Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bethany At Pacific during CMS and state inspections, most recent first.
Essential equipment was not kept in safe operating condition. The high-temp dishwasher had fluctuating rinse temperatures, with survey observations showing readings below the required range and repeated prior repair issues. Hoyer and sit-to-stand lift batteries also failed during use even when indicators showed a full charge, and staff and residents reported repeated transfer interruptions, including residents being left hanging during lifts.
Resident Council concerns were not followed up or documented in the grievance process, leaving issues unresolved and the Council ineffective. Residents reported loud hallway საუბars by staff at night, laundry being returned to the wrong rooms, and a Hoyer lift battery failure that left residents suspended during transfers; staff and the Administrator confirmed these concerns were not logged or resolved in the formal grievance system, and meeting minutes showed no documented follow-up.
The facility failed to provide discharge instructions, assess home health or equipment needs, and arrange home medications for a resident who left AMA, with no discharge summary, instructions, or Notice of Transfer form documented. The facility also failed to provide written transfer notices for two residents sent to the hospital, and staff stated notices had not been provided for residents transferred to the hospital.
A facility failed to properly manage medication storage in a medication room and at a resident's bedside. In one medication room, expired oral antibiotic suspension remained in the refrigerator, vaccine refrigerator temperatures were not consistently documented, and a sharps container was observed over the full line in an unlocked wall mount. A resident also had multiple OTC and prescription medications and creams kept at the bedside without an order allowing bedside storage, and an LPN stated such items were not supposed to be there.
Failure to honor a resident’s food preferences and daily choices. A cognitively intact resident reported repeated service of foods they disliked, including pineapple, chicken, beef, oatmeal, and a prescribed high-protein shake, while staff acknowledged several of these dislikes and noted the kitchen still sometimes served pineapple despite the tray card. The resident’s tray card listed only pineapple as a dislike, and the resident’s weight record showed a decline from 205.1 lbs to 182 lbs.
A resident with bipolar disorder had PASRR Level II recommendations for individualized art-related activities, including drawing, painting, and Play-Doh, but these were not incorporated into the care plan. Staff confirmed the resident was not provided structured individualized art activities and that the PASRR recommendations were not known or implemented by the activity department.
Failure to notify the State PASRR Coordinator after a significant behavior change for a resident with dementia with psychotic disturbance. The resident’s record showed a prior Level 1 PASRR with no SMI or ID indicators, later a new dx of dementia with psychotic disturbance, initiation of quetiapine for paranoia/hallucinations, and an MDS noting behavior was worse than the prior assessment. EMR review showed no updated Level 1 PASRR, and the SSA confirmed it was not completed.
Failure to provide oral care to a dependent resident. A resident with stroke-related right-sided impairment and a hx of brain tumor removal was documented as totally dependent on staff for oral care, yet NA charting showed oral care marked not applicable on multiple evening shifts. The resident stated they were not always offered tooth brushing, had a usual routine of brushing twice daily before hospitalization, and reported not being offered oral care for several days. An NAC stated oral care was expected at least once per shift, usually after meals, but had not been offered that day.
A resident with left eye blindness and right-sided weakness had essential items, including the call light and TV remote, placed on the blind side, and the care plan did not direct staff to position items in the unaffected visual field. Another resident with HTN received a BP medication despite a HR below the ordered hold parameter on multiple occasions, and staff confirmed the order should have been followed.
A resident with stroke-related weakness had a call light left on the floor and it remained out of reach while staff and a collateral contact passed by the room. Another resident with stroke history and a brain tumor removal was identified as high fall risk, but the fall assessment and investigation did not fully evaluate environmental hazards or the resident’s positioning before the resident rolled out of bed and sustained a head abrasion.
A resident with an indwelling catheter for urinary retention and prostatitis had catheter tubing observed on the floor and on a wheelchair wheel, and the catheter bag was repeatedly placed on the floor during emptying. The resident reported the bag had often been left on the floor and described urine spilling during emptying. An NA was observed emptying the catheter bag on the floor without disinfecting the spout, while an LPN/NM stated catheter care should be done every shift, with the spout disinfected and tubing and bag kept off the ground.
Failure to provide ordered CPAP therapy for a resident with OSA. The resident had a physician order for CPAP at HS and off in the AM, but the MAR/TAR had no documentation that the CPAP was applied or removed as ordered, even though daily mask cleaning was signed off by LNs. Staff could not locate the CPAP in the room at first, and the resident said it was not being used; it was later found in a plastic bag in the room. The RCM said the daughter had taken it home and staff were unaware it had been returned, and no documentation of refusal or staff offering the CPAP was available.
Failure to address advance directives and family decision-maker options: A resident with a spinal fracture and moderate cognitive impairment had admission advance directive paperwork and preferences signed by a collateral contact serving as surrogate/translator. Records showed no documented discussions with the resident about advance directives, preferences, or other family members, while staff knew the resident had a son but did not have contact information.
Failure to Provide Ordered Speech Therapy Evaluation: A resident admitted with a stroke diagnosis had an order for ST evaluation and treatment for swallow and cognitive needs, but therapy logs showed no ST minutes and staff could not document that the resident was seen. Staff confirmed the resident was not evaluated within the expected 24-48 hour timeframe because no ST was available, and the provider was not informed of the delay.
A resident discharged home with orders for Home Health (HH) services did not have the HH agency or contact information documented on the Discharge Instruction Form, and there was no physician-signed medication list in the medical record. Staff interviews confirmed that required discharge documentation was incomplete and that HH services were not properly coordinated.
The facility did not provide required social services to eight residents, including lack of support for care planning, advance directives, discharge planning, and mental health referrals. Residents and families reported poor communication and incomplete documentation, while the social services department was understaffed and unable to meet residents' needs.
Two residents with minimal or no cognitive impairment were not offered the opportunity to participate in care conferences or discussions about their person-centered care, including discharge planning and goal setting. Staff interviews and record reviews confirmed that required care plan meetings were neither conducted nor documented, and the residents' care plans lacked discharge planning focus areas.
The facility did not ensure that advance directives or DPOA documentation were obtained, completed, or properly recorded for three residents, including those with cognitive impairment. Staff interviews confirmed that required documentation and follow-up were not completed, despite established procedures for admission and care conferences.
A resident and their representative were not given the required written Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) explaining potential financial liability after Medicare coverage ended. Although a phone call was made to notify about the end of skilled services, no written notice or signature was obtained, and the representative was not informed about appeal rights or specific costs.
The facility did not consistently follow its grievance policy, resulting in unresolved complaints from residents about room cleanliness, missing personal items, and delayed showers. Two residents' grievances were not properly documented or resolved, and concerns raised during resident council meetings were not addressed through the formal grievance process. These failures led to repeated reporting of the same issues without resolution.
A resident with severe cognitive impairment and full dependence on staff was repeatedly observed in a recliner with the legs elevated and an over-the-bed table across their lap, unable to adjust or remove these items independently. Staff confirmed that the recliner's leg rest could only be operated by staff, and there was no documentation of assessment, evaluation, or consent for the use of these devices as potential restraints, contrary to facility policy.
The facility did not identify or report multiple allegations of abuse and neglect, including inappropriate physical contact between residents, delayed response to call lights resulting in resident distress, and staff scolding a resident after a prolonged wait for assistance. Staff and leadership interviews confirmed these incidents should have been reported to the state, but required reporting and documentation did not occur.
The facility did not thoroughly investigate multiple allegations and incidents involving delayed call light response, inappropriate staff behavior, and possible resident-to-resident abuse. For three residents with cognitive impairments and significant medical needs, the facility failed to document allegations, conduct required interviews with staff and residents, perform necessary assessments, or provide evidence of support services, resulting in incomplete investigations and insufficient documentation.
A resident with a diagnosis of major depressive disorder was admitted and received daily antidepressant medication, but the PASARR Level I screening did not indicate a mood disorder, resulting in no Level II evaluation. Staff interviews confirmed the PASARR was not accurately reviewed or updated prior to admission, and this was a repeat deficiency.
A resident with a history of mental health disorders was prescribed new antidepressant and antipsychotic medications after readmission, but the facility did not update the PASRR assessment to reflect these changes. Staff interviews indicated unclear processes and responsibilities for initiating a new PASRR when psychotropic medications were started post-admission, especially in the absence of a social worker.
Surveyors found that three residents received oxygen therapy without proper physician orders and with inconsistent adherence to facility policy on tubing changes and documentation. Staff responses to oxygen tubing found on the floor varied, and there was confusion about the frequency of tubing changes and required documentation. In some cases, oxygen was administered outside the parameters of the physician's order, and care plans were not updated to reflect current oxygen use.
