DON stated there had not been an IP at the facility and that one had only recently been hired within the last three days, and the Administrator stated that an IP was a required QAA committee member and that the facility did not have one prior.
Failure to Track Antibiotic Use and Follow C&S Process
Penalty
Summary
The facility failed to consistently follow its Antibiotic Stewardship Program and complete monthly surveillance for July 2025 through November 2025. The facility’s policy stated that the purpose of the program was to monitor antibiotic use in residents, and the Infection Prevention and Control Program stated that antibiotic usage is evaluated and practitioners are provided feedback on reviews. However, the infection line listing for July 2025 through December 2025 showed no documentation of infections or antibiotic use from July through November 2025. The DON stated the facility had not been formally tracking antibiotic use before December 2025 and that antibiotic use had not been reviewed or discussed at QAPI meetings. The record review showed that residents were prescribed antibiotics during the period that was not being tracked. One nursing progress note showed a resident was started on Augmentin and Doxycycline for Klebsiella pneumoniae, another showed a resident was started on Macrobid for UTI, and another showed a resident had Augmentin ordered after urine testing. Staff B acknowledged that there had absolutely been residents on antibiotics during that time, but stated they could not speak to whether those antibiotics had been tracked before December 2025. The facility also failed to ensure appropriate antibiotic use for one resident. Resident 3 had an order for urinalysis with C&S if indicated for hematuria and possible UTI, and later had Bactrim DS ordered for UTI. The urinalysis lab report did not show C&S results or documentation that results were pending. Staff K stated the resident was started on an antibiotic due to confusion and hematuria, and Staff C stated they did not know what happened and would call the lab to clarify. The Medical Director stated that if a resident had symptoms of UTI, they would start with urinalysis C&S if indicated and would not start treatment without it, and that Resident 3’s C&S should have been completed.
CNA Annual Training Deficiencies
Penalty
Summary
The facility failed to ensure Certified Nursing Assistants had the required annual in-service training, including dementia management and abuse/neglect prevention training. The facility assessment updated on 10/14/2025 stated that nurse aide in-service training must be sufficient to ensure continuing competence, be no less than 12 hours per year, and include dementia management training and resident abuse prevention training. Record review showed Staff M, a CNA hired on 06/19/2023, had no documentation of the required 12 hours of annual training and was documented as having received 6.25 hours. Staff S, a CNA hired on 11/20/2024, had no documentation of the required 12 hours of annual training and was documented as having received 5.15 hours, with no abuse/neglect or dementia management training. Staff T, a CNA hired on 07/20/2023, had no documentation of the required 12 hours of annual training and was documented as having received 7.35 hours, also without abuse/neglect or dementia management training. During interview and record review, the Staffing Coordinator stated CNAs needed 12 hours of annual training that included abuse/neglect and dementia training, and the DON stated they would expect CNAs to have 12 hours annually and abuse/neglect and dementia training upon hire.
Failure to Provide Ordered PT Services Due to Staffing Shortages
Penalty
Summary
The deficiency involves the facility’s failure to provide specialized rehabilitative services according to a resident’s established treatment plan. The facility’s policy on scheduling therapy services states that therapy is to be scheduled in accordance with the resident’s treatment plan. One cognitively intact resident, identified as Resident 15, was admitted in October 2025 and had a physician’s order dated 12/04/2025 for PT/OT to evaluate and treat, with partial weight bearing as tolerated. A PT Evaluation and Plan of Treatment dated 12/11/2025 specified a frequency of two times per week, with a certification period from 12/11/2025 through 02/23/2026. During an interview on 01/06/2026, the resident reported that the last time they received PT was two weeks prior. Record review of PT notes for Resident 15 showed no documentation of PT services provided between 12/19/2025 and 01/05/2026, an 18‑day gap, despite the ordered frequency. The PT (Staff R) stated that residents are to be seen according to the plan of treatment and that refusals should be documented with missed visit notes, but could not find any documentation explaining why Resident 15 did not receive PT during that period and referred the surveyor to the Director of Rehab. The Director of Rehab (Staff Q) stated that the resident did not receive PT services for two weeks due to staffing shortages and that they were not able to schedule the resident, and confirmed that absent staffing issues, the expectation was PT twice weekly. The Administrator (Staff A) stated they expected residents to receive therapy services per their treatment plan and confirmed that this expectation applied to Resident 15’s ordered twice‑weekly therapy.
Failure to Provide SNF ABN Before Medicare Coverage Ended
Penalty
Summary
The facility failed to issue a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) before Medicare coverage ended for Resident 90. The facility’s policy stated that residents would be informed in advance when changes would occur to their bills and that, when Medicare was believed not to pay for otherwise covered skilled services, the resident or representative would be notified in writing of why the services might not be covered and of the resident’s potential liability for payment. Review of the SNF Beneficiary Notification Review form showed Resident 90 received Medicare Part A skilled services from 08/29/2025 to 10/27/2025, but the record did not show that a SNF ABN was provided. The electronic health record also did not document that a SNF ABN was given before the last covered day. Resident 90 discharged from the facility back into the community on 11/02/2025. Staff F, Director of Social Services, stated that a SNF ABN should have been provided and confirmed that it was not. Staff A, Administrator, stated they would expect a SNF ABN notice to be given as required.
Incomplete Investigation of Alleged Neglect
Penalty
Summary
The facility failed to conduct a thorough investigation of an allegation involving Resident 45, who was cognitively intact on admission. On 01/05/2026, Resident 45 stated that Staff N, a CNA, had denied them a salad on one occasion and had left them soiled on more than one occasion, which made them feel bad. The facility policy required all reports of abuse, neglect, exploitation, or misappropriation to be thoroughly investigated and required the alleged employee to be placed on leave with no resident contact until the investigation was complete. The investigation dated 01/07/2026 documented the resident’s allegation that call lights took too long to be answered, that a CNA would not get a salad, and that male CNAs would stand in the doorway at night without helping, but it did not include interviews with the alleged staff member or other residents. Staff N stated on 01/09/2026 that the resident had requested a turkey burger rather than a salad and that they were not aware of the allegations or interviewed about them. Staff E stated the allegations could represent abuse or neglect and should have been reported and investigated, with the alleged staff suspended until the allegation was investigated; Staff E also stated they were not aware of the allegations and Staff N had not been suspended. The DON and Administrator both stated they expected the alleged staff and other residents to be interviewed, and the Administrator acknowledged that the resident’s statement identifying another name was not included in the investigation.
