Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Belmont Terrace during CMS and state inspections, most recent first.
Failure to provide SNF ABNs for two residents whose Medicare Part A coverage had ended while they remained in the facility. Record review found no SNF ABN in either chart, and the SSD confirmed the notices were not provided because staff believed they were only needed for residents who stayed after Part A ended and became private pay.
A facility failed to maintain a homelike environment on one hall because of repeated noise from slamming doors and a resident who yelled day and night. Residents reported the kitchen, housekeeping, and SS doors were loud, staff conversations carried across the hall, and some residents kept doors shut because of the noise. Grievances and Resident Council minutes also documented ongoing complaints about kitchen noise and neighbor yelling, while the DON said they were not aware of the complaints and did not know how to fix the slamming doors.
A resident was transferred to the hospital without documentation that a bed hold was offered, and two residents had incomplete transfer communication records. For one resident, multiple hospital transfers lacked documentation of report to the receiving facility or an e-interact transfer form; for another resident, the transfer form documented report to 911 instead of the receiving hospital and did not show what documents were sent with the resident.
A resident reported missing insulin doses, and the MAR and progress notes contained conflicting documentation that prevented confirmation of whether Tresiba was actually given. Two other residents did not receive ordered care: one on continuous O2 was observed without the ordered humidifier, and another went 6 days without a BM before PRN bowel meds were given. The facility also failed to obtain ordered daily weights or document edema monitoring for a resident with renal disease and diuretic use, and no PT eval was completed for a resident’s wheelchair fit despite an order to assess it.
Restorative nursing programs were not provided at the frequency assessed for multiple residents. Several residents with ordered walking, gait training, or active ROM programs had fewer restorative sessions documented than planned, and one resident with limited mobility was not receiving restorative therapy 3x/week because the restorative aide had other duties and was pulled to cover direct care; the DON confirmed the therapy was not being offered as scheduled.
Insufficient staffing led to delayed resident care, missed showers, limited restorative services, and poor meal supervision. Residents reported long waits for call light response, delayed pain meds, and shower schedules changing without notice, while a dining room observation found trays being passed by a resident’s relative because no staff were present. Records showed shower aides and the restorative aide were repeatedly pulled to cover other duties, and the DON confirmed staffing shortages affected showers and restorative care.
Failure to complete CNA annual performance reviews. Three sampled CNAs had no annual performance review completed for their review periods, and the DON stated that none of the CNA annual performance reviews were completed as required.
Food and drink were not prepared or served at proper temperatures or in a palatable manner. A cook prepared pureed carrots and pork without following a recipe, adding unmeasured water and blending the food before placing it on the steam table. A dietary aide placed beverages on trays too early, and a cup of milk on a tray cart measured 56.5 degrees. A cognitively intact resident was also told by a CNA to wait for a weight check before eating breakfast and was left waiting over 45 minutes, leaving the resident with a cold meal and no morning coffee.
Failure to implement TBP and PPE use for symptomatic residents and a resident on contact precautions. Staff entered a resident’s room on contact precautions without gown or gloves and had direct contact with the resident and environment. Three other residents had cough and congestion documented in nursing notes, but there was no EHR documentation or room signage showing TBP was initiated, and one resident was seen in the hallway without a mask. The IP RN stated TBP should have been in place while infectious causes were being ruled out.
Failure to obtain proper consent for antipsychotic medication: A resident with vascular dementia, depression, and severe cognitive impairment was ordered Olanzapine for hallucinations. The consent form listed risks and a black box warning, but the surrogate consent section was blank and the resident signed as if able to consent. The DON confirmed the record did not show family contact and said this did not meet expectations.
Inaccurate MDS coding affected multiple residents when oral findings, active diagnoses, PASRR status, and restorative services did not match the record. One resident’s MDS missed documented oral pathology and coded anxiety without supporting EMR documentation; another resident’s MDS omitted respiratory failure and COPD; a third resident’s PASRR-related status was not reflected on admission MDSs; and a fourth resident’s restorative nursing documentation was not completed as expected around the MDS process.
PASRR screening was not completed or updated accurately for two residents. One resident’s Level 1 PASRR listed anxiety disorder but omitted depression, even though the resident also had depression and severe cognitive impairment. Another resident’s Level I PASRR identified an intellectual disability and required forwarding to the DDA PASRR Coordinator, but there was no documentation that this was done or that a Level II eval was requested when the resident did not discharge within 30 days.
Incomplete and non-individualized care plans were found for multiple residents. A resident on continuous O2 had no O2 care plan, another resident with dementia frequently refused morning care and was often left partially unclothed without those refusals being documented or fully care planned, and a resident with COPD, acute hypoxemic respiratory failure, and O2 use had no care plan for those needs. Additional care plans failed to address autism, PASRR status, obstructive uropathy, psychotropic medication goals, and documented oral/jaw conditions.
Missed Weekly Showers for a Resident: A resident who was cognitively intact and dependent for ADLs was care planned for one shower weekly and as necessary, but bathing records and progress notes showed missed or delayed showers, including a missed shower after the resident declined one bath and another missed shower due to CNA time constraints. The resident stated they had only one shower since admission and said they were not refusing showers. Staff, including the RCM and DON, confirmed the resident was not receiving a shower once a week.
Failure to Post Daily Nurse Staffing Information: The facility did not consistently post the daily nurse staffing sheet to show the actual nursing staff hours worked on multiple days. Surveyors observed the posting outside the therapy room was outdated and did not include current staffing information, and the DON confirmed the sheet should have been updated daily.
Menu items were not followed as posted, and a cook prepared different entrées and a different dessert than listed, including pureed pork and carrots instead of the planned pureed meal and canned fruit cocktail instead of the diet-specific dessert. The Dietary Supervisor confirmed substitutions were made without RD approval or resident notification, and tray line observation showed two residents ordered for small portions received full portions while two residents ordered for large portions received double portions.
Surveyors found that the facility did not follow through on recommended gradual dose reductions for psychotropic medications for three residents. In each case, the consulting pharmacist's recommendations were accepted by providers, but either the medication was discontinued without proper communication, or no action was taken to adjust the medication orders, resulting in continued administration of the original doses. Staff interviews confirmed that these recommendations were not properly implemented.
Two residents with inconsistent documentation of urinary continence did not receive timely reassessment or updated interventions, despite changes in their bladder status and related care needs. Staff were unable to specify the type of incontinence or explain the lack of follow-up, and care plans were not updated to reflect current conditions.
A resident with chronic pain conditions was discharged with only a limited supply of prescribed oxycodone and no prescription for continued pain management, resulting in unmanaged pain until the resident could see a community provider. The DON confirmed that a prescription should have been provided, but this was missed during the discharge process.
A resident with respiratory failure and COPD was discharged with antibiotics, but the facility did not document end dates for the medications or communicate discontinuation instructions. The resident was sent home with a large quantity of antibiotics remaining and reported confusion about their use. The DON confirmed that end dates and communication were lacking.
A resident with respiratory failure and COPD, who had signed consent to receive the pneumococcal vaccine, was not administered the vaccine. The DON confirmed that, despite the completed consent, the vaccine was not given and there was no documentation of administration.
A resident with respiratory failure and COPD, who had signed consent to receive the COVID-19 vaccine, was not provided the vaccine. The DON confirmed that despite the resident's documented consent, the vaccine was not administered and there was no record of vaccination.
The facility failed to provide Advanced Directives (ADs) for four residents, compromising their right to have healthcare preferences honored. A resident signed an AD receipt but had no prior assistance in formulating one. Three other residents had no ADs or receipts documented in their EHRs, despite being cognitively intact or moderately impaired. Staff confirmed that ADs should have been completed upon admission but were not.
The facility failed to maintain a safe and homelike environment due to worn, stained, and poorly maintained carpets in the Olympic, Mountainview, and Medicare hallways. Observations showed issues like mismatched carpet patches and loose carpet squares, compromising the environment for residents. Staff acknowledged the problem and cited bureaucratic challenges in addressing it.
A facility failed to properly document and address grievances from a resident and the Resident Council. A resident's grievances about lack of services due to staff shortages were not logged or addressed promptly. The Resident Council also reported that their grievances were not consistently resolved, with several concerns not filed as grievances. Staff confirmed these issues should have been documented.
The facility failed to provide written transfer or discharge notices to four cognitively intact residents who were hospitalized, as required by policy. Staff interviews confirmed the absence of these notices, which placed residents and their representatives at risk of not making informed decisions about their transfers or discharges.
The facility failed to provide bed hold notices to three residents during hospital transfers, as required. Despite being cognitively intact, these residents were transferred without proper documentation in their EHRs, as confirmed by the DNS. This oversight risked the residents' ability to make informed decisions about their bed hold status.