A resident with depression and insomnia was evaluated by a mental health provider, who recommended changes to medication and further psychological testing. These recommendations were documented in the medical record but were not reviewed or implemented by nursing staff for over three weeks. Interviews revealed that staff were unaware of the recommendations due to a new documentation process, and the DON confirmed the oversight.
A resident with multiple chronic conditions did not receive restorative therapy services after being moved to a different floor, resulting in a decline in mobility and increased dependence on staff. Staff interviews revealed a lack of documentation and unclear processes for reassessment and reapproach after removal from the restorative program, and the care plan interventions were marked as resolved without supporting documentation.
Two residents with dysphagia did not receive appropriate safety interventions to prevent aspiration. One resident ate meals without required assistance or monitoring for oral pocketing, despite care plan and physician orders. Another resident, ordered NPO with tube feeding, repeatedly consumed outside food without staff awareness, documentation of refusal, or monitoring for aspiration risk. The facility failed to follow its own policy for documenting treatment refusal and updating care plans.
A resident with a history of vascular and cardiac conditions was not assessed or provided with a bowel/bladder retraining program despite being identified as a candidate in multiple assessments. Staff relied on incontinence care and did not implement restorative or toileting interventions, and therapy recommendations for restorative services were not followed. Documentation and staff interviews revealed inconsistencies and a lack of direct resident engagement regarding toileting needs.
A treatment cart containing prescribed medications, wound care supplies, and hypodermic needles was found unlocked and unattended on a unit, accessible to residents and unauthorized staff. Facility policy requires such carts to be locked when not in use, but staff interviews confirmed the cart was left unsecured for an extended period while residents were present in the area.
A resident experienced significant weight loss due to the facility's failure to assess dietary preferences, document nutritional intake accurately, and notify the physician of weight changes. The resident, with multiple health conditions, was not offered meal substitutes when consuming less than 50% of meals and reported dissatisfaction with the food provided. Staff interviews revealed a lack of communication and adherence to policies, contributing to the resident's nutritional risk.
The facility failed to ensure their designated Infection Preventionist (IP), an RN, met the necessary qualifications for the role, leading to a lack of infection surveillance and analysis. The IP was hired without completing the required credentials, and both the Administrator and DON were unaware of the need for specialized training in infection prevention and control.
A long-term care facility failed to comply with infection prevention and control guidelines, particularly in managing a COVID-19 positive resident. Observations revealed inadequate PPE provision and improper donning and doffing procedures by staff. The facility also lacked a comprehensive infection surveillance system and failed to implement a proper Respiratory Protection Program, with many staff not fit-tested for respirators. These deficiencies placed residents and staff at risk of infection.
The facility failed to assist four residents in formulating Advance Directives, compromising their healthcare decision rights. Delays in admission paperwork completion, due to staffing issues, led to the absence of documented Advance Directives for these residents, despite their medical conditions requiring clear healthcare preferences.
The facility failed to ensure a safe and clean environment on the 3rd floor. Maintenance and housekeeping rooms were left unsecured with hazardous items, and a resident's room was found in poor condition with unclean floors and improperly hung pictures. Staff confirmed these issues during interviews.
The facility failed to comply with PASRR requirements for four residents, leading to a lack of necessary Level II evaluations for those with serious mental illnesses. Residents with conditions such as anxiety, depression, bipolar disorder, and psychotic disorders were not properly assessed, and the facility lacked an audit system to ensure PASRR validations. The Social Services Director was unaware of the need for further evaluations, highlighting a systemic issue in the PASRR process.
The facility failed to develop and implement comprehensive care plans for residents, including those with mental health needs, discharge planning, dental care, and safety measures. Residents with PASRR requirements, PTSD, and dental issues lacked appropriate care plans, while a resident with impaired vision had a call light consistently out of reach, highlighting deficiencies in care planning and execution.
The facility failed to update care plans for four residents, leading to potential risks. A resident on hospice care had no specific interventions for oxygen use, while another's care plan did not reflect changes in antidepressant medication. Edema management was not addressed for a third resident, and a fourth resident's preference for female caregivers was not documented. Staff interviews revealed a lack of coordination and awareness.
The facility failed to ensure thorough monthly medication regimen reviews by a consultant pharmacist for three residents, leading to unaddressed medication-related irregularities. This oversight involved missing documentation for March and April reviews and placed residents at risk for adverse consequences due to complex medication regimens.
The facility did not ensure that three NACs received the required 12 hours of in-service education per year. Employee files for these NACs, hired on different dates, lacked evidence of the necessary training. The DON acknowledged the deficiency, noting that education logs were outdated and could not provide further documentation.
A resident was found self-administering medications without proper evaluation or a physician's order. The resident, who had no cognitive impairment, was observed with Pedialyte and NeuroBion B12 Forte at their bedside. An LPN was unaware of the medications, and the resident's care plan did not include a self-medication program. The physician later disagreed with the use of NeuroBion, highlighting a failure in the facility's medication management process.
The facility failed to accurately assess a resident's dental needs and two residents' PASRR requirements. A resident was observed with dental issues not reflected in their MDS, and staff had inconsistent understandings of their oral care needs. Additionally, two residents required Level II PASRR evaluations for potential serious mental illness, but their MDS assessments were not coded correctly.
The facility failed to complete required PASRR evaluations for three residents with serious mental illness or intellectual disabilities. One resident's stay exceeded 40 days without a Level II referral, while two others had no evidence of completed Level II assessments despite indications for such evaluations.
A resident at risk for pressure ulcers was not provided with foam boots as required by their care plan. Despite being identified as needing pressure-reducing devices, the resident was observed without foam boots, and the LPN/RCM was unaware of this requirement. This failure to implement necessary interventions placed the resident at risk for pressure ulcer development.
Two residents with limited ROM did not receive necessary restorative services to maintain their functioning. One resident, with a history of stroke and dementia, had inconsistent ROM services without a specified frequency, and the last evaluation was outdated. Another resident, with peripheral vascular disease and cancer, had a sporadic restorative program despite a care plan for regular sessions. Staff documented refusals inaccurately, and there were concerns about the safety of the walking component for one resident.
A resident with peripheral vascular disease, depression, and cancer experienced a failure in receiving necessary dermatology services due to a lack of coordination and documentation by the facility. Despite a referral for a dermatology consult due to a distressing rash, no appointment was scheduled or documented, and staff were unaware of the referral, placing the resident at risk for unmet care needs.
The facility failed to provide written notice to residents, their representatives, and the Ombudsman for three emergency hospital transfers, preventing informed decision-making and access to advocacy.
The facility failed to provide a written bed hold notice at the time of transfer to the hospital or within 24 hours of transfer for three residents. A review of their medical records showed no documentation that the residents or their representatives had been provided with a written bed hold notification. During an interview, the Administrator was unable to provide any information regarding bed holds for these residents. This failure is in violation of the facility's Bed Hold Policy and WAC 388-97-0120 (4)(a-c).
The facility failed to complete and transmit MDS assessments to CMS within the required timeframes for a resident admitted with altered mental status, dementia, anxiety, and COPD. The resident exhibited severe symptoms, leading to their return to the emergency room. The resident was not activated into the computer system, resulting in incomplete MDS assessments.
Unsafe Equipment Maintenance and Lift Battery Failures
Penalty
Summary
Essential equipment was not maintained in safe operating condition. The facility’s high-temperature dishwasher showed fluctuating rinse temperatures during survey observation and interview. On one observation, the rinse cycle read 178 degrees Fahrenheit when the gauge indicated it should be between 180 and 190 degrees Fahrenheit. A thermal pad test then showed a final rinse temperature of 151.5 degrees Fahrenheit. On later observations, the rinse temperature continued to vary, including readings of 179 degrees Fahrenheit, 170 degrees Fahrenheit during additional trays, and then 200 degrees Fahrenheit. Maintenance records reviewed for the prior 15 months documented 14 instances of dishwasher functioning problems and repairs, and a repair estimate from 10/13/2025 stated the unit was not heating well for the final rinse. The facility also failed to ensure Hoyer lifts and sit-to-stand lifts had functional batteries for safe use. A resident reported that the sit-to-stand machine battery frequently died during transfers, leaving the resident hanging while staff searched for another battery. Staff observed multiple attempts to use different batteries on the Hoyer lift, but the machine would not operate even when the battery indicators showed a full charge. Staff reported this had been happening frequently for months and, in another interview, stated the problem had been ongoing for over a year and had been reported to management. During further observation, staff tested several batteries from charging bases and found that three of five facility batteries were not functional despite showing full charge indicators on both the charging base and the lift screen. Staff identified historical dates on the defective batteries and stated they were unsure whether those dates reflected production or expiration dates and did not know the battery lifespan. Residents stated the same equipment failures had occurred to them as well, including being left halfway in the air during transfers, and the concern had been raised in Resident Council meetings multiple times.