Failure to Provide Written Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide a written transfer/discharge notice for 2 of 3 residents reviewed for hospitalization, identified as Residents 6 and 64. The facility policy titled, Transfer or Discharge Notice, revised in March 2021, stated that residents and/or representatives are to be notified in writing in a language and format they understand, at least 30 days prior to transfer or discharge, or as soon as practicable before the transfer or discharge under certain circumstances. The policy also stated the notice would include the specific reason, date, and location for the transfer or discharge, an explanation of appeal rights, and contact information for the Office of the State Long-term Care Ombudsman. Resident 6 was transferred to the hospital for a change in condition, and the discharge MDS showed an unplanned discharge to a Short-Term General Hospital. Review of the EHR showed no documentation that a written transfer/discharge notice was provided to Resident 6 or the representative. Resident 64 was also transferred to the hospital, and review of the EHR showed no documentation that Resident 64 and/or the representative were provided a written transfer/discharge notice. Staff F stated the facility had been notifying representatives by phone when residents were transferred to the hospital and had not been providing a written notice, and Staff A stated a written notice should have been provided when required.
Late SCSA MDS After Hospice Enrollment
Penalty
Summary
The facility failed to ensure a Significant Change in Status Assessment (SCSA) MDS was completed timely for Resident 9 after the resident enrolled in hospice. The RAI Manual stated that when a terminally ill resident enrolls in hospice or changes hospice providers and remains in the nursing home, a SCSA is required, with the ARD within 14 days of the effective date of hospice election and the assessment completed no later than 14 days after that determination date. The Hospice SNF Notification Form showed Resident 9 started hospice services on 11/03/2025. Resident 9's SCSA MDS was completed on 11/30/2025, which was 27 days after hospice election and 13 days late. During interview and joint record review, the Regional MDS Consultant stated the hospice admission date was the determination date and that the assessment should have been completed by 11/17/2025. The DON also stated that MDS assessments were expected to be completed timely and accurately, and agreed the assessment was completed late.
Inaccurate MDS Coding for Injections and Prognosis
Penalty
Summary
The facility failed to accurately complete MDS assessments for 2 residents by incorrectly coding injections and prognosis information. The report states that accurate assessment requires information from multiple sources, including the resident, direct care staff, the medical record, and physician documentation, and that injection counts must include all injections received during the look-back period. It also states that coding prognosis in item J1400 requires physician documentation showing a life expectancy of less than 6 months. For one resident, the admission MDS recorded 1 injection in item N0300, but the MAR showed 2 injections during the look-back period: a tuberculin intradermal injection and an influenza vaccine intramuscular injection. During interview and record review, the MDS Coordinator acknowledged that both intradermal and intramuscular injections should be counted and stated the resident had received 2 injections, making the MDS inaccurate. For the second resident, the admission MDS recorded 0 injections in item N0300, but the MAR showed 1 tuberculin intradermal injection during the look-back period. The MDS Coordinator confirmed the resident had received 1 injection and that the MDS was inaccurate. The report also found that one resident’s MDS was incorrectly coded for prognosis. The resident had started hospice services, but the electronic record contained no physician note or certification of terminal illness showing a life expectancy of less than 6 months during the look-back period. Despite this, item J1400 on the MDS was marked yes. The MDS Coordinator and the Regional MDS Consultant both stated that physician documentation or hospice certification was required to code prognosis as yes, and the DON stated the resident did not have a certification of terminal illness during the look-back period.
Failure to Refer PASRR After Hospital Exemption Expired
Penalty
Summary
The facility failed to ensure that a Level II PASARR referral was made for one resident who had been reviewed for PASRR screening. The resident was admitted to the facility after acute inpatient hospital care, and the Level 1 PASRR completed on 10/21/2025 marked Section IA for SMI indicators, including mood disorders and anxiety. The form also indicated that no Level 2 evaluation was needed at that time because the admission was treated as an exempted hospital discharge, with Level 2 to be completed if the scheduled discharge did not occur after 30 days from admission. Record review showed the resident had diagnoses including psychosis and anxiety, and the electronic record from 10/27/2025 through 01/09/2026 showed no new Level 1 PASRR completed after 30 days of admission and no Level 1 PASRR sent to the PASRR Coordinator. In interview, the Director of Social Services stated the facility’s process was to send exempted hospital discharge Level 1 PASRR forms to the PASRR Coordinator on day 31, and the Administrator stated residents admitted under the hospital exemption who had not discharged by day 30 would have a new Level 1 PASRR completed and sent on day 31. The resident’s Level 1 PASRR should have been sent after 30 days of admission, but it was not.
Failure to Notify PASRR Coordinator After Significant Change
Penalty
Summary
The facility failed to notify the State PASRR Coordinator after a significant change in condition for one resident who was reviewed for PASRR screening. Resident 9 was admitted to hospice services on 11/03/2025, and a Level 1 PASRR completed on 11/07/2025 identified mood disorders in Section IA and indicated that a Level 2 evaluation referral was required for the significant change. Review of the electronic health record showed no documentation that the Level 1 PASRR form dated 11/07/2025 was sent to the PASRR Coordinator. During a joint record review on 01/09/2026, the Director of Social Services stated that Level 1 PASRR forms were completed when residents were admitted to hospice services and then sent to the PASRR Coordinator for Level 2 evaluation, and acknowledged that Resident 9's form should have been sent after it was completed on 11/07/2025. The Administrator stated on 01/10/2026 that Level 1 PASRR forms with Level 2 recommendations were expected to be sent to the PASRR Coordinator timely after completion.