The facility failed to ensure accurate MDS assessments for several residents, leading to potential risks for unmet care needs. Errors included incorrect documentation of weight loss programs, unrecorded significant weight loss, misclassification of medical devices, and missing active diagnoses despite medication use. These inaccuracies were acknowledged by facility staff.
The facility failed to ensure accurate and updated care plans for several residents, leading to discrepancies in bathing preferences, psychotropic drug use documentation, and intake/output monitoring. One resident's care plan did not reflect their current abilities or goals, and there was a discrepancy in their nutritional care plan regarding water intake. These issues highlight a lack of proper care plan management and documentation.
The facility failed to provide restorative services at the required frequency for six residents, leading to a deficiency in maintaining or improving their range of motion and mobility. Staffing issues were a significant factor, as the Restorative Aide was often pulled to work the floor, resulting in incomplete restorative programs. The Administrator acknowledged the staffing shortage, which affected the provision of necessary services, placing residents at risk for decreased ROM and other complications.
Expired medications and supplies were not removed from a medication storage room, including items like blood glucose lancets, ibuprofen, and a vaccine vial. Staff indicated that nursing staff were responsible for managing these items, but they were not removed by their expiration dates.
The facility did not seek Resident Council approval or provide bedtime snacks when extending the meal interval from 14 to 15 hours. Residents in various halls experienced a 15-hour gap between dinner and breakfast. The DON confirmed the lack of documentation for approval and stated that only diabetic residents were routinely given bedtime snacks, though snacks were available upon request.
The facility failed to follow infection control protocols, including improper use of PPE for a resident with a gastric tube, cross-contamination risks with PPE and food carts, and inadequate hand hygiene and equipment handling for residents with catheters and wound treatments. Staff acknowledged these practices did not meet expectations.
Three residents who consented to receive pneumococcal vaccines did not receive them due to the facility's failure to order and administer the vaccines. Staff acknowledged the oversight, which did not meet the facility's expectations.
The facility failed to maintain emergency fire doors in working order, with a loose metal piece in the floor causing significant difficulty in opening the doors. Staff and a resident using a walker struggled to open the door due to the resistance. Attempts to fix the issue included gluing the metal piece, but the problem persisted.
The facility failed to provide scheduled bathing and shaving assistance to several residents, leading to significant gaps in personal hygiene care. Residents reported dissatisfaction with the lack of services, and documentation confirmed extended periods without bathing or shaving, despite care plans indicating the importance of these activities. Staff acknowledged the oversight and the absence of specific documentation for these tasks.
The facility failed to administer the correct enteral formula volume to a resident, did not monitor fluid intake accurately for residents on fluid restrictions, and did not identify significant weight loss in a timely manner. These deficiencies involved residents with conditions such as malnutrition, kidney disease, and heart failure, leading to risks of inadequate nutrition and fluid imbalances.
The facility experienced significant staffing shortages, leading to unmet care needs and diminished quality of life for residents. Residents reported long wait times for assistance with ADLs, while staff confirmed being overworked and unable to complete daily tasks. The lack of sufficient staff affected the provision of restorative and bathing services, as aides were frequently reassigned to cover other duties. Facility leadership acknowledged the staffing issues and their impact on resident care.
The facility failed to provide meals that were appetizing and served at appropriate temperatures, as reported by several residents. Observations showed delays in meal delivery and improper handling of beverages, leading to meals being served cold. Residents expressed dissatisfaction with the taste, texture, and variety of the food, and their meal preferences were not always honored.
The facility failed to provide prescribed therapeutic diets and correct portion sizes to residents, affecting their nutritional needs. Dietary staff placed tartar sauce on trays for residents with restricted diets and used incorrect spoodle sizes for portion control, leading to potential medical complications. The dietary manager confirmed these practices but did not take corrective action.
The facility failed to ensure effective communication and coordination with hospice providers for two residents, lacking current hospice care plans and documentation of visits and services in the EHR. Staff acknowledged communication issues and were in the process of improving documentation, but deficiencies persisted.
The facility failed to respect residents' privacy by not knocking or announcing themselves before entering rooms. Staff, including a CNA and housekeeping, entered rooms without notice, contrary to the facility's policy on resident rights. This repeated failure was acknowledged as unacceptable by the Resident Care Manager and the DON.
A resident with depression and dementia was prescribed risperidone, but the facility used incorrect consent forms with varying side effects listed. Additionally, venlafaxine was administered before obtaining consent. The Resident Care Manager and Director of Nursing Services acknowledged the expectation for correct classification and prior consent.
The facility failed to honor the bathing preferences of two residents, both of whom were cognitively intact and had identified their bathing choices as very important. One resident reported dissatisfaction with the quality of the shower received, while the other preferred more frequent showers than scheduled. The care plans did not reflect the residents' preferences, and there was no documentation in the EHR to show efforts to support resident choice. Staff indicated that residents were initially assigned one shower per week, with potential adjustments based on feedback.
The facility failed to ensure accurate PASRR documentation and timely Level II referrals for two residents, impacting their access to mental health services. One resident's PASRR inaccurately documented an anxiety disorder instead of depression, and another resident's PASRR was incorrectly updated to indicate a mood disorder. Staff confirmed these discrepancies, highlighting a lapse in the facility's processes.
The facility failed to develop comprehensive care plans for two residents, leading to potential risks for unmet care needs. One resident lacked care plans for activities and edema, and had an incorrect wound treatment site listed. Another resident had no care plan for their PICC line, despite receiving IV antibiotics. Staff interviews confirmed unmet care planning expectations.
A resident with moderate hearing difficulty did not receive complete earwax removal treatment, as the facility staff failed to flush the ears after administering Debrox ear drops. The care plan directed staff to administer ear drops and communicate effectively, but the medication records lacked instructions for ear flushing. The DON acknowledged the oversight, which left the resident with clogged ears and hearing issues.
A resident with sepsis and cellulitis was admitted with a PICC for IV antibiotics, but the facility failed to provide specific orders for the central line or a care plan. The EHR lacked administration rates for the antibiotics, and staff interviews revealed missing measurements and dressing change orders, leading to potential risks.
The facility failed to follow physician orders for two residents requiring dialysis care, specifically regarding post-dialysis fistula access care. A resident with End Stage Renal Disease was removing their own pressure dressing without documented training or authorization, leading to a hospital transfer due to bleeding. Staff interviews confirmed the absence of necessary documentation and adherence to care plans.
A facility failed to act on a pharmacist's Medication Regimen Review (MRR) recommendations for a resident with malnutrition and gastrostomy status. The MRR advised that Carafate, which could affect the absorption of other medications, be given on an empty stomach and separate from other medications. However, the resident's medication schedule showed Carafate and oxycodone were administered together, with no documentation of the MRR being reviewed or implemented.
Failure to Provide SNF ABNs
Penalty
Summary
The facility failed to ensure that Skilled Nursing Facility Advanced Beneficiary Notices (SNF ABNs) were provided for 2 residents whose Medicare Part A covered stays had ended while they remained in the facility. Resident 56’s Medicare Part A stay began on 11/07/2025 and had a last covered day of 01/21/2026, and Resident 18’s Medicare Part A stay began on 12/24/2025 and had a last covered day of 01/29/2026. Record review found no SNF ABN in either resident’s record. During interview on 02/26/2026 at 4:13 PM, the Social Services Director stated that no SNF ABN was provided to Resident 56 and that a SNF ABN was not provided to Resident 18 because staff believed SNF ABNs were only given to residents whose Medicare Part A services ended, who remained in the facility, and who were private pay.
Noise and Door Slamming Disrupted a Homelike Environment
Penalty
Summary
The facility failed to maintain a homelike environment on Mountain View Hall because of repeated noise issues involving slamming doors and resident yelling. Residents reported that the kitchen door, housekeeping door, and social services door were slamming shut, and one resident said the kitchen staff were very loud and conversations could be heard from across the hall. Another resident said the hall did not feel like home because of the yelling and door slamming, and residents reported keeping doors shut because of the noise. A resident also reported that another resident yelled all day and all night, and another resident said a resident on the hall continued to scream all day and night to the point that the resident yelled back. Observations on Mountain View Hall documented multiple instances of the kitchen door, housekeeping door, social services door, and a resident room door slamming shut as staff entered and exited. Grievances from the prior six months included complaints about noise outside the kitchen, a neighbor yelling, and noise concerns about a next-door neighbor. Resident Council minutes also documented a complaint that there was too much noise coming from the kitchen, including voices, banging, and dishes echoing throughout the hall. When interviewed, the DNS said they were not aware of complaints about the noise levels and stated there had been complaints about doors slamming, but they did not know how to fix the issue.