Resident Council Concerns Not Resolved or Documented
Penalty
Summary
The facility failed to provide follow-up responses to concerns raised by the Resident Council, leaving multiple issues unresolved and making the Resident Council process ineffective at improving resident quality of life. Facility policy required the facility to act on Council concerns and communicate decisions back to the Council, and the grievance policy allowed concerns voiced during Resident Council meetings to be handled as grievances with prompt efforts toward resolution. However, review of Resident Council meeting minutes and the grievance resolution log showed no documented resolution or facility follow-up for concerns raised about staff talking loudly in the hallways, staff talking in different languages and laughing loudly in the hallways, and laundry items being returned to the wrong residents with bleach stains. During a group interview, residents stated that nursing assistants talked very loudly in the hallways at night, that they frequently received other residents’ clothing from laundry, and that a Hoyer lift battery failure had left residents hanging in the air during transfers. Residents stated these concerns had been brought up in Resident Council meetings, but no change occurred. Staff confirmed that grievance forms were completed for Resident Council concerns and passed to the DON and Administrator, but follow-up on outcomes was not being done. The Administrator stated the facility did not log group concerns from Resident Council meetings into the formal Grievance Log and did not file official grievance reports, and later stated there were no in-service training records or resolution documentation related to the hallway noise or laundry concerns. Review of Resident Council minutes from the period reviewed also showed no documentation of the Hoyer lift concern.
Failure to Provide Discharge Instructions and Required Transfer Notices
Penalty
Summary
The facility failed to provide discharge instructions, evaluate the need for home health support or equipment, and arrange for home medications for Resident 88 when the resident discharged home against medical advice. The progress note for the discharge did not document any instructions, services, or equipment needs, and the electronic medical record contained no discharge summary, discharge instructions, or Notice of Transfer form. Staff interviews showed that the resident left without notice, no services were set up, and no follow-up contact was made after discharge to offer services. The facility also failed to provide written Notice of Transfer forms to the resident or representative for three residents who were transferred or sent to the hospital. Resident 11 was transferred to the hospital, and Resident 9 was sent to the emergency room and did not return, but neither resident had a Notice of Transfer form documented in the medical record. Staff later stated that the facility staff should have included the Notice of Transfer form with transfer instructions, and that they could not find forms for Residents 9 or 11. The report also states that the facility had not been providing notices to residents who were transferred to the hospital.
Medication Storage and Bedside Access Deficiencies
Penalty
Summary
The facility failed to ensure expired medications were removed from a medication room refrigerator, failed to keep a sharps container from being filled past the full line, and failed to document and monitor vaccine refrigerator temperatures in one of the medication rooms. During observation of the sixth-floor medication room, the vaccine refrigerator contained flu vaccine vials, but the temperature logs for multiple dates showed missing AM and PM temperature entries and initials. The same refrigerator also contained a bottle of liquid Amoxicillin and Clavulanate Potassium for Oral Suspension with a pharmacy label showing a filled date of 05/01/2026 and an expiration date of 05/11/2026. A sharps container mounted on the wall adjacent to the vaccine refrigerator was observed filled past the full line and was hanging in an unlocked wall mount. The facility also failed to ensure medications were secured and not accessible at the bedside for one resident. Resident 93 had nasal sprays, triamcinolone cream, Vicks VapoRub, Systane eyedrops, and multiple OTC antifungal creams observed on the overbed table and windowsill during several observations. The resident stated they used the nasal sprays, cream, Vicks, and eyedrops for their symptoms. The resident's order summary did not contain an order allowing bedside medication storage, and an LPN stated that medications and creams such as antifungal creams were not supposed to be at the resident's bedside.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to allow a cognitively intact resident to make choices about daily routines and food preferences. Resident 12, admitted to the facility and assessed as cognitively intact on the admission MDS, reported repeated provision of foods they disliked, including pineapple in fruit cups and chicken in meals. During interviews and observations, the resident stated they disliked pineapple, chicken, beef, and oatmeal, and preferred eggs, sausages, and chocolate milk over the ordered health shake. Staff members acknowledged that the resident disliked chicken, certain green vegetables, oatmeal, pineapple, and some beef dishes, and one staff member stated the kitchen still occasionally served pineapple even though the tray card documented no pineapple. Record review showed Resident 12 had a high-protein diet order dated 04/28/2026, and the lunch tray card documented pineapple as a dislike but did not include the other food restrictions or dislikes reported by the resident and staff. The tray card also showed an order for a health shake that had been manually crossed out. The resident’s weight record showed a decrease from 205.1 pounds on 12/23/2025 to 182 pounds. The report also included the spouse’s statement that before a stroke the resident ate all types of meat, but now disliked chicken and fish due to texture and ate very limited beef, specifically disliking hamburgers.
PASRR Recommendations Not Incorporated Into Care Plan
Penalty
Summary
The facility failed to ensure that Resident 84’s PASRR Level II recommendations were incorporated into the comprehensive care plan and failed to implement individualized activities to meet the resident’s specialized behavioral health needs. Resident 84 was admitted with a diagnosis of bipolar disorder. The facility policy stated that specialized services from a PASARR Level II determination and/or evaluation report would be incorporated into the resident’s assessment, care planning, and transitions of care. Resident 84’s PASRR Level II Initial Psychiatric Evaluation Summary documented recommendations for artwork-related activities, including drawing, painting, and Play-Doh. However, the resident’s care plan contained no interventions for artwork activities. Staff AA confirmed the resident was not provided individualized artwork activities, and Resident 84 stated they liked artwork, painting, drawing, and Play-Doh but there was not much in the facility and they needed more supplies and assistance to set up. Staff X confirmed the resident did not have structured individualized art activities and was unaware of the PASRR activity recommendations or documented preferences. Staff D stated PASRR Level II evaluations were forwarded to other departments by email and that the recommendations should be implemented into the resident’s care plan.
Failure to Update PASRR After Significant Behavior Change
Penalty
Summary
The facility failed to notify the State PASRR Coordinator after a significant change in behavior status for Resident 40. Resident 40 was initially admitted and later readmitted to the facility. The resident’s Level 1 PASRR, dated 11/11/2024, showed no indicators of SMI or ID. The resident’s diagnosis list later included dementia with psychotic disturbance on 08/13/2025, and quetiapine was initiated on 08/28/2025 for paranoia and/or hallucinations. A minimum data set assessment dated 03/09/2026 documented that Resident 40’s current behavior status was worse compared to the prior assessment. Review of the resident’s EMR showed no updated Level 1 PASRR. During interview and record review on 05/14/2026, the Social Service Assistant stated that if a resident had a change in behavior status or a new mental health diagnosis, a new Level 1 PASRR should be completed, and confirmed that an updated Level 1 PASRR was not done when the resident developed dementia with psychotic disturbance and started medication for that condition.
Failure to Provide Oral Care to a Dependent Resident
Penalty
Summary
The facility failed to ensure oral hygiene was performed for one resident who was unable to complete activities of daily living independently. The resident was admitted with diagnoses including stroke with right-sided involvement and removal of a brain tumor. The care plan dated 04/10/2026 documented that the resident was totally dependent on staff for oral care, and the facility policy stated residents unable to perform ADLs would receive necessary services to maintain oral hygiene based on their choices and comprehensive care plan. Review of the nursing assistant documentation for 05/01 through 05/17/2026 showed oral care was marked as not applicable on the evening shift on 7 of 18 opportunities. During interviews, the resident stated they were not always offered tooth brushing, that brushing teeth twice daily was their routine before hospitalization, and that a toothbrush and toothpaste were present in the room. The resident later stated they had not had their teeth brushed since the night before last and had not been offered oral care for several days. A nursing assistant stated oral care was expected at least once per shift, usually after meals, but had not offered oral care that day and was unaware of the resident's prior routine.
Failure to Follow Vision Care and Medication Parameters
Penalty
Summary
Resident 12 was admitted with right side hemiplegia and hemiparesis following a cerebral infarction and was documented as cognitively intact on the admission MDS. The resident stated that the left eye was blind and that items placed on the left side could not be seen. During observation, the call light was placed beside the resident's left upper arm, the television remote control was on the bedside table, and both the bedside table and nightstand were situated on the resident's left side within the blind field. On a later observation, the resident asked where the call light was and it was found lying on the bed to the resident's left. The admission nursing assessment documented impaired vision due to left eye blindness, and the care plan documented impaired visual function related to left eye blindness, but it did not include an intervention directing staff to place the call light and other essential items on the resident's unaffected right side. The admission MDS visual function area also did not document the left eye blindness or related care planning information. Resident 84 was admitted with high blood pressure and had a physician order for a blood pressure medication to be given twice daily with instructions to hold the medication if the heart rate was below 60 bpm. Review of the MAR showed the medication was administered when the resident's heart rate was below 60 bpm on multiple occasions in April 2026 and again on the morning of 05/03/2026. Staff interviews confirmed the order should have been followed and the medication held when the heart rate was below the ordered parameter, and the DON stated the expectation was to read the parameter and hold the medication if it was out of range.