Failure to Monitor Weight Gain and Notify Provider for Resident on Diuretic
Penalty
Summary
The facility failed to monitor a resident receiving furosemide for fluid retention and failed to notify the provider of significant weight gains for a resident with chronic heart failure. The resident had diagnoses including CHF, and the physician orders printed on 01/06/2026 directed staff to weigh the resident daily and call the cardiologist if the resident gained 3 lbs in 24 hours or 5 lbs in a week. The resident’s CHF care plan also included monitoring, documenting, and reporting changes in weight to the MD. Review of the resident’s weights showed multiple gains greater than 3 lbs in 24 hours, including 11/07/2025 to 11/08/2025, 11/28/2025 to 11/29/2025, 12/23/2025 to 12/24/2025, and 12/29/2025 to 12/30/2025. During interviews and joint record review, the RN stated the cardiologist had not been notified when the resident had more than a 3 lb weight gain in 24 hours. The Charge Nurse stated staff expected to notify the physician and document, and also stated the resident should have been reweighed when there was a weight gain, but did not see that this was done. The DON stated staff should follow physician orders, monitor weights for residents on diuretics, and call the cardiologist and alert the facility doctor when there was a weight gain in a resident with CHF.
Expired Insulin Pen Used Beyond Allowed Time
Penalty
Summary
Pharmaceutical services were not provided to meet the needs of Resident 15 when the facility failed to ensure an opened insulin Lispro (Humalog) pen was discarded within the required 28-day use period. Facility policy required opened multi-dose vials and similar medications to be dated and discarded within 28 days unless the manufacturer specified otherwise, and the medication administration process required checking the expiration or beyond-use date before administration and recording the date opened on the container. The manufacturer instructions and the facility’s pharmacy reference list both stated that insulin Lispro should be thrown away 28 days after first use. Resident 15’s MAR showed multiple doses of insulin Lispro were administered from the same pen after the open date had passed. During observation and interview, Staff C, Charge Nurse, confirmed the resident had an insulin Lispro pen with an open date and stated it should have been discarded after 28 days. Staff C also stated the resident should not have received insulin doses from that pen after the discard date. The Pharmacist Consultant stated insulin Lispro should be discarded 28 days after first opening and should not be provided after that time, and the DON stated medications were expected to be discarded by their expiration date. The record review showed the resident received insulin from the same pen after the date it should have been discarded.
MRR recommendations were not completed accurately or timely
Penalty
Summary
The facility failed to ensure monthly Medication Regimen Review (MRR) recommendations were completed accurately and in a timely manner for 2 of 6 residents reviewed for unnecessary medications. The facility policy titled, Medication Regimen Review, stated that the facility should encourage the physician/prescriber or other responsible parties receiving the MRR and the DON to act upon the recommendations, and that if an irregularity did not require urgent action but should be addressed before the consultant pharmacist's next monthly MRR, staff and the consultant pharmacist would confer on the timeliness of attending physician responses based on the resident's clinical condition. For Resident 15, who had a diagnosis of hypertension, the pharmacist's MRR recommendation identified that BP and pulse documentation should be added to the MAR for an order for amlodipine with hold parameters for systolic BP and pulse. The December 2025 MAR showed BP and temperature were documented, but pulse was not documented. A later pharmacist recommendation again noted that temperature was being recorded rather than pulse and that amlodipine was not likely to affect temperature. Staff stated they expected the recommendation to be followed correctly and completed within about a week to 10 days, but the recommendation was not updated until 01/07/2026. For Resident 5, who had physician orders for digoxin and alendronate, the September and October 2025 MRRs noted that a digoxin level was ordered but the result was missing from the EHR and recommended ordering the lab if still unavailable and following up to ensure the result was documented. The EHR showed no documentation of follow-up on the September recommendation, and the digoxin level was not completed until 11/05/2025. The November and December 2025 MRRs recommended discontinuing alendronate, but the medication was not discontinued until 01/07/2026. Staff stated that MRR recommendations should be followed up as soon as possible and that the alendronate recommendation was not addressed timely.
Medication Parameters Not Followed
Penalty
Summary
The facility failed to ensure physician orders with parameters were followed for medications administered to two residents. For one resident, the record showed orders for insulin glargine to be held when blood sugar was 120 or less and metoprolol to be held when heart rate was less than 55. Review of the MARs showed insulin glargine was administered on multiple occasions when blood sugar readings were below 120, and metoprolol was administered on multiple occasions when heart rates were below 55. Staff interviews confirmed that these medications should have been held when the ordered parameters were not met. For another resident, the record showed PRN oxycodone orders for pain with specific dose ranges tied to pain levels, along with an order to observe each shift and offer non-pharmacological interventions before giving PRN pain medication. Review of the MARs showed the resident received oxycodone repeatedly without documented evidence that non-pharmacological interventions were attempted or provided before administration. Staff interviews confirmed that the resident should have been offered non-pharmacological interventions before receiving PRN oxycodone and that this should have been documented. The record review also showed the resident received oxycodone outside the ordered pain parameters. The resident received the 5 mg dose when pain levels were below 5 or above 7, and received the 10 mg dose when pain levels were below 8. Staff interviews confirmed that the PRN oxycodone doses should not have been given outside the ordered pain ranges and that the physician should have been notified if pain medication was requested outside the parameters.
Expired Insulin Pen Kept on Medication Cart
Penalty
Summary
The facility failed to ensure that medications and biologicals were discarded when expired for 1 of 2 medication carts reviewed, specifically the Team-One Second Floor Medication Cart. During observation and interview, Resident 15 was found to have an insulin Lispro pen on the cart with an open date that had passed the 28-day discard timeframe identified in the facility policy, the manufacturer’s instructions, and the pharmacy’s expiration reference list. The facility policy stated that opened multi-dose vials are to be dated and discarded within 28 days unless otherwise specified, and that outdated medications are to be returned or destroyed according to pharmacy instructions. A joint observation and interview with the Charge Nurse confirmed that Resident 15’s insulin Lispro pen should have been discarded 28 days after first use and should have been thrown away after the listed date. Record review showed the insulin label instructed that any remaining medicine be discarded 28 days after first use. The DON also stated that the insulin pen opened on the listed date should have been discarded after the 28-day period.