Failure to Offer Bed Hold and Communicate Transfer Information
Penalty
Summary
The facility failed to offer a bed hold when Resident 7 was transferred to an acute care hospital. Review of the 01/20/2026 discharge MDS showed the resident was transferred with return anticipated, and the EHR contained no documentation that a bed hold was offered. When asked on 03/02/2026, the DNS/RN stated there was no documentation showing Resident 7 was offered a bed hold. The facility also failed to communicate required information to the receiving hospital for Resident 7 and Resident 80 during hospital transfers. Resident 7 was transferred to the hospital on three separate occasions, and for each transfer the EHR showed no documentation that staff called report to the receiving hospital, no e-interact transfer form was completed, and no documentation identified what, if any, documents were sent with the resident. For Resident 80, the e-interact transfer form documented report was called to 911 rather than the receiving facility, and the section for documenting what papers were sent with the resident and EMT acknowledgment was not completed. The DNS stated there was no documentation that staff called report to the receiving hospital or identified what documents were sent with Resident 80.
Missed insulin, bowel care, oxygen setup, and ordered monitoring not completed
Penalty
Summary
Quality of care was not provided according to orders for insulin administration for a cognitively intact resident who reported missing 3 days of Tresiba because the facility did not have it in supply. Review of the February 2026 MAR and progress notes showed contradictory documentation: the MAR indicated the insulin was given on the dates in question, while progress notes documented that Tresiba had not been given and that it was unavailable on some dates. During interview, the DNS and LPN/RCM reviewed the records and could not confirm whether the resident actually received the medication, and the DNS stated the expectation was for staff to contact the provider when medication was unavailable. Quality of care was also not provided for bowel management and oxygen administration. One cognitively intact resident on continuous oxygen therapy was observed receiving oxygen by nasal cannula at 2 L/min without a humidifier, despite an order to change the oxygen humidifier every Sunday on night shift. Staff later acknowledged the resident did not have a humidifier at the bedside, and the DNS stated the resident did not need one because the oxygen was at 2 L, although the order did not say that. Another resident with constipation had standing PRN bowel orders for MiraLax, bisacodyl suppository, and Fleet enema, but went 6 days without a bowel movement before PRN bowel medication was administered. The DNS confirmed the resident did not receive MiraLax after 3 days without a bowel movement as ordered. The facility also failed to complete ordered monitoring and evaluation for edema, weight changes, and wheelchair fit. One resident with renal disease and diuretic use had orders for daily weights for 3 days and weekly weights for 4 weeks, but the treatment record showed the daily weights were left blank, and there was no documentation to monitor edema or notify the provider after a 10.4 lb weight gain in 10 days. The resident later developed significant shortness of breath, 4+ pitting edema, and coarse breath sounds and was transferred to the hospital. Another resident who used a manual wheelchair reported the chair was too small and had been waiting about a year for a new one; although there was an order for PT to evaluate whether the chair was appropriate, the Rehabilitation Director confirmed no evaluation was completed and no documentation was found.
Restorative nursing programs not provided at assessed frequency
Penalty
Summary
The facility failed to ensure restorative nursing programs were provided at the frequency residents were assessed to require for 6 of 7 residents reviewed for restorative services. Resident 15 had a restorative walking program with a front wheeled walker for 15 minutes as tolerated up to three times per week and an active ROM program to both upper and lower extremities using the Omni cycle for 15 minutes as tolerated up to three times per week, but over a 28-day review period the walking program was offered/provided only two times with one refusal and the active ROM program six times with no refusals. Resident 26 had a restorative gait training program up to 20 feet and an active ROM program using the Omni cycle, both up to three times per week, but the documentation showed the gait training program was offered three times with one refusal and the active ROM program six times with one refusal. Resident 30 had a walking program and active ROM program, both up to three times per week, but the walking program was offered six times and the active ROM program seven times with one refusal. Resident 32 had an active ROM program using the Nu-step up to three times per week, but it was offered eight times with two refusals. Resident 9 had an active ROM program using the Nu-step or Omni cycle up to three times per week, but it was offered three times with one refusal. Resident 24’s record showed limited physical mobility related to impaired balance, impaired mobility, and weakness, with restorative interventions for an Omni cycle program and a walking program up to three times per week. The 30-day reviews showed the resident walked four times and participated in active ROM three times during the review periods, with one refusal documented for walking and no refusals documented for active ROM. During interview, the restorative aide said Resident 24 was scheduled for restorative therapy three times a week but did not receive it three times a week because the aide had other duties and was pulled to the floor to cover direct nursing care. The DON stated Resident 24 was not receiving restorative therapy three times a week and was not refusing, and that restorative therapy was not being offered three times a week.
Insufficient Staffing Affected Resident Care, Showers, Restorative Services, and Meal Supervision
Penalty
Summary
The facility failed to provide sufficient nursing staff every day to meet resident needs and to have a licensed nurse in charge on each shift. Based on resident interviews, staff interviews, resident council input, and record review, residents reported long waits for assistance, missed or delayed showers, delayed pain medication, and delayed response to call lights. Resident interviews described call light waits ranging from 30 minutes to an hour, with one resident reporting that on night shift no one would respond and they had to go into the hall to find staff. Another resident reported only one shower since admission, and another said shower days were changed without notice. Dining supervision was also affected by staffing shortages. During observation, the meal cart had been delivered to the Garden dining room and no staff were present; a resident’s relative was passing meal trays to residents because food was getting cold. Staff stated the Garden dining room was a supervised eating area, that a shower aide usually helped pass trays, and that there was no shower aide available that day. Resident council minutes also documented concerns that aides were short during meal times, that residents were not assisted with eating, and that residents were not being notified when shower aides were pulled from their duties. Record review showed shower aides were repeatedly pulled from shower assignments to cover floor staffing needs, and the restorative aide/driver was frequently used for resident transportation instead of restorative duties. Staff documented multiple February dates when shower aides were pulled to cover units and 17 of 20 days when the restorative aide had transportation duties. Staff confirmed that restorative services and showers were both affected by insufficient staffing and that shower aides were pulled to cover other duties on the floor. Grievances and resident council minutes also reflected ongoing concerns about missed showers, delayed care, late meals, rude staff interactions, and call lights not being answered in a timely manner.
Failure to Complete CNA Annual Performance Reviews
Penalty
Summary
The facility failed to routinely complete CNA annual performance reviews for 3 of 5 sampled nursing assistants reviewed for performance reviews. Staff I, a CNA hired on 12/27/2024, had no annual performance review completed for the 12/2024-12/2025 review period. Staff J, a CNA hired on 08/07/2024, had no annual performance review completed for the 08/2024-08/2025 review period. Staff K, a CNA hired on 07/29/2024, had no annual performance review completed for the 07/2024-07/2025 review period. On 02/27/2026 at 10:50 AM, the DON stated that none of the CNA annual performance reviews were completed for their review periods and that they should have been.
Food Preparation and Meal Service Temperature Deficiencies
Penalty
Summary
Food and drink were not prepared and served in a manner that conserved nutritive value, palatability, and appropriate temperature. During meal preparation, a cook prepared pureed carrots and pureed pork by placing unmeasured amounts of food into smaller metal containers, adding unmeasured amounts of water, and blending the mixtures without following a written recipe. The pureed foods were then covered and placed on the steam table. During tray preparation, a dietary aide placed beverages and desserts on resident trays before tray line began, and a cup of milk later checked on a tray cart was 56.5 degrees. Resident 30, who was cognitively intact per the quarterly MDS, was observed sitting in a wheelchair with a breakfast tray on a bedside table and had not eaten the meal. The resident stated a CNA told them to wait while the resident's weight was obtained, but the CNA did not return for over 45 minutes. The resident reported the breakfast was cold and said they were used to eating a cold breakfast because this happened often and they never got their morning coffee. An LPN/RCM confirmed the resident should not have been told not to eat and left waiting that long, and the DON stated it was not acceptable for a resident to be told not to eat or to wait over 45 minutes for breakfast.