Call Light Accessibility and Fall Risk Assessment Deficiencies
Penalty
Summary
The facility failed to keep a call light within reach for one resident who had a stroke affecting the left side. The resident’s Kardex directed staff to ensure the call light was within reach and to encourage use for assistance. During continuous observation, the resident was lying in bed with the door open and the call light on the floor on the left side of the bed. The call light remained on the floor while multiple staff and a collateral contact passed by or entered the room, and it was not returned to the resident until a nurse manager later entered the room and picked it up. The facility also failed to fully assess and analyze the fall risk for another resident who had diagnoses including stroke with right-sided involvement and removal of a brain tumor. The resident stated they had fallen out of bed and sustained an abrasion to the head, and they had since been placed in a larger bed. At the time of observation, the resident was in a bariatric bed with bolsters defining the mattress border and fall mats on each side. Records showed the resident was left-hand dominant, had been identified as a high fall risk, and required maximum assistance from two staff for bed mobility. The fall investigation documented that the resident rolled out of bed onto the left side and hit their head, but the investigation did not determine which side the resident had been positioned on before the fall and did not include additional witness statements even though the resident required two-person assistance. The root cause analysis attributed the fall to involuntary movements, but progress notes from the admission period through the date of review did not document involuntary movements. A grievance also documented concern about how the resident had been left positioned in bed during a transfer, including the resident’s head being pressed against the headboard.
Inadequate catheter care and infection control
Penalty
Summary
The facility failed to ensure appropriate catheter care for Resident 44, who was admitted with diagnoses including acute prostatitis and urinary retention and had an indwelling catheter related to urinary retention. The resident’s care plan dated 04/29/2026 documented a goal of no catheter-related trauma. Progress notes from 04/29/2026 through 05/13/2026 documented urine testing on 05/08/2026, blood-tinged urine in the catheter bag on 05/11/2026, fever on 05/12/2026 with another urine sample sent to the lab, and a UTI diagnosed on 05/13/2026 with antibiotics started. During observation on 05/13/2026, Resident 44 was seen in a wheelchair with the catheter tubing on the floor and dragging across the floor. On 05/18/2026, the resident was again observed in a wheelchair with the catheter tubing resting on the wheelchair wheel. The resident stated the catheter bag had often been left on the floor and described a recent episode in which staff emptied a full catheter bag and overfilled a urinal, causing urine to spill on the floor, catheter bag, and tubing. That same day, Staff BB was observed emptying the catheter bag by placing it on the floor, placing the urinal on its side on the floor, opening and closing the catheter spout without use of a surface disinfectant, and then rehanging the bag on the wheelchair. Staff BB stated space was limited and that disinfectant was not always used. Staff V stated the expectation was for catheter care to be completed every shift, the spout to be disinfected, and the catheter tubing and bag to never be on the ground.
Failure to Provide Ordered CPAP Therapy
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not maintained for Resident 55, who had a diagnosis of obstructive sleep apnea and a physician order dated 04/21/2026 for CPAP to be on at bedtime and off in the morning, with the mask to be cleansed daily with mild soap and water and air dried. Facility policy for noninvasive ventilation required documentation of machine use, resident tolerance, any skin, respiratory, or other changes, and responses. Review of the April and May 2026 MAR/TAR showed no documentation that the CPAP was applied at bedtime or removed in the morning, although the TAR did contain daily documentation for cleaning the CPAP mask and was signed by licensed nurses. During observation and interview on 05/14/2026, the resident’s CPAP machine was not at the bedside, and the resident stated it was at their daughter’s home and that they were not using it. Staff interviews showed the CNA and LPN had not seen a CPAP machine in the room. Later that day, a social services assistant found the CPAP machine in a plastic bag inside the resident’s room after checking the bedside table cabinet and a drawer by the closet, and the resident stated they did not know it was there and had not been using it. The resident care manager stated the daughter had taken the machine home and staff were not aware it had been brought back, and also stated the resident had a history of refusing to use the CPAP machine, but no documentation of refusal or of staff offering the CPAP could be provided. The admission MDS dated 04/28/2026 documented that the resident used CPAP, but the MDS nurse later stated they could not find documentation supporting CPAP use during the look-back period and would modify the MDS.
Failure to Address Advance Directives and Family Decision-Maker Options
Penalty
Summary
The facility failed to provide medically related social services and to advocate for a cognitively impaired resident regarding advance directives. Resident 81 was admitted with diagnoses including a fall with wedge compression fracture of the upper/middle back, and the care plan documented Mandarin as the primary language. Admission documents, including advance directive options and preferences, were signed by Collateral Contact 4 as the resident surrogate, and preferences were also completed and signed by CC 4. Record review showed an interpreter was used for a brief mental status interview, and the resident scored 11/15, which was indicative of moderate cognitive impairment. CC 4 told staff the resident had a brother, no other siblings, no power of attorney, and no spouse, and stated the resident had relied on them for decisions and was cognitively intact, while also serving as the translator. The Social Services Director stated staff were aware the resident had a son but did not have contact information, and that CC 4 had wanted to handle everything. Progress notes from 04/30/2026 through 05/12/2026 did not document any discussions with the resident about advance directives, preferences, or other family members.
Failure to Provide Ordered Speech Therapy Evaluation
Penalty
Summary
The facility failed to ensure speech therapy services were provided for Resident 91, who was admitted with a diagnosis of stroke and had intact cognition on the admission MDS dated 05/14/2026. Resident 91 stated in interview that they had not seen a speech therapist since admission and said they had to wait for the speech therapist to evaluate them before their meal texture could be upgraded. The resident’s orders included speech therapy evaluation and treatment for swallow and cognitive evaluation, with an order date of 05/07/2026. However, the therapy service log matrix report printed on 05/13/2026 contained no documentation of speech therapy minutes. Staff Q stated residents are normally seen by speech therapy within 24-48 hours after the order is placed, but could not provide notes showing Resident 91 was seen. Staff R confirmed Resident 91 was not seen by speech therapy within 24-48 hours after the order was placed and stated there was no available speech therapist at that time. Staff R also stated the provider was not informed about the delay in the speech therapy evaluation.
Failure to Coordinate Home Health Services and Provide Complete Discharge Documentation
Penalty
Summary
The facility failed to coordinate Home Health (HH) services, provide a medication list, and complete discharge instructions for one resident who was discharged home. The resident had a history of subluxation of the left shoulder, falls, difficulty walking, and chronic pain, and required setup for showers and supervision for ambulation. The discharge summary indicated the resident would require HH services for physical and occupational therapy as well as RN services. However, the Discharge Instruction Form did not include the HH agency or contact information, and there was no documentation of a physician-signed medication list in the resident's medical record. Interviews with facility staff confirmed that Social Services was responsible for arranging HH services and that the discharge instruction form should have included the HH agency name, contact information, and a complete medication list. Staff acknowledged that the Discharge Instruction Form for the resident was incomplete and that there was no documentation of the HH agency or contact information. Additionally, staff were unable to provide documentation of a signed medication list or evidence that HH services had been arranged for the resident at the time of discharge.
Failure to Provide Medically-Related Social Services and Care Planning
Penalty
Summary
The facility failed to provide medically-related social services to all eight residents reviewed, resulting in unmet social service needs. Several residents did not receive support with the care planning process, as evidenced by missing or incomplete documentation of care conferences and lack of communication with residents and their families. For example, one resident's family member, who was the power of attorney, reported a lack of updates and care conferences, despite the resident's declining condition. Another resident expressed frustration over not receiving assistance from social services to address a Medicaid-related issue due to physical limitations, and there was no documentation of recent care conferences for this resident. The facility also failed to provide support for advance directive (AD) formulation and discharge planning. Two residents had no documentation or evidence of being assisted with ADs, and their care plans did not address this area. Additionally, two residents were not kept informed about their discharge plans, with one resident and their family left uncertain about the discharge process and another resident expressing concern about financial matters related to discharge. Documentation in the electronic health records was lacking, and there were no recent notes or updates regarding discharge planning for these residents. Furthermore, the facility did not complete referrals or follow up on recommendations for appropriate mental health services for residents with depression or other mental health diagnoses. In one case, a resident had a psychological evaluation with recommendations, but there was no update to the plan of care by social services. Another resident's PASARR assessment was found to be inaccurate and not updated for a necessary level II evaluation. The facility's social services department was understaffed during this period, with key staff positions vacant or on leave, and temporary support from another facility was being used to cover essential social work tasks.