Failure to Offer Updated COVID-19 Vaccine to a Resident
Penalty
Summary
The facility failed to ensure the COVID-19 vaccine was offered to 1 of 5 residents reviewed for immunizations, Resident 5. The facility policy titled, Coronavirus (COVID-19)-Vaccination of Residents, revised in June 2022, stated that each resident is offered the COVID-19 vaccine unless it is medically contraindicated or the resident has already been immunized, and that vaccine recommendations and schedules are consistent with CDC guidance. The CDC document reviewed during survey stated that a 2025-2026 COVID-19 vaccine was recommended for people ages 6 months and older and was especially important for people living in a long-term care facility. Resident 5 was admitted to the facility on [DATE]. Review of the resident's EHR, including progress notes, miscellaneous records, and the immunizations tab, showed the last documented COVID-19 vaccine was administered on 04/14/2022. There was no documentation that Resident 5 was offered the most recent 2025-2026 COVID-19 vaccine. During a joint interview and record review on 01/09/2026, the DON stated that the facility offered the COVID-19 vaccination to residents on admission and annually, and then stated that Resident 5 was not offered the most recent COVID-19 vaccine.
Survey Results Binder Missing Complaint Survey Findings
Penalty
Summary
The facility failed to ensure the survey results binder included the results and plans of correction for 4 of 8 complaint surveys that resulted in citations since the last annual survey. During review of the state inspection survey results binder on 01/07/2026 and again on 01/10/2026, the binder did not contain the complaint survey results and associated plans of correction from 08/12/2025, 09/16/2025, 10/14/2025, and 12/09/2025. In interview, the Administrator stated the binder was expected to include annual surveys and any complaints that occur, and acknowledged that the missing survey results should have been in the binder, stating, "I missed that."
Failure to Provide Required Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide written notice of transfer or discharge to a resident and/or their representative, as well as to the Office of the State Long Term Care Ombudsman, as required by both facility policy and regulation. Review of the electronic health record for the resident who was discharged showed no documentation that such notice was given. Multiple staff interviews confirmed a lack of awareness or implementation of the process for providing and documenting these notifications. The Social Services Director, who was new to the role, was unsure if the notice had been provided and could not locate any related documentation. The Charge Nurse stated that providing such notice was a new policy and that nothing had been sent to the ombudsman. The Regional Nurse Consultant and the Administrator both acknowledged that the required notifications were not present in the resident's record and confirmed that notification to the ombudsman is a regulatory requirement. The facility's policy, revised in March 2021, specifies that residents and/or their representatives must be notified in writing, in a language and format they understand, of the specific reason for transfer or discharge, the date, the location, and their rights to appeal. It also requires that a copy of the notice be sent to the Office of the State Long-Term Care Ombudsman. Despite these requirements, there was no evidence that the resident or their representative received the required written notice, nor that the ombudsman was notified, at the time of the resident's discharge.
Failure to Maintain Safe Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, and there was insufficient oversight to protect residents from potential harm. Specific actions or inactions leading to this deficiency include the presence of accident hazards and a lack of proper supervision, as directly observed by surveyors during their review.
Failure to Suspend Alleged Perpetrator During Abuse Investigation
Penalty
Summary
The facility failed to follow and implement its abuse and neglect policies and procedures during the investigation of an abuse allegation involving a cognitively intact resident. According to the facility's policies, any employee accused of abuse, mistreatment, neglect, or exploitation must be immediately suspended pending the outcome of the investigation. However, when a resident reported feeling threatened and fearful after an interaction with a staff member described as the head of nurses, the staff member fitting that description (the Director of Nursing) was not suspended or ruled out as a possible alleged perpetrator at the outset of the investigation. The investigation report showed that the resident initially described the alleged perpetrator as a tall nurse and the head of nurses, which matched the Director of Nursing. Despite this, the Director of Nursing conducted a follow-up interview with the resident, during which the resident provided a different description. The Director of Nursing then ruled themselves out as the alleged perpetrator based on this new description and their claim of not being present during the alleged incident. There was no documentation that the Director of Nursing was suspended or excluded from the investigation process, as required by policy. Interviews with other staff confirmed their understanding that any staff member accused of making a resident feel threatened or afraid should be suspended pending investigation. Staff also identified the Director of Nursing as the head of nurses, matching the resident's initial description. The Executive Administrator stated that staff are expected to follow the facility's abuse and neglect policies, but the investigation did not reflect adherence to these procedures in this case.
Failure to Report Suspected Abuse to Law Enforcement
Penalty
Summary
The facility failed to notify local law enforcement of a reasonable suspicion of abuse involving a resident. The incident involved a Certified Nursing Assistant (CNA) who allegedly did not respect the resident's request to stop touching her during a shower, making the resident feel powerless and vulnerable. The grievance form filled out by the resident indicated that the CNA's actions were perceived as abusive, yet the facility did not report the incident to law enforcement as required by their policy and state regulations. The facility's policy, as well as state guidelines, mandate that such incidents be reported to law enforcement, especially when involving staff-to-resident concerns. Despite the resident's clear expression of feeling abused and the facility's acknowledgment of the incident as an abuse allegation, there was no documentation of law enforcement being notified. Interviews with the Director of Nursing and the Executive Administrator confirmed that the facility did not contact the police, acknowledging a failure to comply with reporting requirements.