Failure to Implement Transmission-Based Precautions
Penalty
Summary
The facility failed to follow and/or implement transmission-based precautions for 4 of 4 residents reviewed for TBP. The report states that staff did not ensure appropriate PPE use and did not implement TBP for symptomatic residents, and that this failure placed residents and staff at risk for cross-transmission with infectious pathogens. The facility policy required gown and gloves for contact precautions, with PPE donned on room entry and removed before exiting, and required droplet precautions for residents known or suspected to have infections transmitted by respiratory droplets. Resident 52 had an order for contact precautions and signage outside the room indicating contact precautions were in place. On 02/25/2026, an Activities staff member was observed in the resident’s room without PPE while adjusting the resident’s shirt, pushing the call light button, holding the resident’s hand, and leaning on the resident’s blankets. When questioned, the staff member stated she should have worn a gown and gloves. The Infection Preventionist stated that staff interacting with a resident on contact precautions were expected to follow the signage instructions, and that the observed interaction did not meet expectations. Resident 40 had a moist productive cough documented in nursing and alert charting notes, Resident 58 had a moist productive cough with upper lung congestion and thick yellowish-brown sputum, and Resident 17 had a cough with chest congestion and a mild non-productive congested cough. The electronic health records for these residents showed no documentation that TBP had been initiated, and observations showed no TBP signage on the room doors. Resident 17 was also observed in the hallway without a mask. The Infection Preventionist stated that while residents were being ruled out for a potentially infectious process, TBP should have been initiated, but it was not.
Failure to Obtain Proper Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident and/or the resident’s representative were informed and provided consent before an antipsychotic medication was administered. Resident 2 was admitted with diagnoses including anxiety disorder, vascular dementia, and depression. The resident’s quarterly MDS dated 02/04/2026 indicated severe cognitive impairment with inattention and disorganized thinking continuously present, and the care plan documented a need for supervision and assistance with all decision making due to impaired cognitive function and thought processes. Resident 2 had an order for Olanzapine daily at bedtime for vascular dementia with hallucinations. The EHR contained a consent form for anti-psychotic medication dated 10/31/2025 that listed side effects and a black box warning, but the section for the legal representative/surrogate decision-maker was left blank. The form indicated Resident 2 was able to understand and consent and was signed by Resident 2. During interview, the DNS stated that family, POA, and the resident would typically be involved in psychoactive medication consent, and after reviewing the record confirmed there was no progress note showing the family had been contacted and said this did not meet expectations.
Inaccurate MDS Coding for Oral Status, Diagnoses, PASRR, and Restorative Services
Penalty
Summary
The facility failed to ensure resident assessments accurately reflected residents’ health status and care needs for 4 of 20 residents whose MDSs were reviewed. The deficiencies involved inaccurate coding of oral status, active diagnoses, PASRR status, and restorative services on the MDSs for Residents 43, 80, 7, and 24. For Resident 43, the MDSs documented the resident as edentulous with no abnormal mouth tissue, ulcers, masses, or lesions, but dental consults documented exposed bone to the lower right jaw, possible osteonecrosis, and prior lower right buccal retromolar ulcers. The dental consults also instructed staff to assist with cleaning oral tissues and referenced prior notes and referral to oral surgery. Staff U, MDS Coordinator, stated the oral status on the 03/23/2025 Annual and 12/02/2025 Significant Change MDSs was inaccurate and needed modification. The same resident’s Quarterly and Significant Change MDSs also coded anxiety disorder as an active diagnosis, but the PASRR identified mood disorder and did not identify anxiety disorder, and the EMR contained no documentation showing the resident was treated or monitored for anxiety. For Resident 80, the hospital history and physical documented acute hypoxemic respiratory failure in the setting of influenza A, pneumonia, and COPD, with dyspnea worsened by obesity and rib fractures. The admission MDS did not code respiratory failure or COPD as active diagnoses, and Staff U stated both should have been coded and the MDS needed modification. For Resident 7, the admission MDSs coded autism but did not reflect the Level II PASRR recommendation for specialized services; the Level II PASRR was scanned into the EMR as a PASRR invalidation. For Resident 24, the Annual MDS documented restorative nursing programs for active ROM and transfer, while the restorative nursing summary stated continued active ROM and ambulation were needed; Staff U and the DON stated the restorative nursing assessment/summary was not completed quarterly as expected.
PASRR Screening Not Completed or Updated Accurately
Penalty
Summary
PASRR screening for mental disorders or intellectual disabilities was not completed accurately for 2 of 5 sampled residents. One resident was admitted with diagnoses including anxiety disorder, vascular dementia, and depression, and the quarterly MDS dated 02/04/2026 showed severe cognitive impairment with inattention and disorganized thinking continuously present. The resident arrived with a Level 1 PASRR dated 10/20/2025 that identified anxiety disorder and required a Level 2 evaluation referral for serious mental illness, but the PASRR did not include the resident’s depression diagnosis under mood disorders. The Social Services Director stated that she and the Admissions Director reviewed PASRRs on admission and acknowledged that this PASRR should have been corrected and that a new Level 1 including depression should have been completed. The second resident had a Level I PASRR dated 12/02/2024 showing an intellectual disability or related condition and indicating the PASRR should be forwarded to the regional DDA PASRR Coordinator. The resident qualified for an exempted hospital discharge and could admit without a Level II at that time, but the Level I also stated that a Level II evaluation would be required if discharge within 30 days did not occur. Record review showed the resident remained in the facility until 03/14/2025, and the EMR contained no documentation that the Level I PASRR was forwarded to the DDA Coordinator on admission or that a Level II evaluation was requested when the resident did not discharge within 30 days. The Social Services Director stated there was no documentation to show either action was completed.
Incomplete and Non-Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, individualized care plans for 5 sampled residents. For Resident 36, who was cognitively intact and receiving continuous oxygen therapy, the care plan did not identify oxygen therapy as a focus, goal, or intervention/task. Staff acknowledged that an oxygen care plan should have been present and that oxygen should have been added to the care plan. For Resident 2, who had vascular dementia and required supervision or touching assistance with dressing, staff observed the resident repeatedly wearing only an open sweatshirt with the body exposed and reported that the resident often refused morning care and dressing assistance. The electronic record did not show a place for CNA documentation of morning care refusals, and there was no progress note documenting the refusal. The resident’s care plan addressed dressing assistance and shower refusal, but did not address the frequent refusals of care or the resident’s preference not to be fully clothed until after the issue was discussed and the care plan was later revised. For Resident 80, who was cognitively intact and required supplemental oxygen, the record showed diagnoses of acute hypoxemic respiratory failure, influenza A, pneumonia, COPD, obesity, and rib fractures affecting breathing. Although the resident had an order for oxygen and received oxygen daily, the care plan addressed only respiratory infection related to influenza and pneumonia and did not include COPD, acute hypoxemic respiratory failure, or supplemental oxygen therapy. For Resident 7, who had autism, neurogenic bladder, obstructive uropathy, and a Level II PASRR determination, the comprehensive care plan did not identify or address autism, PASRR status, or obstructive uropathy. For Resident 43, who had dementia with behaviors and was receiving psychotropic medications, the care plan for antidepressant therapy did not identify the goal of the therapy, the antipsychotic care plan listed dementia with psychosis without supporting documentation, and the oral health care plan did not address osteonecrosis of the right lower posterior jaw despite documentation of that condition in the record.
Missed Weekly Showers for a Resident
Penalty
Summary
The facility failed to provide necessary care and services to ensure that Resident 3 received weekly showers. Resident 3 was admitted on [DATE] and, on the admission MDS dated 01/26/2026, was documented as cognitively intact and dependent to substantial/moderate assist with ADLs. The care plan for ADL self-care performance deficit related to weakness, immobility, surgery on the nervous system, and spinal fusion aftercare was revised on 02/12/2026 and included bathing/showering with one person one time weekly and as necessary. Resident 3 stated on 02/23/2026 that they had only one shower since admission and said delays occurred because of things such as PT; they also said they were not refusing showers and wanted a shower. The bathing record showed a shower on 02/06/2026 and 02/07/2026, a full body bath on 02/12/2026, a sponge bath on 02/22/2026, and one refusal on 01/31/2026. A progress note on 01/31/2026 documented the resident declined the scheduled bath because they had family/visitors and requested it the following day, and a note on 02/01/2026 documented the assigned shower aide was made aware of the request for a bed bath that day. Another note on 02/11/2026 documented the resident did not receive a shower that shift due to CNA time constraints. Staff later confirmed the resident was not getting a shower once a week and that the shower expected after the 01/31/2026 refusal was not documented.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that daily nurse staffing information was consistently posted to include the actual nursing staff hours worked for 3 of 6 days, specifically 02/22/2026, 02/23/2026, and 02/27/2026. On 02/23/2026 at 9:53 AM, surveyors observed the staffing sheet posted outside the therapy room showing only 02/19/2026, 02/20/2026, and 02/21/2026, with no staffing information posted for 02/22/2026 or 02/23/2026. On 02/27/2026 at 8:56 AM, the posted staffing sheet was dated 02/26/2026. The DON was stopped and confirmed that the posting was still dated 02/26/2026 and stated that the daily nurse staffing should have been updated; after the earlier observation was explained, the DON stated the daily nurse staffing should be updated daily.