Failure to Involve Residents in Care Plan Development
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were offered the opportunity to participate in care conferences for two of six sampled residents. Both residents had minimal or no cognitive impairment and were capable of participating in their care planning. Interviews revealed that neither resident was informed about care plan meetings, nor were they involved in discussions regarding their person-centered care, including discharge planning and goal setting. Review of their electronic medical records showed no documentation of interdisciplinary care plan meetings or discussions about initial comprehensive admission care plans, resident-specific goals, or discharge planning. Staff interviews confirmed that the process for arranging and documenting initial care plan meetings was not followed for these residents. The facility's policy requires encouraging and assisting residents or their representatives to participate in care planning, including establishing goals and discharge planning, but there was no evidence this occurred for the two residents in question. The care plans for both residents also lacked focus areas addressing discharge planning.
Failure to Obtain and Document Advance Directives for Multiple Residents
Penalty
Summary
The facility failed to ensure that advance directives (ADs), such as living wills or Durable Power of Attorney (DPOA) for health care, were obtained and completed for three residents. For one resident with minimal cognitive impairment, the admission documentation indicated uncertainty about having an AD, and there was no evidence in the electronic health record (EHR) or care plan that assistance was provided to formulate one. Another resident, who was alert and oriented, also had no AD or DPOA documented, and no follow-up or assistance was recorded in the EHR or care plan. For a third resident with moderate cognitive impairment, the admission packet noted a DPOA, but no copy was found in the EHR, and care conference notes did not mention the AD or DPOA. Interviews with staff, including the Medical Records staff, Assistant Director of Nursing Services, and Director of Nursing, confirmed the absence of required AD documentation and lack of follow-up to assist residents in formulating ADs. Staff described the expected process for obtaining and uploading ADs, as well as social services' responsibility to follow up during initial care conferences, but could not explain why documentation was missing. This deficiency was noted as a repeat issue from a previous survey.
Failure to Provide Written Notice of Medicare Non-Coverage and Potential Liability
Penalty
Summary
The facility failed to provide written notification to a resident and their designated representative regarding potential financial liability for services not covered by Medicare following the end of the resident's skilled nursing facility (SNF) Medicare Part A stay. The resident, who had mild cognitive impairment and an advance directive designating a representative, was notified by phone that Medicare coverage for skilled services would end. However, the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN), which details the costs the resident would be responsible for if they remained in the facility, was not issued to either the resident or their representative. The record showed that while a Notice of Medicare Non-Coverage (NOMNC) was communicated by phone, no written ABN was provided, nor was a signature obtained. The resident's representative confirmed they were not informed about appeal rights, specific costs, or asked to sign any forms, despite being available for in-person communication. The facility administrator acknowledged that both the NOMNC and ABN should have been provided in person or sent by mail or email, with a physical signature obtained as soon as possible.
Failure to Address and Resolve Resident Grievances
Penalty
Summary
The facility failed to ensure that resident grievances were properly addressed and resolved, as required by their grievance policy. Review of the policy indicated that the social services director was designated as the Grievance Official, and staff were expected to document grievances and provide written decisions at the conclusion of investigations. However, during resident council meetings in February and March, residents raised concerns about garbage not being emptied, delays in room painting, and requests for assistance with room organization, but there was no documentation of resolution for these issues. The Activity Director stated that grievances from resident council meetings were sometimes handled informally, such as by writing notes to maintenance, rather than following the formal grievance process. For individual residents, the facility did not follow the grievance process as outlined. One resident reported a missing blanket to their nursing aide and a collateral contact, but no grievance form was completed, and the issue was not entered into the grievance log. The administrator confirmed that no grievance had been filed for this incident. The nursing aide involved stated that a grievance form would only be completed if the resident was upset or needed the item replaced immediately, which is not consistent with the facility's policy. Another resident complained during a resident council meeting about not receiving a shower for four weeks. Although a grievance form was completed and indicated that a shower would be provided the next day, electronic health records showed that the resident did not receive a shower until seven days later. The DON confirmed that the resident should not have had to wait that long for a shower. These failures resulted in residents repeatedly reporting the same care issues without resolution.
Failure to Assess and Care Plan for Use of Potential Physical Restraint
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints unless required for medical treatment, as required by policy. A resident with severe cognitive impairment, Parkinson's, Alzheimer's, and full dependence on staff for mobility and transfers was observed multiple times sitting in a recliner with the legs elevated and an over-the-bed table across their lap. The resident was unable to control the recliner or remove the table independently, and staff confirmed that the recliner's leg rest could only be adjusted manually by staff. There were no physician orders for the recliner, and the resident's medical record lacked documentation of an assessment for safety, evaluation, or consent regarding the use of the recliner and table as potential restraints. Interviews with nursing assistants, an LPN/Staff Development Coordinator, and the Director of Nursing confirmed that the resident could not operate the recliner independently and that required assessments, evaluations, and consents for the use of such equipment were not present in the medical record. The facility's policy required therapy assessment, documentation of medical symptoms warranting restraint use, consent, and care plan updates for any device that could restrict movement, none of which were completed for this resident.
Failure to Identify and Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to identify and report allegations of abuse and/or neglect for three of five sampled residents. For one resident with severe cognitive impairment, a family member submitted a grievance after witnessing the resident's roommate engage in inappropriate physical contact, including kissing the resident on the lips. The facility's social worker investigated by interviewing the resident and others, but did not report the incident to the state, as required by policy. Staff interviews confirmed that all were aware of their mandated reporter responsibilities, and both the LPN/Staff Development Coordinator and the Administrator acknowledged that the incident should have been reported as an allegation of abuse. Another resident, who was alert and oriented, reported waiting 30 minutes for their call light to be answered when needing to use the bathroom, causing distress. The facility documented the incident as a grievance and determined that abuse and neglect were ruled out, as the nursing assistant had gone on break without informing the nurse. The incident was not initially reported to the state, and the LPN/SDC who investigated was unsure why it was handled as a grievance. The Administrator later submitted an incident report to the state after being questioned. A third resident, with moderate cognitive impairment and a history of brain injury, complained during a resident council meeting about waiting over 30 minutes for assistance with toileting and being scolded by an aide after self-transferring to the toilet. There was no documentation of this allegation in the resident's health record, nor was it reported to the state. Staff interviews confirmed that such incidents should be reported as potential abuse or neglect, and facility leadership agreed that the complaint should have been escalated and reported.
Failure to Conduct Thorough Investigations of Abuse and Neglect Allegations
Penalty
Summary
The facility failed to conduct thorough investigations into allegations and incidents involving three residents, as required by its own policies and state regulations. For one resident with a history of a left arm fracture and moderate cognitive impairment, an allegation of delayed call light response was reported during a resident council meeting. However, there was no documentation of the allegation in the state reporting log or the resident's health record, and the investigation lacked interviews with night shift staff, physical or psychosocial assessments, and evidence of support services provided to the resident. Another resident, who had a contusion and laceration of the cerebrum and required moderate assistance with transfers, reported waiting over 30 minutes for call light response at night and being scolded by a nursing assistant after self-transferring to the bathroom. The facility did not log this allegation, failed to document the incident in the resident's health record, and did not conduct or document interviews with relevant night shift staff or provide evidence of education or training for night shift staff. The investigation also lacked ongoing assessments, care plan revisions, and interviews with other residents or staff involved in the incident. A third resident with severe cognitive impairment and Alzheimer's was the subject of a grievance alleging inappropriate touching by a roommate. There was no investigation conducted for this allegation, and key staff were unaware of the grievance. The facility did not escalate the grievance to an abuse allegation or initiate a thorough investigation as required. These failures resulted in incomplete investigations and insufficient documentation for incidents and allegations of abuse or neglect.
Failure to Complete Accurate PASARR Screening for Resident with Mental Disorder
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) Level I was accurately completed for a resident with a diagnosis of recurrent and unspecified major depressive disorder. The resident was admitted with this diagnosis and was receiving daily antidepressant medication, as documented in the Minimum Data Set (MDS) and Medication Administration Record. However, the Level I PASARR form did not indicate the presence of a mood disorder under the Serious Mental Illness (SMI) indicators section, and therefore, no Level II evaluation was initiated. Interviews with facility staff confirmed that the PASARR should have been obtained prior to admission and reviewed for accuracy by social services. The Director of Nursing acknowledged that the PASARR for this resident was not accurate and should have been updated and sent for Level II evaluation before admission. This deficiency was also noted as a repeat issue from a previous survey.
Failure to Update PASRR Assessment After Significant Change in Resident Condition
Penalty
Summary
The facility failed to ensure that Preadmission Screening and Resident Review (PASRR) assessments were completed for residents following a significant change in status or when newly evident or possible serious mental disorders were present. Specifically, one resident with a history of depression, psychotic disorder with delusions, and dementia was readmitted and subsequently prescribed both antidepressant and antipsychotic medications. However, the resident's most recent PASRR did not reflect the use of these medications, nor did it indicate a Level II recommendation, and no updated PASRR was found in the electronic health record. Interviews with facility staff revealed that the process for reviewing and updating PASRR assessments was not consistently followed, particularly in the absence of a social worker. Nursing staff described their roles in monitoring psychotropic medication use and obtaining consents, but there was a lack of clarity regarding responsibility for initiating a new PASRR when a resident began new psychotropic medications after admission. This lapse resulted in a potential delay in access to appropriate Level II PASRR services for the resident.