Failure to Post Nurse Staffing Information on All Floors
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted in prominent locations on both floors, specifically on the second floor, as required by their policy. The policy, dated August 2018, mandates that within two hours of the beginning of each shift, the number of licensed nurses and unlicensed nursing personnel responsible for patient care should be posted in a prominent location accessible to patients and visitors. Observations on multiple dates revealed that the nurse staffing information was consistently posted only on the first floor by the administration office and not on the second floor. Interviews with staff and a resident confirmed the deficiency. Staff G, responsible for scheduling and staff development, acknowledged that the staffing information was only posted on the first floor and agreed that it was not in a prominent place accessible to all residents and visitors, particularly those on the second floor. Staff A, the administrator, believed the posting location was adequate due to the first floor's central activities and office locations. However, a resident noted that the posting was not easily visible, especially for older individuals, and suggested that it should be posted in other locations, including the second floor.
Food Safety and Hygiene Deficiencies in Facility
Penalty
Summary
The facility failed to adhere to professional standards of food safety, as evidenced by improper food handling and storage practices. Observations revealed that food items in the walk-in refrigerator were not labeled with use-by dates, and some items were past their use-by dates, such as sausage gravy, cheese, and egg salad. Staff C, the Dietary Manager, acknowledged these discrepancies and stated that the items should have been discarded. Additionally, in the dry storage room, an opened container of molasses and cinnamon raisin bread were found past their use-by dates, which Staff C also agreed should be discarded. Hand hygiene and glove use were not consistently practiced by the kitchen staff. Staff O, P, and Q were observed not performing hand hygiene after removing gloves, despite handling various food items and equipment. Staff O admitted to not washing hands after glove removal, while Staff P and Q acknowledged that they sometimes forgot to perform hand hygiene. Staff C, the Dietary Manager, and Staff E, the Infection Preventionist, both stated that they expected staff to perform hand hygiene before and after glove use. The use of hair coverings in the kitchen was also neglected. Staff C was observed without a hairnet while handling food, which they admitted was against the facility's policy. Additionally, uncovered food items were delivered to residents' rooms, with desserts being transported without covers, exposing them to potential contamination. Staff AA and Staff X were observed carrying uncovered desserts down hallways, and Staff C admitted that desserts were not covered due to frosting. Staff E and Staff B, the Director of Nursing, expressed concerns about uncovered food being carried long distances, as it could be exposed to contaminants.
Failure to Provide Access to Survey Results
Penalty
Summary
The facility failed to ensure that the survey result binder included the results for the 2021 recertification and complaint surveys that resulted in citations. Additionally, the facility did not post notices of the availability of survey reports in prominent and accessible areas for the public. This oversight prevented residents, their representatives, and visitors from exercising their right to review past survey results and the facility's plan of corrections. During a residents' meeting, two residents who regularly attended monthly meetings stated they were unaware of the availability of survey reports. Observations on the facility's first and second floors confirmed the absence of postings or notices regarding the survey reports. A review of the survey binder revealed missing recertification and complaint survey results for 2021, including specific complaint survey results from February, March, September, and October, as well as the recertification survey result from June. The Executive Director acknowledged the absence of these documents and confirmed that all annual recertification and complaint survey results with citations should be included in the binder.
Failure to Provide Baseline Care Plans to Residents
Penalty
Summary
The facility failed to develop and provide a baseline care plan and a written summary to residents and/or their representatives within 48 hours of admission, as required by their policy. This deficiency was identified for five residents during the survey. For Resident 94, the baseline care plan was not marked as provided to the resident or their representative, and the staff admitted to not giving a written summary. Similarly, Resident 194 did not recall receiving a written summary, and the staff confirmed that it was not provided unless requested. Resident 15 also expressed uncertainty about receiving the summary, and the records showed it was not provided. Resident 20's records lacked a baseline care plan entirely, and the staff could not locate it. Resident 5 was unsure about receiving the summary, and the records confirmed it was not provided. The Director of Nursing stated that the expectation was for the written summary to be offered and provided to residents, which was not consistently done. This failure to adhere to the facility's policy placed residents at risk for unmet care needs and a diminished quality of life.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for four residents, leading to unmet care needs and potential risks. Resident 23, who was admitted with dementia and severely impaired cognition, was observed using a tilt-in-space wheelchair without a corresponding care plan. Staff acknowledged the absence of a care plan for the wheelchair, which was necessary for the resident's positioning. Resident 193 was observed with a Ventolin inhaler at their bedside, but there was no care plan for self-administration of medication, despite an order allowing the inhaler to be kept at the bedside. Staff confirmed that a care plan should have been initiated for self-administration of medication. Similarly, Resident 9 had an Afrin nasal spray for unsupervised self-administration, but no care plan was in place, contrary to the facility's policy. Resident 29, diagnosed with dysphagia following a stroke, had a care plan requiring supervision during meals to prevent aspiration. However, staff left the resident unsupervised with a breakfast tray, contrary to the care plan's directives. Staff interviews confirmed the expectation for one-on-one supervision during meals, which was not followed, placing the resident at risk of aspiration.
Safety and Supervision Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure the safety of the first-floor hallway carpet and provide adequate supervision for a resident, leading to potential accident hazards. Observations revealed multiple areas of bubbling in the carpet, creating bumps that residents had to navigate over, posing a tripping risk. Staff interviews confirmed awareness of the issue, with attempts to address it being delayed due to pending corporate actions. The Executive Director acknowledged the safety concern, noting that the facility primarily serves short-term rehabilitation residents who frequently use the hallways for therapy. Additionally, the facility did not provide the required supervision for Resident 29, who was at high risk for aspiration due to dysphagia following a stroke. Despite care plan instructions for one-on-one supervision during oral intake, Staff N left the resident's breakfast tray unsupervised, allowing the resident to drink independently. Staff interviews confirmed the need for strict adherence to the care plan, emphasizing the importance of supervision to prevent aspiration. The Director of Nursing reiterated the expectation for staff to follow care plans and not leave food or fluids within the resident's reach without supervision.