Menu substitutions and incorrect portion sizes
Penalty
Summary
The facility failed to ensure written menus were followed, planned menu items were served at the appropriate serving size, substitutions were only made when necessary and approved by the Registered Dietician, and menu changes were communicated to residents. On 02/26/2026, the posted lunch menu listed country fried steak, garlic mashed potatoes, garden blend vegetables, and banana pudding, with diet-specific alternatives for residents on renal, 2-gram sodium, or low fat/low cholesterol diets. However, observation of the steam table showed Staff BB, Cook, had prepared pureed pork and carrots instead of the planned pureed country style steak, beef patties, and garden blend vegetables. Staff CC stated pork was used because it was easier to puree, and pork and rice was also prepared because it had already been cooked from the prior day’s lunch service. The dessert offered also differed from the posted menu, as canned fruit cocktail was provided instead of oranges with whipped topping for renal diets. A facility document titled Fruits to avoid on Renal Diet listed papaya as a fruit to be avoided. During tray line observation, Staff BB provided incorrect portion sizes for residents whose tray cards indicated small portions and large portions: two residents who were to receive small portions were given full portions of country style steak, and two residents who were to receive large portions were given double portions. The Dietary Supervisor later confirmed the menu was not followed, substitutions were made without Registered Dietician approval or resident notification, and the portion sizes provided did not match the tray cards.
Failure to Implement Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that recommendations for gradual dose reductions (GDR) of psychotropic medications were followed for three residents. For one resident with vascular dementia and anxiety disorder, the consulting pharmacist recommended a GDR of escitalopram, which was accepted by the provider. The resident’s guardian was informed and objected to the reduction, but the medication was discontinued. Following the discontinuation, the resident exhibited increased behavioral symptoms, required additional medication for anxiety, and eventually had the escitalopram restarted after the guardian expressed distress over the discontinuation. Another resident with chronic obstructive pulmonary disease and Alzheimer's disease was due for a GDR of aripiprazole as recommended by the consulting pharmacist. The provider accepted the recommendation, but no new medication orders were written, and the resident continued to receive the original dose. Staff confirmed that the GDR was not implemented as recommended. A third resident with congestive heart failure and morbid obesity was also due for a GDR of bupropion, with the provider accepting the recommendation to discontinue the medication. However, no instructions were given to staff to discontinue the medication, and the resident continued to receive the same dose. Staff acknowledged that the order should have been clarified and acted upon. These failures were identified through observation, interview, and record review.
Failure to Assess and Address Changes in Urinary Incontinence
Penalty
Summary
The facility failed to accurately assess and identify changes in urinary incontinence for two residents, resulting in a lack of appropriate treatment planning and interventions. For one resident admitted with a history of arm fracture and no cognitive impairment, initial assessments and progress notes showed inconsistencies in bladder continence status. Despite documentation of frequent urination, use of diuretics, and initiation and discontinuation of medication for bladder spasms, there was no evidence of reassessment or updated interventions to address the resident's changing continence needs. Staff were unable to specify the type of incontinence or explain the lack of follow-up. Another resident, admitted with a cognitive communication deficit and no cognitive impairment, also had conflicting documentation regarding bladder continence. The care plan did not address bladder status, and progress notes indicated the resident experienced both small and large amounts of urinary incontinence, as well as a urinary tract infection requiring treatment. Staff interviews confirmed the absence of reassessment and care plan updates to address these inconsistencies. The facility did not implement further assessments or interventions for either resident, as required.
Failure to Provide Adequate Pain Management at Discharge
Penalty
Summary
A resident with a history of respiratory failure, COPD, and osteoporosis was admitted to the facility and experienced ongoing pain, for which oxycodone was prescribed and administered as needed. The care plan required staff to assess and monitor the resident's pain each shift and document medication side effects. During the resident's stay, pain levels ranged from 4 to 7 out of 10, and oxycodone was given two to three times daily. Upon discharge, the resident was sent home with only three oxycodone tablets and no prescription to ensure continued pain management until follow-up with a community provider. The resident reported feeling overwhelmed by the number of medications provided at discharge and did not initially notice the insufficient supply of pain medication. It was later discovered that no prescription for additional oxycodone was provided, resulting in the resident experiencing pain until they could see their provider. The Director of Nursing confirmed that a prescription should have been sent but was not, possibly due to an oversight by a new staff member handling the discharge process.
Failure to Implement Antibiotic Protocols and Communicate Medication End Dates
Penalty
Summary
The facility failed to consistently implement antibiotic protocols to ensure antibiotics were appropriately prescribed and managed for one of three sampled residents reviewed for antibiotic use. A resident with respiratory failure and chronic obstructive pulmonary disease was discharged from the hospital with orders to take cefuroxime and metronidazole, each for 14 doses. However, the facility's order summary did not specify end dates for these antibiotics, and the resident was later sent home with a large quantity of both medications remaining. The resident reported confusion about the medications and was not informed about discontinuing them. The Director of Nursing confirmed that end dates should have been documented and communicated at discharge, but this was not done.
Failure to Administer Pneumococcal Vaccine After Consent
Penalty
Summary
The facility failed to provide a pneumococcal vaccination to a resident who had been admitted with respiratory failure and chronic obstructive pulmonary disease. Documentation showed that the resident had signed a consent form indicating their wish to receive the pneumococcal vaccine, and the form was signed by a nurse on the same day. However, review of the resident's electronic health record revealed no documentation that the vaccine was administered. The Director of Nursing confirmed that, despite the signed consent, the vaccine was not given.
Failure to Administer COVID-19 Vaccine After Consent
Penalty
Summary
The facility failed to provide the COVID-19 vaccine to a resident who had expressed consent to receive it. The resident, admitted with respiratory failure and chronic obstructive pulmonary disease, had a signed consent form dated 01/15/2025 indicating their wish to receive the COVID-19 vaccine, with the form also signed by a nurse on the same day. However, review of the resident's electronic health record showed no documentation that the vaccine was administered. The Director of Nursing confirmed that although consent was obtained, the vaccine was not given as it should have been.
Failure to Provide Advanced Directives for Residents
Penalty
Summary
The facility failed to provide Advanced Directives (ADs) for four out of five sampled residents, which compromised their right to have their healthcare preferences and decisions honored. Resident 59, who was cognitively intact, signed an AD receipt indicating a choice not to formulate an AD, but there were no documented attempts to offer or assist in formulating an AD prior to this. Staff I, the Patient Advocacy Resource, confirmed the absence of other ADs for Resident 59, and the Director of Nursing Services acknowledged the issue. For Residents 28, 43, and 60, there were no ADs or AD receipts found in their Electronic Health Records (EHRs). Resident 28's EHR lacked documentation of any inquiry about an AD or informing them of their right to formulate one. Resident 43, who was moderately cognitively impaired, and Resident 60, who was cognitively intact, also had no ADs or AD receipts documented. Staff I confirmed that ADs or AD receipts should have been completed upon admission for these residents but were not.
Facility Fails to Maintain Safe and Homelike Environment Due to Carpet Issues
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment, as evidenced by the poor condition of the carpets in several areas, including the Olympic, Mountainview, and Medicare hallways. Observations revealed worn areas, stains, and the use of tape to prevent carpet peeling, which compromised the homelike environment for residents. Specific issues included worn and heavily soiled carpets with multiple stains in the Olympic Hallway's activity room, mismatched carpet patches secured with duct tape in the Mountainview Hallway, and large stains and loose carpet squares in the Medicare Hallways. Interviews with staff members confirmed awareness of the carpet issues. The Administrator acknowledged the need for carpet replacement and mentioned plans to start the work soon. The Maintenance Supervisor also recognized the poor condition of the carpets and expressed challenges in addressing the issue due to bureaucratic obstacles. These observations and staff admissions highlight the facility's failure to uphold the residents' right to a safe and homelike environment, as required by regulations.
Failure to Properly Address and Document Grievances
Penalty
Summary
The facility failed to ensure that grievances were properly initiated, logged, investigated, and resolved in a timely manner for a resident and the Resident Council. Resident 40, who was cognitively intact, filed two grievances regarding the lack of restorative services and showers due to staff shortages. These grievances were not documented on the grievance log and were not addressed until 14 days later, contrary to the facility's policy which required a response within three working days. The Director of Nursing Services acknowledged that the grievances should have been documented and discussed in meetings. Additionally, the Resident Council expressed concerns about the grievance process, indicating that their grievances were not consistently addressed or resolved. Multiple concerns raised during Resident Council meetings were not filed as grievances, including issues related to staffing, appointment notifications, and pharmacy services. A grievance filed by the Resident Council regarding appointment notifications did not include any notification of resolution. Staff members confirmed that these concerns should have been documented as grievances and acknowledged the failure to meet expectations in handling these issues.