Failure to Ensure Professional Standards in Oxygen Therapy Administration
Penalty
Summary
The facility failed to ensure that professional standards of practice were implemented for residents receiving oxygen therapy. For three residents reviewed, there were multiple instances where oxygen was administered without a current physician's order, and facility staff were inconsistent in following the facility's policy regarding the changing and dating of oxygen tubing. Observations revealed that oxygen tubing was found on the floor on several occasions, and staff responses to this situation varied, with some staff cleaning and reusing the tubing, while others replaced it. There was also confusion among staff regarding the frequency of tubing changes and the proper documentation required. For one resident with COPD, oxygen was observed in use during the day, despite the physician's order specifying nighttime use only. The oxygen tubing was repeatedly found on the floor, and staff provided conflicting accounts of how to handle such situations. Another resident with chronic respiratory failure reported that their oxygen tubing had not been changed since admission, and observations confirmed that the tubing was undated. The oxygen flow meter settings did not match the physician's order, and staff were unclear about the correct procedures for changing and dating the tubing. A third resident was observed using oxygen without a current physician's order, as the previous order had been discontinued and not renewed. The care plan did not address oxygen use, and staff were unaware of the need for an order or the appropriate care plan updates. Interviews with nursing staff and management revealed a lack of clarity regarding facility policy and expectations for oxygen administration and tubing changes, as well as inconsistent documentation practices.
Failure to Implement Mental Health Recommendations for Resident with Depression
Penalty
Summary
A deficiency occurred when the facility failed to provide treatment and care in accordance with professional standards for a resident with depression and insomnia. The resident, who had moderately impaired cognition and moderate depression, was evaluated by a mental health provider who recommended starting an antidepressant, discontinuing the current sleep medication, conducting further psychological testing, and scheduling a follow-up. Despite these recommendations being documented in the resident's medical record, none were implemented into the plan of care for over three weeks following the evaluation. Interviews with facility staff revealed a lack of awareness regarding the mental health provider's recommendations. The LPN/Staff Development Coordinator was unaware that the resident had been seen by a mental health provider and did not know about the recommendations, citing a new process where mental health providers document directly into the medical record. The DON confirmed that the expectation was for nursing staff to review and implement such recommendations, but acknowledged that the recommendations for this resident were missed and not reviewed.
Failure to Provide and Document Restorative Therapy Services for Resident with Declining Mobility
Penalty
Summary
The facility failed to ensure that restorative therapy services were implemented to prevent avoidable reduction of range of motion (ROM) for a resident with a history of peripheral vascular disease, high blood pressure, and atrial fibrillation. The resident reported not receiving any therapy since being moved to a different floor about a year prior, and stated that therapy was discontinued due to insurance coverage issues. Review of the resident's Minimum Data Set (MDS) assessments showed a decline in mobility and increased dependence on staff for transfers and bed mobility, but no significant change MDS was completed to reflect this change in status. The care plan documented resolved interventions for restorative nursing services, but there was no documentation in the progress notes regarding the implementation or resolution of these services. Interviews with staff revealed a lack of clarity regarding the resident's participation in restorative therapy and the process for reassessment and reapproach after removal from the program. The restorative nurse confirmed that the resident had refused the Restorative Nursing Program and was removed from it, with no current system in place to reassess or reapproach residents who had been discontinued from the program. The Director of Nursing Services acknowledged a performance improvement plan related to restorative nursing services, but it was not active and did not address reassessment of residents previously on the program.
Failure to Implement and Document Aspiration Precautions for Residents with Dysphagia
Penalty
Summary
The facility failed to ensure appropriate safety interventions were developed and implemented for two residents with dysphagia who were at risk for aspiration. For one resident with a history of stroke, heart failure, and facial weakness, observations showed that the resident was eating meals without assistance, despite care plan directives and physician orders for aspiration precautions and checks for oral pocketing after meals. Staff interviews revealed confusion and lack of awareness regarding the resident's swallowing issues and the required level of assistance, with some staff stating the resident did not require help and others indicating the care plan called for substantial assistance. Documentation and communication among staff were inconsistent, and the care plan was not consistently followed. For another resident with dysphagia and a feeding tube, the facility did not address the resident's refusal to comply with an NPO (nothing by mouth) order. The resident was observed eating food brought from outside and reported ordering and consuming regular food, despite a care plan and diet order indicating tube feeding only. There was a lack of documentation regarding the resident's refusal of the NPO order, absence of monitoring for aspiration risk, and no evidence that the physician or family/legal representative was notified. Staff were unaware of the resident's oral intake, and the care plan and Kardex were not updated to reflect the resident's non-compliance or the need for monitoring. The facility's policy required documentation of treatment refusal, notification of the physician and legal representative, referral to social services, and care plan updates when refusal or non-compliance occurred. However, these steps were not followed for the resident who refused the NPO order. The lack of appropriate interventions, monitoring, and documentation placed both residents at risk for aspiration and related health complications.
Failure to Provide Bowel/Bladder Retraining and Appropriate Toileting Services
Penalty
Summary
A resident with a history of peripheral vascular disease, hypertension, and atrial fibrillation was admitted to the facility and initially assessed as frequently incontinent of bowel and bladder, requiring extensive assistance for toileting. Over time, the resident's care documentation showed a progression to total dependence for toileting, with no transfers to the toilet occurring. Despite quarterly and admission assessments indicating the resident was a possible or likely candidate for bowel and bladder retraining, there was no documentation of any assessment or implementation of a bowel/bladder retraining program. The resident reported being able to use the toilet for bowel movements during therapy but was told to use briefs after being moved to a different floor, where staff stated there was no accessible bathroom. Staff interviews revealed inconsistencies and errors in the completion of bowel and bladder assessments, with some staff unaware of the resident's current abilities or not having spoken directly to the resident about toileting needs. The care plan directed staff to check and change the resident every two to three hours but did not address restorative or retraining interventions. Therapy discharge notes indicated the resident would benefit from restorative nursing services, but no further therapy or restorative services were provided. The lack of appropriate assessment and services to restore continence contributed to the deficiency identified in the report.
Unlocked Treatment Cart with Medications and Needles Left Unattended
Penalty
Summary
A treatment cart on the 3 South Unit was found unlocked and unattended, containing prescribed topicals, ointments, wound cleaning agents, and hypodermic needles. Observations showed that the drawers of the cart were accessible to anyone passing by, including residents, with no licensed staff present in the area. Items found in the cart included a tube of topical pain gel, three bottles of Dakin's solution, multiple tubes of Medi honey, iodine swabs, five bottles of nystatin powder, several hypodermic needles, and various wound bandages. The facility's policy requires that medications and biologicals be stored properly and only accessible to licensed nursing personnel, with supplies remaining locked when not in use or unattended. Interviews with staff confirmed that the expectation was for treatment carts to always be locked when not in use. The Registered Nurse on duty was stationed elsewhere and did not have the cart in view, and the Assistant Director of Nursing Services/Infection Preventionist reiterated that treatment carts should always be locked. The Director of Nursing Services was unaware that the cart had been left unlocked and unattended for 22 minutes. Residents were observed moving past the unlocked cart during this time.
Failure to Address Nutritional Needs Leads to Significant Weight Loss
Penalty
Summary
The facility failed to adequately assess and document the dietary preferences and nutritional intake of a resident, leading to significant weight loss. Resident 46, who was admitted with conditions including sepsis, urinary tract infection, diabetes, muscle wasting, and atrophy, experienced a severe weight loss of 11.8% over 34 days. The facility did not maintain accurate documentation of the resident's nutritional intake, failed to notify the physician of the significant weight loss, and did not perform consistent and accurate weight measurements. Additionally, the care plan for the resident did not include any food preferences, and the resident reported not receiving culturally appropriate meals. Observations and interviews revealed that Resident 46 was not consistently offered meal substitutes or replacements when consuming less than 50% of their meals. The resident expressed dissatisfaction with the food provided, stating a preference for vanilla shakes over chocolate, which was not communicated to the dietary staff. Despite the resident's significant weight loss, the facility staff failed to notify the physician or take appropriate action to address the resident's nutritional needs. The documentation inaccurately reflected the resident's meal consumption, further complicating the assessment of their nutritional status. Interviews with facility staff highlighted a lack of communication and coordination in addressing the resident's nutritional needs. Staff members were unclear about their responsibilities in notifying the physician of weight loss and offering meal alternatives. The facility's policies on weight monitoring and nutrition were not followed, contributing to the resident's continued weight loss and diminished quality of life. The failure to adhere to these policies and procedures placed the resident at nutritional risk and compromised their overall well-being.