Expired and Improperly Labeled Medications Found in Medication Carts
Penalty
Summary
The facility failed to ensure that expired medications were disposed of in a timely manner and that drugs were properly labeled and stored according to current accepted professional standards. During an observation of the first floor Team 1 medication cart, several expired medications were found, including Senna plus, Iron, Bisacodyl, Aspirin, Vitamin D3, and Fish oil. Additionally, a bottle of Tylenol liquid was not labeled with the date it was opened or the date it should be discarded. Staff U, an LPN, acknowledged that the expired medications should have been discarded and that liquid medications should have been labeled with the date they were opened. Similarly, an observation of the first floor Team 2 medication cart revealed expired medications such as Vitamin D3, Aspirin, Fexofenadine hydrochloride, and Melatonin. A bottle of Lactulose solution was also found without a label indicating when it was opened or when it should be discarded. Staff V, an RN, confirmed that the expired medications should have been discarded and that liquid medications should have been labeled upon opening. The Director of Nursing, Staff B, stated that the facility's expectation was for expired medications to be discarded and for liquid medications to be labeled when opened.
Facility's Ineffective Resource Management Leads to Hazardous Carpet Conditions
Penalty
Summary
The facility failed to manage its resources effectively to maintain the residents' highest practicable physical, mental, and psychosocial well-being, as evidenced by the poor condition of the carpet in the first-floor hallways. Observations revealed multiple areas of bubbling in the carpet, creating potential hazards for residents, particularly those using mobility aids such as walkers and canes. Staff interviews confirmed the presence of these hazards, with one staff member noting that residents had to lift their feet to navigate the uneven carpet, increasing the risk of tripping. The facility's Executive Director acknowledged awareness of the carpet issue, which had been ongoing for several months. Despite attempts to address the problem, including contacting corporate for quotes to repair or replace the carpet, there was a lack of follow-through, as the corporate office claimed not to have received or could not find the quotes. This inaction left the hazardous carpet condition unaddressed, posing a risk to residents, particularly those undergoing short-term rehabilitation and using the hallways for therapy.
Infection Control Deficiencies in Hand Hygiene and EBP Implementation
Penalty
Summary
The facility failed to ensure proper hand hygiene practices and the use of gloves by staff members during resident care and meal tray delivery. Observations revealed that Staff K, an LPN, did not perform hand hygiene before entering resident rooms or after removing gloves while delivering meal trays. Similarly, Staff G, responsible for scheduling and staff development, did not perform hand hygiene before glove use when assisting residents. Interviews with the staff confirmed their awareness of the hand hygiene protocols, yet these were not consistently followed, as expected by the facility's infection preventionist and director of nursing. The facility also failed to implement Enhanced Barrier Precautions (EBP) for residents with indwelling catheters, which are necessary to protect against multidrug-resistant organisms. Residents 37, 193, and 5, all of whom had indwelling urinary catheters, did not have EBP signage on their doors, and staff did not wear gowns during high-contact care activities. Observations showed that catheter tubing was often touching the floor, contrary to the facility's catheter care policy. Interviews with staff indicated a lack of awareness regarding EBP requirements and the absence of a policy for EBP implementation. Resident 37's catheter tubing was observed touching the floor multiple times, and staff did not wear gowns during high-contact care. Similarly, Resident 193 and Resident 5, both with indwelling catheters, were not placed on EBP, and staff did not consistently perform hand hygiene between glove changes. The facility's failure to adhere to infection control protocols and implement EBP for residents with indwelling catheters increased the risk of infection for residents, staff, and visitors.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to inform a resident and/or their representative before administering psychotropic medications, specifically antidepressant and antianxiety medications. This deficiency was identified during a review of the facility's policy on psychotropic drug utilization, which mandates obtaining informed consent prior to the administration of such medications. The policy, last updated in November 2017, requires licensed staff to secure informed consent when a psychoactive medication is indicated in the plan of care. Resident 5, who was admitted to the facility with moderately impaired cognition, was receiving both antidepressant and antianxiety medications as per the order summary report. However, a review of the resident's electronic health record revealed that informed consent for these medications was not documented. During interviews, both a Licensed Practical Nurse and the Director of Nursing confirmed that informed consent should have been obtained and documented before administering the medications. Despite a verbal consent being mentioned, it was not recorded in the electronic health record or on a hard copy consent form.
Failure to Assess and Obtain Orders for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents were properly evaluated and assessed for self-administration of medications, and did not obtain the necessary physician orders for two residents. Resident 193 was observed with a Ventolin FHA inhaler and Stiolto Respimat inhaler on their bedside table without a completed self-administration assessment or a physician's order for the Stiolto Respimat. Despite the presence of an order for the Ventolin FHA, the assessment was incomplete, and the medications were left at the bedside, contrary to the facility's policy. Similarly, Resident 34 had Aspercreme and Xylimelts on their bedside table, which were their home medications. Although the resident claimed these were cleared by a doctor, there was no documented order or assessment for self-administration in their electronic health record. Staff interviews confirmed that medications should not be at the bedside without an assessment and order, highlighting the facility's failure to adhere to its policy and placing residents at risk for medication errors.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident, identified as Resident 7, to the State Agency as required. The facility's policy mandates that all alleged violations involving abuse, neglect, exploitation, or mistreatment must be reported immediately, or within 24 hours if the violation does not involve abuse and has not resulted in serious injury. Despite this, the facility did not report the incident involving Resident 7, who felt threatened by the food served to them after they complained about it. Resident 7, who was cognitively intact, reported to a registered nurse that they received 'throw away food' and 'goopy' food, which they considered a threat. The resident expressed fear regarding the situation. However, the facility's administrator, Staff A, stated that they were not informed of Resident 7 feeling threatened or afraid. Staff A mentioned that the resident only complained about the quality of the food, such as the casserole and meatloaf having fillers, and did not use terms like 'goopy' or 'throw away food.' The facility's incident log did not document Resident 7's concerns of feeling threatened or afraid, although the grievance log did note a grievance related to food and fear. Staff A admitted that they did not report the incident to the State Agency, as they interpreted the guidelines to mean that it was not necessary due to the lack of harm. However, upon reviewing the guidelines, Staff A acknowledged that the incident should have been reported and logged as an incident.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to identify and thoroughly investigate an abuse allegation involving a resident who was cognitively intact. The resident reported feeling threatened and afraid after receiving what they described as 'throw away food' and 'goopy food' following complaints about the facility's food. The resident communicated these concerns to a registered nurse and later to the dietary manager. However, the administrator, who was aware of the resident's food complaints, did not initially recognize these concerns as an abuse allegation. The administrator stated that the resident never expressed feeling threatened or afraid during their conversations. The facility's incident log did not document the resident's concerns, although the grievance log did note a grievance related to food and fear. The administrator acknowledged that an investigation was not conducted and that the process for reporting and investigating abuse was not followed. The administrator admitted that they should have completed an investigation report and logged the incident in the facility's incident reporting log. The failure to investigate the resident's concerns placed the resident at risk for repeated incidents and unidentified abuse.