Failure to Provide Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide written transfer or discharge notices to residents and their representatives for four residents who were hospitalized. This deficiency was identified during a review of the facility's records and interviews with staff. The facility's policy, revised in November 2016, mandates that information regarding transfers should be provided to residents and their representatives in a language they understand. However, for Residents 18, 40, 16, and 60, there was no documentation in the electronic health records (EHR) indicating that they were offered or provided with a transfer or discharge notice when they were hospitalized. Resident 18, who was cognitively intact, was transferred to the hospital and returned without any record of a transfer notice. Similarly, Resident 40, also cognitively intact, was transferred to the hospital without a completed transfer notice. Staff interviews confirmed the absence of these notices, with the Director of Nursing Services acknowledging that the notices should have been completed. Residents 16 and 60, both cognitively intact, were also hospitalized and returned without documented transfer notices. The lack of these notices placed residents and their representatives at risk of not being able to make informed decisions about their transfers or discharges.
Failure to Provide Bed Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to provide a bed hold notice to residents or their representatives during hospital transfers, affecting three out of four sampled residents. Resident 40, who was cognitively intact, was transferred to the hospital on July 1, 2024, and returned to the facility without any documentation of a bed hold notice in their Electronic Health Record (EHR). Staff E, a Resident Care Manager/Registered Nurse, confirmed that Social Services was responsible for completing bed hold notifications but could not find any record of it. Staff B, the Director of Nursing Services, acknowledged that the bed hold notification for Resident 40 was not completed as required. Similarly, Resident 16, also cognitively intact, was hospitalized from March 16 to March 20, 2024, without any bed hold notice documented in their EHR. Resident 60, who was hospitalized from September 13 to September 19, 2024, also lacked documentation of a bed hold notice. Staff B confirmed the absence of bed hold notices for both Resident 16 and Resident 60, stating that these notifications should have been completed. This oversight placed the residents and their representatives at risk of not being able to make informed decisions regarding bed hold policies, potentially affecting their quality of life.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected the status of six residents, leading to potential risks for unmet care needs and diminished quality of life. Resident 53 was incorrectly documented as being on a prescribed weight loss program due to diuretic use, while Resident 10's significant weight loss was not recorded on the MDS. Resident 21 was mistakenly coded as having an ostomy when they only had a suprapubic catheter. Resident 56 was inaccurately documented as having a diagnosis of depression, which was not present in their records. Additionally, Resident 176's MDS incorrectly indicated that the pneumococcal vaccination was not offered, despite documentation showing consent and offer. Resident 23's MDS failed to include active diagnoses of psychosis, anxiety, or depressive disorders, despite receiving antipsychotic medication and having a PASRR evaluation indicating serious mental illness. These inaccuracies in the MDS assessments were acknowledged by the facility staff during interviews.
Care Plan Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure that resident care plans were reviewed, revised, and accurately reflected the residents' care needs for several residents. For Resident 62, the care plan directed staff to provide assistance with bathing according to the resident's chosen schedule, but it did not specify what that schedule was. Similarly, Residents 176 and 376 expressed a desire for more frequent showers than what was scheduled, but their care plans did not reflect their preferences for the type or frequency of bathing. Resident 67's care plan also lacked details about their preferred bathing type and frequency. Resident 23's care plan for psychotropic drug use required documentation of hallucinations and delusions but did not specify the nature or effect of these experiences or any actions staff should take. Resident 28's care plan included monitoring intake and output (I&O) as per facility policy, but there was no order for I&O, and staff were not monitoring it. Similar issues were noted for Resident 176, whose care plan also included I&O monitoring without an order or actual monitoring taking place. Resident 21's care plan was outdated and did not reflect their current abilities or goals. The care plan included interventions for physical therapy and daily activities that were not being provided or were beyond the resident's current capabilities. Additionally, there was a discrepancy in the nutritional status care plan regarding the amount of water to be given, which had not been updated to match the current order. These deficiencies indicate a lack of proper care plan management and documentation, potentially affecting the quality of care provided to the residents.
Deficiency in Restorative Services Due to Staffing Issues
Penalty
Summary
The facility failed to provide restorative services at the frequency required for six residents, leading to a deficiency in maintaining or improving their range of motion (ROM) and mobility. Residents 48, 22, 55, 46, 25, and 61 were assessed to need specific restorative nursing programs (RNPs) to prevent decline in ROM and contracture formation. However, the facility did not consistently offer these programs as required. For instance, Resident 48 was supposed to receive an active ROM program five times a week but only received it on 10 of 25 days in September and 7 of 26 days in October. Similarly, Resident 22 was to participate in an active ROM program five times a week but only received it on 14 of 21 days in October. The deficiency was further highlighted by the facility's staffing issues, which were acknowledged by both the Restorative Aide and the Administrator. The Restorative Aide, Staff FF, reported being frequently pulled from their duties to work the floor, which resulted in most restorative programs not being completed. This staffing shortage was confirmed by the Administrator, who admitted that the lack of restorative staff detracted from the provision of services at the required frequency. Resident 61 also reported receiving physical therapy less frequently than prescribed due to these staffing issues. The report indicates that the facility's failure to provide the necessary restorative services placed residents at risk for decreased ROM, development of contractures, increased dependence on staff, and diminished quality of life. The deficiency was documented under WAC 388-97-1060, highlighting the facility's non-compliance with the required standards for restorative care.
Expired Medications and Supplies Not Removed
Penalty
Summary
The facility failed to ensure the removal and disposal of expired medications and supplies in one of the two medication storage rooms reviewed. During an observation on November 4, 2024, several outdated items were found, including blood glucose lancets, blood glucose strips, ibuprofen, vitamin B-6, a daily vitamin formula with iron, an Arexvy vaccine vial, a tuberculin purified protein derivative vial, and urine reagent strips. These items had expiration dates ranging from June to October 2024, and some were opened but not dated. Staff C, the Resident Care Manager, indicated that nursing staff were responsible for managing expired medications and supplies. On November 12, 2024, Staff B, the Director of Nursing, expressed that expired medications should be destroyed or removed by their expiration date.
Failure to Obtain Resident Council Approval and Provide Bedtime Snacks
Penalty
Summary
The facility failed to obtain approval from the Resident Council and did not ensure that residents were provided a nourishing snack at bedtime when the interval between dinner and breakfast was extended from 14 hours to 15 hours. This deficiency was identified through interviews and record reviews. Specifically, residents in the Garden Room, Medicare A hall, Medicare B, [NAME] Mountain, and Mountain View Halls were served dinner between 5:00 PM and 5:20 PM and breakfast between 8:00 AM and 8:20 AM, resulting in a 15-hour gap between meals. The Director of Nursing Services confirmed the lack of documentation for Resident Council approval and stated that only diabetic residents were routinely served snacks at bedtime, although snacks were available upon request for other residents.
Infection Control Deficiencies in PPE and Equipment Handling
Penalty
Summary
The facility failed to adhere to infection prevention and control protocols, particularly in the use of Enhanced Barrier Precautions (EBP) for Resident 7, who had a gastric feeding tube. Staff W, an LPN, admitted to not wearing the required PPE while administering medication to Resident 7, despite the EBP order. This oversight was acknowledged by both the Infection Preventionist and the Director of Nursing, who confirmed that the expectation was for staff to follow the EBP orders. Additionally, the facility did not maintain proper hygiene practices with PPE and food carts. Observations revealed that staff placed personal items and food on PPE carts, which were then used to store and transport PPE items into resident rooms. Similarly, food carts were improperly used, with coffee stored on the bottom shelf while used trays were placed above, risking cross-contamination. Staff interviews confirmed that these practices did not meet the facility's expectations for infection control. The facility also failed to follow standard precautions in handling medical equipment and performing hand hygiene. Resident 21's catheter tubing was observed to be improperly positioned, with urine pooling in the tubing and the bag touching the floor. Staff did not perform hand hygiene when handling the catheter. Similarly, Resident 56's negative pressure wound treatment tubing was found on the floor, contrary to infection control expectations. These observations were confirmed by staff interviews, indicating a lack of adherence to infection control protocols.
Failure to Administer Pneumococcal Vaccines
Penalty
Summary
The facility failed to provide pneumococcal vaccines to three residents who had consented to receive them, placing them at a higher risk for pneumococcal infections. Resident 176 was admitted to the facility and had consented to the pneumococcal vaccination, as documented in the Admission Minimum Data Set and a consent form. Despite this, the resident was not administered the vaccine during their stay and was discharged without receiving it. The Infection Preventionist, Staff X, acknowledged that they were not notified of the consent and confirmed the vaccine was not given. Similarly, Resident 10 and Resident 21 both consented to receive the pneumococcal vaccine, but it was not ordered from the supplier. Staff C, the Resident Care Manager, and Staff B, the Director of Nursing Services, both acknowledged that the vaccines were not ordered and that this did not meet the facility's expectations. These oversights were identified during interviews and record reviews, highlighting a lapse in the facility's vaccination administration process.