Inadequate Qualifications for Infection Preventionist Role
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP) met the necessary qualifications for experience, education, and training or certification required for the role. This deficiency was identified through interviews and record reviews, which revealed that the IP, a Registered Nurse (RN) named Staff C, was hired on 05/06/2024 but only completed their infection prevention credentials on 06/06/2024. The facility's policy requires the IP to lead surveillance activities, maintain documentation, and report findings, but Staff C was not adequately prepared to fulfill these responsibilities. Further investigation showed that there was no interpretation or analysis of infection data for March and April 2024, and no infection surveillance was conducted in May 2024. During an interview, Staff C admitted to being unaware of the infection surveillance process for the facility's Quality Assurance Improvement Process and acknowledged the need for more training. Additionally, the facility's Administrator and Director of Nursing Services were unaware that the IP role required specialized training in infection prevention and control, confirming that Staff C had been in the role since their hire date.
Infection Control and PPE Failures in LTC Facility
Penalty
Summary
The facility failed to ensure compliance with Infection Prevention and Control Guidelines, particularly in the management of a resident who tested positive for COVID-19. Resident 14, who had a history of heart disease and stroke, was placed on transmission-based precautions after testing positive for COVID-19. However, observations revealed that the necessary personal protective equipment (PPE) was not adequately provided, as there was no eye protection available near the resident's room. Additionally, staff were observed not following proper donning and doffing procedures for PPE, including the reuse of N95 respirators and improper hand hygiene practices. The facility also failed to maintain an effective infection surveillance system. Despite requests, the facility could not provide a comprehensive infection surveillance log for the past 90 days, particularly for May 2024. The logs that were provided lacked analysis, interpretation, and evaluation of infection data, which are essential components of an infection prevention and control program. This lack of documentation and analysis indicates a failure to monitor and manage infections effectively within the facility. Furthermore, the facility did not implement a proper Respiratory Protection Program (RPP) for its staff. A significant number of employees had not been fit-tested for respirators, and some had never been fit-tested at all. Observations showed staff wearing N95 respirators incorrectly, with facial hair interfering with the seal, and discomfort due to improper fit. The Infection Preventionist, who was responsible for overseeing the RPP, had not received training on the process, further contributing to the facility's failure to protect staff and residents from respiratory hazards.
Failure to Formulate Advance Directives for Residents
Penalty
Summary
The facility failed to obtain, provide, and assist with completing Advance Directives for four out of five sampled residents, which compromised their right to have their healthcare preferences and decisions honored. Resident 32, admitted with a tibia fracture and infection, had no Advance Directives formulated upon review of their medical record. Although the facility's process included Advance Directive documentation in the admission agreement, a delay in completing admission paperwork due to a new administrative assistant resulted in the absence of a signed Advance Directive document for Resident 32 until several days after admission. Similarly, Resident 65, admitted with multiple fractures, also lacked formulated Advance Directives in their medical record. Staff could not confirm the existence of such documents until days later. Resident 22, a long-term care resident, reported not being asked about Advance Directives, and their medical record showed no documentation of being informed of their rights. Resident 62, admitted for aftercare treatment post-heart surgery, had no Advance Directives formulated, and the admission paperwork indicating they were offered information was signed 23 days post-admission. The facility's social services and administrative staff were behind on admission agreements, contributing to these deficiencies.
Failure to Maintain a Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on the 3rd floor, as observed during a survey. Maintenance and housekeeping rooms near a resident's room were found unlocked and unsecured, containing potentially hazardous items such as paint, caulk, tools, and chemicals like Aromazyne drain and grease trap maintenance odor eliminator. Staff interviews confirmed that these rooms were supposed to be locked, yet they remained unsecured during multiple observations. Additionally, a resident's room was observed to be in poor condition, with walls showing stains, patches of different colors, and improperly hung pictures. The floor was not cleaned, as evidenced by the presence of small, round debris near the bedside table and oxygen concentrator, which remained over several days. The oxygen tubing was found touching the debris, and a staff member confirmed that the floor was not cleaned despite daily housekeeping visits.
Failure to Ensure PASRR Compliance for Residents
Penalty
Summary
The facility failed to ensure compliance with the Preadmission Screening and Resident Review (PASRR) requirements for four residents, which is a federal mandate to ensure individuals with mental disorders or intellectual disabilities receive appropriate care. Resident 7, who was admitted with diagnoses including anxiety, depression, and bipolar disorder, had a PASRR indicating a serious mental illness and the need for a Level II evaluation. However, there was no documentation in the medical record showing that the PASRR had been validated or that there was any communication with the PASRR validator. Similarly, Resident 42, admitted with multiple psychiatric disorders, had a PASRR indicating a serious mental illness and the need for a Level II evaluation. The medical record lacked documentation of PASRR validation or communication with the validator. Staff D, the Social Services Director, admitted there was no audit system in place to follow up on PASRRs requiring further assessments or validations, and they were unaware of the need for Level II evaluations for Residents 7 and 42. Resident 21, with a history of major depressive disorder and psychotic disorder, had a PASRR that inaccurately indicated no need for a Level II evaluation despite evidence of psychosis and antipsychotic medication use. Resident 26, diagnosed with depression and cancer, also had a PASRR that did not indicate the need for a Level II evaluation, despite documented depressive symptoms. Staff D was unaware of the inaccuracies in the PASRRs for Residents 21 and 26, indicating a systemic issue in the facility's PASRR process.
Deficiencies in Care Planning and Implementation
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for several residents, leading to deficiencies in care. Resident 32 and Resident 6, both with diagnoses including depression and anxiety, had positive Level I PASRR screenings indicating the need for a Level II PASRR care plan. However, their clinical records showed no such care plans were developed. Interviews with staff revealed confusion about responsibility for completing these care plans, with social services identified as the responsible department, yet no action was taken. Resident 65, admitted with fractures, expressed concerns about discharge planning, specifically regarding the need for a hospital bed at home. Despite the resident's imminent discharge, no care plan was in place, and the resident reported no discussions with facility staff about their discharge needs. Staff interviews confirmed that discharge planning should have been initiated upon admission, but it was not completed for this resident. Additional deficiencies were noted for Resident 42, who had PTSD and other mental health diagnoses, yet lacked a care plan addressing their PTSD. Staff were unaware of the resident's PTSD diagnosis due to the absence of a psycho-social assessment. Resident 26, with dental issues, had no care plan for dental care despite assessments indicating potential cavities and broken teeth. Lastly, Resident 422, with impaired vision and communication, had a care plan intervention to keep the call light within reach, but observations showed the call light was consistently out of reach, indicating a failure to implement the care plan effectively.
Failure to Revise Comprehensive Care Plans
Penalty
Summary
The facility failed to revise comprehensive care plans for four residents, leading to potential risks for unmet care needs. Resident 8, who was admitted to hospice services, had an oxygen concentrator in their room, but their care plan lacked specific interventions related to hospice aide use, medication changes, or oxygen concentrator use. Staff interviews revealed a lack of awareness and coordination between hospice and facility staff, with no hospice care plan maintained by the facility. Resident 21's care plan did not reflect changes in their antidepressant medication use, despite pharmacy reviews and representative input indicating medication adjustments due to side effects like lethargy. The care plan still listed outdated medications, and there was no routine interdisciplinary meeting to update care plans for residents on psychotropic medications, as confirmed by the Social Services Director. Resident 26's care plan did not address edema management, despite observations of swelling and interventions like medication use and leg elevation being in place. The care plan only mentioned cellulitis and skin integrity issues. Additionally, Resident 58's care plan failed to document their preference for female caregivers, even after a fall incident and family input indicated this preference. The care plan only addressed scheduled toileting without considering the resident's caregiver preference.
Failure in Conducting Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that the consultant pharmacist conducted thorough monthly medication regimen reviews (MRRs) and identified and reported medication-related irregularities for three of the five sampled residents. This deficiency was identified during a review of pharmacy consultant reports and interviews with facility staff. The facility was unable to provide pharmacy reviews for March and April 2024 initially, and later, when the reports were found, there was no documentation that recommendations had been reviewed and acted upon. This lack of action placed residents at risk for medication-related adverse consequences and unnecessary psychotropic medications. Resident 18, who was admitted with multiple diagnoses including chronic pain syndrome, diabetes, and PTSD, had a complex medication regimen involving multiple medications for cardiac use, blood sugar regulation, pain management, mental health, and bowel movements. There was no documentation of a pharmacist's review of this resident's medication regimen. Similarly, Resident 21, with diagnoses including major depressive disorder and Alzheimer's disease, and Resident 26, with peripheral vascular disease and cancer, also had no documented pharmacist review of their medication regimens since February 2024. These oversights in medication management highlight the facility's failure to adhere to established guidelines for medication regimen reviews.