Failure to Provide Written Notice of Transfer
Penalty
Summary
The facility failed to provide written notice of transfer or discharge to a resident and their representative, as well as to the Office of the State Long Term Care Ombudsman, as required by their policy. This deficiency was identified during a review of the case of a resident who was transferred to an acute hospital. The facility's policy, dated June 2018, mandates that written notice be given to the resident and/or their representative, and a copy sent to the Ombudsman, especially when an immediate transfer is necessitated by urgent needs. However, the clinical health record lacked documentation of such written notice for the resident in question. Interviews with various staff members, including registered nurses, licensed practical nurses, and social services personnel, revealed that the facility's practice was to notify families verbally when residents were transferred to the hospital. The staff admitted that they did not provide written notifications. Additionally, the receptionist responsible for notifying the Ombudsman by fax on a monthly basis failed to include the resident in question on the list of discharged residents. The Executive Director confirmed that the nurses were responsible for notifying families and acknowledged that the Ombudsman was not notified about the resident's transfer.
Failure to Timely Transmit Resident Assessment Data
Penalty
Summary
The facility failed to transmit resident assessment data to the Centers for Medicare & Medicaid Services within the required timeframe for one resident, identified as Resident 30, who was reviewed for discharge assessments. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, discharge Minimum Data Set (MDS) assessments must be completed no later than 14 days after the discharge date and submitted within 14 days of the MDS completion date. Resident 30 was discharged to a community, but a review of their MDS schedule on October 9, 2024, revealed that the discharge MDS was not completed, making it 87 days late. In a phone interview, Staff H, an MDS Registered Nurse, acknowledged that the discharge MDS for Resident 30 was not completed and was missed. Staff H stated that typically, the discharge MDS would be completed within 14 days from the discharge date and transmitted within the week. The Director of Nursing, Staff B, confirmed the expectation for timely completion of discharge MDS assessments.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to accurately assess two residents using the Minimum Data Set (MDS) assessment tool, which is crucial for identifying and meeting residents' care needs. Resident 5, who was admitted with an indwelling catheter, was incorrectly coded as occasionally incontinent in the MDS, contrary to the RAI manual's instructions to code such cases as 'not rated.' This error was identified during a joint record review and interview with the MDS Registered Nurse, who acknowledged the inaccuracy and indicated that the assessment would be modified. Resident 40's discharge status was inaccurately recorded in the MDS as discharged to an acute hospital, while nursing progress notes and a joint record review confirmed the resident was discharged to an Assisted Living Facility. This discrepancy was also recognized by the MDS Registered Nurse during a review of the electronic health record. The Director of Nursing expressed an expectation for staff to adhere to the RAI manual and ensure MDS accuracy, highlighting the facility's responsibility to conduct precise assessments.
Failure to Conduct Required PASARR Level II Evaluation
Penalty
Summary
The facility failed to properly review and validate the Preadmission Screening and Resident Reviews (PASARR) for a resident with a diagnosis of bipolar disorder. The resident's Level I PASARR, dated November 2, 2023, indicated a positive result for Serious Mental Illness/Intellectual Disabilities (SMI/ID) due to the diagnosis of bipolar disorder. However, the PASARR documentation did not show that a Level II evaluation was indicated or that a referral for such an evaluation was sent, as required by the updated guidance from the Department of Social and Health Services. Interviews with facility staff revealed a lack of adherence to the updated PASARR guidance. Staff F, responsible for reviewing PASARRs upon resident admission, did not ensure the accuracy and completion of the Level I PASARR, which should have led to a Level II referral. Additionally, Staff A, the Executive Director, acknowledged awareness of the new PASARR guidance but failed to ensure its implementation, resulting in the oversight. This deficiency placed the resident at risk of not receiving appropriate care and services tailored to their needs.
Failure to Conduct Timely Care Conferences for Residents
Penalty
Summary
The facility failed to conduct care conferences for two residents, which is a requirement to be completed within seven days of admission according to the facility's policy. Resident 37 was admitted to the facility, but a review of their electronic health record showed no documentation of a care conference. Interviews with the resident's representative and staff confirmed that no care conference had been held. Staff F, responsible for scheduling these conferences, acknowledged the oversight and stated that the resident should have had a care conference. The Director of Nursing and the Executive Director both expressed that care conferences are expected to be held within the stipulated timeframe. Similarly, Resident 193, who was admitted to the facility, did not have a care conference documented in their records. The resident confirmed that no care conference had been conducted since their admission. Staff F, during a joint record review, confirmed the absence of a care conference for this resident as well. The Executive Director reiterated the expectation that care conferences should occur within seven days of admission. This failure to conduct timely care conferences placed the residents at risk of not having input regarding their care goals and unmet needs, potentially affecting their quality of life.