Emergency Fire Door Malfunction
Penalty
Summary
The facility failed to maintain the emergency fire doors in working order in one of the three main halls, specifically outside a room. During an observation, a square metal piece in the floor of the Medicare A and B hallway was found to be loose and protruding. This metal piece affected the functionality of the fire door, requiring significant force to open it. Staff members, including a Licensed Practical Nurse and a Certified Nursing Assistant, encountered difficulties in opening the door, with the CNA needing both hands to do so. A resident using a walker was also unable to open the door due to the resistance. The Maintenance Supervisor attempted to fix the issue by gluing the metal piece, but the glue had not cured, and further attempts to secure it were planned. The Administrator later stated that the metal piece had been repaired to eliminate the tripping hazard.
Failure to Provide Scheduled ADL Assistance
Penalty
Summary
The facility failed to provide scheduled bathing and showering opportunities for six residents who required assistance with activities of daily living (ADLs). Resident 43, who was moderately cognitively impaired, did not receive a shower for 14 days despite being scheduled for weekly showers. Staff acknowledged the oversight, confirming that the resident should have been showered and documented on the scheduled day. Similarly, Resident 176, who was cognitively intact and expressed a preference for more frequent showers, was only offered a bath once in a 21-day period, contrary to their care plan. Resident 19, who required extensive assistance with ADLs, expressed dissatisfaction with the lack of shaving services, stating that they had to repeatedly request a shave without success. The resident's care plan and electronic health record lacked documentation regarding shaving activities. Resident 64, also moderately cognitively impaired, reported similar issues with shaving and haircuts, with documentation showing infrequent offers of shaving despite a physician's order for regular offers. Staff confirmed the lack of specific documentation for shaving tasks in the electronic health record. Residents 67 and 62, both cognitively intact, experienced significant gaps in bathing services due to staffing issues. Resident 67 went without bathing for extended periods, including a 25-day gap, while Resident 62 experienced a 42-day gap without being offered a bath. Both residents' care plans indicated the importance of bathing preferences, yet these were not consistently honored. Staff confirmed the documentation gaps and acknowledged the failure to provide the necessary care as per the residents' preferences and care plans.
Deficiencies in Nutritional and Fluid Management
Penalty
Summary
The facility failed to ensure that residents receiving enteral feedings were administered the correct formula at the physician-ordered rate and volume. Specifically, Resident 21, who had diagnoses including malnutrition and hyponatremia, was ordered to receive 1400 milliliters of formula but was only given 406 ml on one occasion and 938 ml on another, with no documentation explaining the discrepancies. Additionally, Resident 21's weight was not monitored as required, with no weights recorded since August, despite recommendations for updated weights in September and October. The facility also failed to monitor and document fluid intake accurately for residents on fluid restrictions. Resident 58, who had kidney disease and heart failure, was on a 1500 ml/day fluid restriction, but there was no system in place to reconcile fluid intake from meals and nursing records to calculate a 24-hour total. Similarly, Resident 10, with heart failure and end-stage renal disease, was on a 1000 ml/day fluid restriction, but fluid intake records were incomplete, lacking documentation of fluids given by nursing staff. Furthermore, the facility did not identify and address significant weight loss in residents. Resident 64, who had end-stage renal disease, experienced a significant weight loss of more than 7.5% over three months, which was not identified until a quarterly review. The facility's failure to obtain routine weights and identify weight loss trends in a timely manner contributed to this oversight. These deficiencies placed residents at risk for inadequate nutrition, fluid imbalances, and other medical complications.
Staffing Shortages Impact Resident Care
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of its residents, as evidenced by multiple resident and staff interviews, grievances, and observations. Residents reported long wait times for assistance with activities of daily living (ADLs), such as grooming, showers, and bathroom use. Some residents expressed frustration with the inconsistency of staff response times, which varied depending on who was on duty. The lack of available staff also affected the provision of restorative services and infection control, as aides were frequently pulled from their assignments to cover other duties. Staff interviews corroborated the residents' concerns, with several staff members indicating that they were unable to complete their daily tasks due to staffing shortages. Certified Nursing Assistants (CNAs) and Licensed Practical Nurses (LPNs) reported being overworked, often having to work overtime or longer shifts to manage their responsibilities. The facility's Director of Nursing Services and Administrator acknowledged the staffing issues and their impact on resident care, including the inability to provide scheduled bathing and restorative services. The report highlighted specific instances where residents filed grievances due to missed showers and lack of restorative services. Resident Council minutes further documented ongoing concerns about insufficient staffing and the impact on residents' quality of life. The facility's failure to maintain adequate staffing levels resulted in unmet care needs and diminished quality of life for the residents, as they were unable to receive timely assistance and services as required by their care plans.
Deficiency in Meal Preparation and Delivery
Penalty
Summary
The facility failed to ensure that meals were appetizing, palatable, and served at appropriate temperatures for several residents. Multiple residents reported dissatisfaction with the food, describing it as having poor taste, inappropriate texture, and being served at incorrect temperatures. Specific complaints included meals being consistently cold, food tasting bland or freezer burnt, and a lack of variety in the menu. Observations confirmed that meal carts were delayed in delivery, leading to meals being served cold. Additionally, residents noted that their meal preferences were not always honored, contributing to their dissatisfaction. Further investigation into meal preparation revealed that beverages were removed from refrigeration and placed on meal trays well in advance of meal service, resulting in them being served at unsafe temperatures. A test tray confirmed that beverages and food items were not at appropriate temperatures when served. Staff indicated that this practice was intended to streamline the tray line process, but no measures were taken to ensure beverages remained cold, such as placing them on ice. This oversight in meal preparation and delivery placed residents at risk for decreased nutritional intake and dissatisfaction with their meals.
Failure to Provide Prescribed Therapeutic Diets and Portion Sizes
Penalty
Summary
The facility failed to ensure that residents received therapeutic diets as prescribed by their physicians and assessed by the interdisciplinary team. During an observation, it was noted that dietary staff placed tartar sauce on all resident trays, including those for residents on specific diets that should not have included tartar sauce. This affected five residents who were on various restricted diets, such as renal, no added salt (NAS), and low sodium diets. The dietary manager confirmed the error but did not take corrective action to remove the tartar sauce from the trays of affected residents. Additionally, the facility did not provide the correct portion sizes for residents with specific dietary orders. Six residents with orders for small or large portions received incorrect serving sizes. Staff used a standard 1/2 cup spoodle and visually adjusted the amount, rather than using the appropriate size spoodle for the ordered portion sizes. This practice was confirmed by the dietary manager and staff, who acknowledged that the method used was not acceptable. The failure to adhere to prescribed diets and portion sizes placed residents at risk for medical complications and unmet nutritional needs.
Deficient Communication and Coordination with Hospice Services
Penalty
Summary
The facility failed to ensure effective communication, collaboration, and coordination of care between the facility and the hospice provider for two residents receiving hospice services. For Resident 64, the facility did not maintain a current hospice coordinated plan of care or document hospice visits and care provided in the Electronic Health Records (EHR). The hospice care plan indicated limited hospice involvement, with the facility responsible for most Activities of Daily Living (ADL) assistance. However, the facility's hospice service binder lacked comprehensive documentation, and there was no designated person for hospice communication, leading to inadequate record-keeping and coordination. Similarly, for Resident 28, the facility did not have a current coordinated hospice plan of care, and the EHR lacked documentation of hospice visits and services provided. The hospice care plan required weekly nurse and aide visits, but the facility could not verify these visits or their details. Staff acknowledged issues with communication and documentation between hospice and the facility, and efforts to improve this were in progress, but the deficiencies remained unaddressed at the time of the survey.
Failure to Respect Resident Privacy and Dignity
Penalty
Summary
The facility failed to respect and value the residents' private space by not knocking and/or announcing themselves before entering the rooms of three out of four sampled residents. This deficiency was observed during a survey where staff members, including a Certified Nursing Assistant (CNA), housekeeping staff, and a CNA/Shower Aid, entered residents' rooms without prior notice. Specifically, Staff F, a CNA, entered a room without knocking or announcing themselves and later acknowledged that this was not acceptable behavior. Similarly, Staff G from housekeeping entered rooms without knocking or announcing themselves on multiple occasions, admitting to forgetting the protocol. The facility's policy on Residents Rights, revised in 2016, clearly states that residents have the right to a dignified existence, which includes staff knocking and announcing themselves before entering a room. Interviews with the Resident Care Manager and the Director of Nursing Services confirmed that the expectation is for staff to knock and announce themselves, and the repeated failure to do so was deemed unacceptable. This lack of adherence to policy placed residents at risk of being treated with a lack of dignity and a diminished quality of life.
Failure to Obtain Proper Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents were fully informed and had signed consent prior to the administration of psychotropic medications. Specifically, Resident 21, who had diagnoses of depression and dementia with psychosis, was prescribed risperidone, an antipsychotic medication. However, the consent forms signed for this medication were inconsistent and incorrect, as they were classified under different drug categories such as anticonvulsant and antianxiety, each listing different side effects. This inconsistency in classification and information provided to the resident was acknowledged by the Resident Care Manager and the Director of Nursing Services, who both stated that the expectation was for risperidone to be classified correctly as an antipsychotic. Additionally, the facility administered venlafaxine, an antidepressant, to Resident 21 before obtaining the necessary consent. The administration of venlafaxine began on May 3, 2024, while the consent was only signed on May 17, 2024. Both the Resident Care Manager and the Director of Nursing Services confirmed that their expectation was for consent to be obtained prior to the administration of the medication. These actions placed the resident at risk of receiving medication without proper knowledge of the medication or its side effects, potentially impacting their quality of life.
Failure to Honor Resident Bathing Preferences
Penalty
Summary
The facility failed to honor the bathing preferences of two residents, both of whom were cognitively intact and had identified their bathing choices as very important. Resident 376, who was admitted to the facility, reported not being asked about their bathing preferences and was informed they would receive one shower a week. The resident expressed dissatisfaction with the quality of the shower received, noting it did not meet their standards of cleanliness. The resident's care plan indicated assistance with bathing once a week, but there was no documentation in the electronic health record (EHR) to show that the facility attempted to support the resident's choice. Similarly, Resident 176 was not consulted about their preferred bathing frequency or type and was also scheduled for one shower per week. The resident preferred daily showers but was willing to accept a shower every three days while at the facility. The care plan for Resident 176 required substantial assistance with bathing but did not specify the frequency. The EHR lacked documentation of efforts to facilitate the resident's self-determination regarding bathing preferences. Staff interviews revealed that residents were initially assigned one shower per week upon admission, with the possibility of changes based on resident requests or feedback during care conferences.
Inaccurate PASRR Documentation and Delayed Referrals
Penalty
Summary
The facility failed to ensure the accuracy and timely referral for Level II PASRR evaluations for two residents, which could impact their access to specialized mental health services. Resident 60 was admitted with a diagnosis of depression, but the Level I PASRR inaccurately documented an anxiety disorder. Despite the exemption for a hospital discharge with an anticipated stay of less than 30 days, a Level II PASRR referral was delayed beyond the required timeframe. Staff interviews confirmed the discrepancy between the PASRR documentation and the resident's actual diagnosis, highlighting a failure to identify and correct the error in a timely manner. Similarly, Resident 56's Level I PASRR was updated to indicate a serious mental illness with a mood disorder, despite the absence of such a diagnosis in the resident's health records. Staff acknowledged the incorrect coding of the PASRR, which did not reflect the resident's actual mental health status. These inaccuracies in PASRR documentation for both residents demonstrate a lapse in the facility's processes for ensuring accurate mental health assessments and timely referrals, as required by regulations.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, leading to potential risks for unmet care and safety needs. Resident 56, who was admitted with diagnoses including surgical amputation, muscle weakness, and hypertension, did not have a care plan addressing their interest in activities or their documented edema. Additionally, there was an error in the care plan regarding the site of negative pressure wound treatment, which was incorrectly listed as the left side instead of the right side where the amputation wound was located. Resident 126, admitted with sepsis and cellulitis, was receiving intravenous antibiotics through a PICC line. However, there was no care plan addressing the management of the PICC line. Interviews with staff, including the Resident Care Manager and the Director of Nursing Services, revealed that the expectations for care planning were not met for both residents, as essential aspects of their care were not documented or addressed in their care plans.
Failure to Complete Earwax Removal Treatment
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 176, received appropriate treatment and services to maintain their hearing. Resident 176, who was cognitively intact and had moderate difficulty hearing, reported experiencing ear pain and hearing difficulties due to earwax build-up. The resident had requested staff assistance to address the issue. Although the nursing staff administered Debrox ear drops as part of the treatment plan, they did not complete the treatment by flushing the resident's ears with warm water, as required by the medication's instructions. The care plan for Resident 176, which was revised to address hearing loss, directed staff to administer ear drops as ordered and to communicate with the resident by moderately elevating their tone. However, the medication administration records did not include instructions to flush the ears after the treatment, leading to incomplete care. The Director of Nursing Services acknowledged that the treatment should have included ear flushing and that the nursing staff should have identified and clarified the incomplete order. This oversight resulted in the resident continuing to experience clogged ears and difficulty hearing.
Deficiency in IV Medication Administration and Central Line Management
Penalty
Summary
The facility failed to administer parenteral medication in accordance with professional standards for a resident who was receiving intravenous antibiotics. The resident, who had been diagnosed with sepsis and cellulitis, was admitted with a peripherally inserted central catheter (PICC) for medication administration. However, the electronic health record (EHR) lacked specific orders for the central line, and there was no care plan in place for the PICC. Additionally, the orders for the IV antibiotics did not specify the rate of administration, which is a critical component of safe medication delivery. Interviews with staff revealed further deficiencies in the management of the resident's care. The Resident Care Manager/Registered Nurse (RCM/RN) was unable to find a previous measurement of the external catheter length, which is necessary for monitoring the PICC. The Director of Nursing Services confirmed that the facility's expectations were not met, as the measurement should have been taken upon admission and with dressing changes. Furthermore, there were no orders for the frequency of dressing changes, and the staff were expected to confirm the rate of administration with each medication order, which was not done. These oversights placed the resident at risk for complications and infections.
Failure to Follow Dialysis Care Orders
Penalty
Summary
The facility failed to ensure that physician orders were followed for two residents requiring dialysis care, specifically regarding the post-dialysis fistula access care. Resident 72, who was cognitively intact and diagnosed with End Stage Renal Disease, was dependent on renal dialysis and had a dialysis fistula in their left arm. The physician's order and the care plan both instructed that the pressure dressing should be removed two hours after dialysis. However, Resident 72 reported that they often removed the pressure dressing themselves, sometimes waiting until much later in the day, and had previously experienced bleeding from the fistula site due to early removal, which resulted in a hospital transfer. Interviews with facility staff revealed that there was no documented training or teaching for Resident 72 to self-manage their pressure dressing removal. Staff C, the Resident Care Manager, could not locate any documentation of such training in the Electronic Health Record (EHR). Additionally, Staff B, the Director of Nursing Services, stated that there should have been a self-administration form, care plan address, and physician order for Resident 72 to remove their own dressing, none of which were documented. This lack of documentation and adherence to the care plan and physician orders led to the deficiency.
Failure to Implement Pharmacist's Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure that the pharmacist's Medication Regimen Review (MRR) recommendations were acted upon for a resident reviewed for unnecessary medications. The facility's policy required that MRR recommendations be provided to the responsible physician, Medical Director, and Director of Nursing within a week of the review, with documentation in the resident's medical record regarding any actions taken. However, for Resident 21, who had diagnoses of malnutrition and gastrostomy status and experienced constant pain, there was no documentation that the MRR recommendations were implemented. Specifically, the recommendation noted that Carafate, which could alter the absorption of other medications, should be given on an empty stomach and two hours before or after other medications. Despite this recommendation, the medication administration record for August and September showed that Resident 21 was scheduled to receive both oxycodone and Carafate at the same times. Interviews with facility staff revealed that there was no documentation of the MRR recommendations being implemented or reviewed, nor was there evidence that the provider was aware of the recommendation. The Director of Nursing Services confirmed the expectation that the doctor would have confirmed a conversation about the medication, but they were unable to provide documentation that this occurred.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,218 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bremerton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bremerton Trails Post Acute | 0.1 mi | ★★★★★ | 55 | 0 |
| Port Washington Post Acute | 1.9 mi | ★★★★★ | 15 | 0 |
| Washington Veteran Home-retsil | 2.7 mi | ★★★★★ | 19 | 0 |
| Life Care Center Of Port Orchard | 4.6 mi | ★★★★★ | 20 | 0 |
| Avamere Rehabilitation At Ridgemont | 4.6 mi | ★★★★★ | 16 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Belmont Terrace.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.