Medication Administration and Monitoring Deficiencies
Penalty
Summary
The facility failed to ensure proper medication administration practices were followed, leading to deficiencies in care. A registered nurse, Staff T, did not prime an insulin pen before selecting a dose of 6 units for Resident 195, contrary to the manufacturer's instructions. This oversight was acknowledged by Staff T during an interview, and the Director of Nursing confirmed that the expectation was for nurses to prime the insulin pen before dose selection. Additionally, medications were left unattended for Resident 10, as observed when two medication cups with crushed medications in applesauce were found on the resident's bedside table without a licensed nurse present to ensure the medications were taken. Staff V, an RN, confirmed that leaving medications unattended was not acceptable, and this was reiterated by Staff J, an LPN/Charge Nurse, and Staff B, the Director of Nursing. Furthermore, the facility did not consistently check vital signs before administering blood pressure medication to Resident 25, who had a diagnosis of hypertension. The resident's medication administration record indicated that Carvedilol should be withheld if the systolic blood pressure was less than 100 or the heart rate was less than 55. However, vital signs were only documented once a day, despite the medication being administered twice daily. Staff U, an LPN, and Staff J confirmed that vital signs should be taken before each administration of blood pressure medication, and Staff B stated that this was the facility's expectation.
Failure to Provide Nail Care and Wheelchair Transfer Assistance
Penalty
Summary
The facility failed to provide necessary assistance with nail care and wheelchair transfer for Resident 20, who was admitted with diagnoses including diabetes, muscle weakness, and a need for assistance with personal care. Observations over several days showed that Resident 20's fingernails were long, untrimmed, and had brown debris underneath, with a split nail on the left thumb. Despite Resident 20 expressing discomfort and a desire for nail care, there was no documentation of nail care being scheduled or provided, particularly important due to the resident's diabetes diagnosis, which requires licensed nurses to perform such care. Additionally, the facility did not document any wheelchair transfers for Resident 20, despite the care plan indicating a need for substantial assistance with chair/bed-to-chair transfers. Interviews with staff revealed that fingernail care was not scheduled on the Treatment Administration Record (TAR) for October 2024, and there was no indication that Resident 20 refused care. The Director of Nursing expected nail care to be provided weekly by licensed nurses and for nurse aides to assist with transfers, but these expectations were not met, leading to the deficiency.
Failure to Administer PRN Medication and Follow Bowel Protocol
Penalty
Summary
The facility failed to provide care and services consistent with professional standards for a resident experiencing significant weight gain and the use of diuretic medication. Resident 20, who was admitted with a diagnosis of heart failure, had a significant weight gain of 12 pounds over three days. Despite having a PRN order for Torsemide to address fluid retention, edema, or weight gain, no action was taken to administer the medication or contact the physician. Staff interviews revealed that the order did not specify the amount of weight gain required to administer the medication, and the staff failed to reassess the resident or inform the charge nurse and physician about the significant weight gain. The facility also failed to implement the bowel management protocol for Resident 9, who experienced multiple episodes of constipation. The bowel protocol required the administration of Milk of Magnesia (MOM) if no bowel movement occurred in three days, followed by a Bisacodyl suppository if MOM was ineffective. Resident 9 did not have bowel movements for several days on multiple occasions, yet the MAR showed that MOM or Bisacodyl was not administered as required. Staff interviews confirmed that the bowel protocol was not followed, and there was no documentation of the resident refusing the medication. These deficiencies placed the residents at risk of unmet care needs and potential medical complications. The staff's failure to adhere to the established protocols and physician orders resulted in a lack of appropriate interventions for the residents' conditions. The Director of Nursing acknowledged the expectation for licensed nurses to follow physician orders and the bowel management protocol, highlighting the need for adherence to care standards.
Failure to Provide Consistent Restorative Services for a Resident
Penalty
Summary
The facility failed to consistently provide services to maintain or improve the range of motion (ROM) for Resident 145, who was on a restorative program due to limited ROM in the upper extremity on one side. The facility's policy required treatment and services to prevent further decrease in ROM, but documentation showed missing records for active ROM exercises and ambulation training for an entire week. Observations confirmed that Resident 145 was in bed during the times when exercises should have been conducted, and interviews with the resident revealed that no exercises had been performed with them recently. Interviews with staff highlighted that the Certified Nursing Assistant (CNA)/Restorative Aide responsible for the restorative program was often pulled to cover other duties, leading to the neglect of the restorative program. The Director of Nursing acknowledged the lack of documentation and confirmed that the restorative program was not carried out as required. This oversight placed Resident 145 at risk for a decline in ROM and unmet care needs, as the facility did not adhere to its own policy or the resident's care plan.
Failure to Properly Store and Label Nebulizer Equipment
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident by not labeling, dating, and properly storing the nebulizer treatment set and tubing. This deficiency was observed in the case of a resident with Chronic Obstructive Pulmonary Disease (COPD), who had been prescribed Albuterol Sulfate Nebulization Solution to be administered via nebulizer every four hours as needed. Observations on two separate occasions revealed that the nebulizer machine treatment set and tubing were left on top of the resident's chair without being labeled or stored in a bag, contrary to the facility's policy. During an interview, a Licensed Practical Nurse/Charge Nurse confirmed that the nebulizer treatment set and tubing should have been labeled, dated, and bagged. The Director of Nursing also stated that the nebulizer set should be changed weekly and labeled when changed, and the mouthpiece should be rinsed and stored in a bag after each use. The failure to adhere to these procedures placed the resident at risk for respiratory infections and related complications.
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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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bellevue
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Redmond Care And Rehabilitation Center | 3 mi | ★★★★★ | 1 | 0 |
| Corwin Center At Emerald Heights | 4.6 mi | ★★★★★ | 0 | 0 |
| Covenant Shores Health Center | 5.1 mi | ★★★★★ | 25 | 0 |
| Marianwood Health And Rehabilitation | 5.8 mi | ★★★★★ | 22 | 0 |
| Life Care Center Of Kirkland | 6.4 mi | ★★★★★ | 30 | 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 July 2026) and official state health department websites.