Deficiency in Required In-Service Education for NACs
Penalty
Summary
The facility failed to ensure that three Certified Nursing Assistants (NACs), identified as Staff G, H, and I, received the required 12 hours of in-service education per year. This deficiency was identified through a review of employee files and interviews. Staff G was hired on 05/19/2019, Staff H on 03/10/2020, and Staff I on 12/03/2022. None of their files showed evidence of the required in-service education for the prior year. During an interview, the Director of Nursing Services, Staff B, acknowledged that the education logs were mostly from 2022 and could not provide further documentation to verify the required training hours for the staff in question.
Failure to Evaluate and Approve Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident was properly evaluated and assessed for self-administration of medications, and a physician's order was not obtained for this practice. Resident 46, who was admitted without cognitive impairment, was observed with a bottle of Pedialyte and a box of NeuroBion B12 Forte on their bedside table. The resident reported taking one dose of NeuroBion daily. However, there was no documentation in the resident's care plan indicating they were on a self-medication program. During an interview, an LPN stated they were unaware of the Pedialyte and did not see the NeuroBion container. The LPN also did not know if the resident was on a self-medication program. A nursing progress note later revealed that the resident's physician did not agree with the use of NeuroBion due to potential problems and allowed only a limited quantity of Pedialyte. This oversight placed the resident at risk for adverse medication interactions and complications.
Inaccurate Assessments for Dental and PASRR Needs
Penalty
Summary
The facility failed to complete accurate assessments for several residents, leading to potential unmet care needs. Resident 58, who was admitted with diagnoses including kidney failure and atrial fibrillation, was observed to have visibly missing teeth and dark gray discoloration at the gumline, despite their Minimum Data Set (MDS) assessment indicating no dental issues. Interviews with staff revealed inconsistencies in the understanding of Resident 58's oral care needs, with some staff believing the resident completed oral care independently or with assistance from their spouse. The MDS nurse stated that if a resident would not allow an oral cavity assessment, the MDS should be coded as unable to examine, but this was not done for Resident 58. Additionally, the facility failed to accurately complete the Pre-Admission Screening and Resident Review (PASRR) for two residents. Resident 6 and Resident 32 both had positive Level I PASRR screenings, indicating the need for a Level II evaluation due to potential serious mental illness. However, their MDS assessments did not reflect this requirement, and interviews with the Social Services Assistant confirmed the MDS was not coded correctly for these residents. These inaccuracies in assessments could lead to inadequate care planning and support for the residents' mental health needs.
Failure to Complete PASRR Evaluations for Residents
Penalty
Summary
The facility failed to ensure the completion of the Pre-Admission Screening and Resident Review (PASRR) forms according to federal guidelines for three residents. Resident 2 was admitted from an acute care hospital and was initially exempted from a Level II PASRR referral due to an expected discharge within 30 days. However, the resident's stay exceeded 40 days without a Level II referral being made, despite the resident no longer meeting skilled Medicare criteria. Staff E, a Social Services Assistant, confirmed that no referral was made, and there were no notes indicating such an action. Residents 6 and 32 were both admitted with diagnoses including depression and anxiety, and their Level I PASRRs indicated the need for a Level II assessment. However, there was no evidence in their clinical records that these evaluations were completed. Staff E and Staff D, the Social Services Director, acknowledged the oversight and stated they would follow up with the PASRR coordinator. The lack of completed Level II evaluations for these residents indicates a failure in the facility's process for ensuring appropriate assessments and referrals for residents with serious mental illness or intellectual disabilities.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to provide necessary care planned interventions for a resident at risk for pressure ulcers (PU). The resident, who was admitted with diagnoses including stroke, high blood pressure, spinal stenosis, and a rotator cuff tear, was identified as being at risk for skin breakdown due to incontinence and immobility. The care plan for the resident included the use of a low air loss mattress, pressure reduction cushion, and foam boots to prevent PU development. However, observations and interviews revealed that the resident was not provided with foam boots as required by their care plan. Despite the care plan and Kardex directing the use of foam boots for protection, the resident was observed without them on multiple occasions. The Licensed Practical Nurse/Resident Care Manager (LPN/RCM) was unaware of the resident's need for foam boots and stated there was no order for them. This lack of implementation of pressure-reducing devices, as per the physician's orders, placed the resident at risk for the development and worsening of pressure ulcers.
Inadequate Restorative Care for Residents with Limited ROM
Penalty
Summary
The facility failed to provide necessary services to maintain or improve the range of motion (ROM) for two residents, leading to a deficiency in care. Resident 14, who had a history of stroke and dementia, was supposed to receive active and passive restorative ROM services. However, the care plan did not specify the frequency of these services, and the last restorative evaluation was conducted in 2021. Documentation showed inconsistent provision of ROM services, with numerous refusals and instances marked as not applicable, without clear indication of the expected frequency. Interviews revealed that staff documented refusals even when services were not offered, and there was no current restorative assessment to support the program. Resident 26, diagnosed with peripheral vascular disease, depression, and cancer, also did not receive adequate restorative care. Although their care plan included a restorative program to be conducted five to six times a week, documentation showed sporadic implementation of the program. The resident expressed concerns about losing strength due to inactivity and stated they were not receiving the restorative program. Staff interviews indicated that refusals were documented when the program was not administered, and there were concerns about the resident's ability to safely participate in the walking component of the program. Overall, the facility's failure to ensure consistent and appropriate restorative services for these residents placed them at risk for decreased ROM and diminished quality of life. The lack of updated assessments, clear documentation, and proper implementation of care plans contributed to the deficiency identified by the surveyors.
Failure to Coordinate Dermatology Services for Resident
Penalty
Summary
The facility failed to obtain necessary dermatology services for Resident 26, who was admitted with diagnoses including peripheral vascular disease, depression, and cancer. Despite a dermatology referral being made on 01/18/2024 due to a distressing rash on the resident's legs, there was no follow-up or documentation of a scheduled dermatology appointment in the resident's progress notes. The resident expressed a desire for a second opinion regarding the rash, but was informed by a nurse practitioner that they could not see a skin specialist. Interviews with facility staff revealed a lack of awareness and coordination regarding the dermatology referral. Staff M, a Licensed Practical Nurse/Resident Care Manager, mentioned that an appointment had been scheduled but was canceled at the resident's request, yet there was no documentation to support this claim. Staff W, a Health Unit Coordinator, was unaware of any dermatology referrals and confirmed that no documentation existed in the electronic medical record about such an appointment. This lack of coordination and documentation placed the resident at risk for unmet care needs.
Failure to Provide Written Notice of Emergency Transfers
Penalty
Summary
The facility failed to provide a written notice to the resident, resident's representative(s), and the Office of the State Long-Term Care Ombudsman of an emergency transfer for three residents reviewed for hospitalizations. This failure did not allow residents and/or their representatives to make informed decisions about transfers and prohibited access to an advocate who could inform them of their options and rights. Specifically, Resident 1 was transferred to the hospital without any documentation of a transfer/discharge form or notification to the relevant parties. Similarly, Resident 2 and Resident 3 were also transferred to the hospital without the necessary documentation and notifications. During a joint interview and record review, the facility's administrator confirmed that there were no transfer/discharge notices completed for the three residents when they were transferred to the hospital. The facility's policy on transfer and discharge, revised on 05/01/2024, mandates that a notice of transfer and the facility's bed hold policy be provided to the resident and representative, and copies of notices for emergency transfers be sent to the Ombudsman when practicable. However, this policy was not followed in the cases of Residents 1, 2, and 3.
Failure to Provide Bed Hold Notice
Penalty
Summary
The facility failed to provide a written bed hold notice at the time of transfer to the hospital or within 24 hours of transfer for three residents. Resident 1 was discharged to the hospital on April 20, 2024, Resident 2 on April 15, 2024, and Resident 3 on February 22, 2024. A review of their medical records showed no documentation that the residents or their representatives had been provided with a written bed hold notification. During an interview on May 16, 2024, the Administrator was unable to provide any information regarding bed holds for these residents. This failure is in violation of the facility's Bed Hold Policy dated May 1, 2024, and WAC 388-97-0120 (4)(a-c).
Failure to Complete and Transmit MDS Assessments Timely
Penalty
Summary
The facility failed to complete and transmit resident assessment data to CMS within the required timeframes for one resident whose MDS assessments were reviewed for timeliness. Resident 1 was admitted with diagnoses including altered mental status, dementia, anxiety, and Chronic Obstructive Pulmonary Disease. Upon review, it was found that an Entry or Discharge MDS assessment had not been completed for this resident. Staff D, an LPN/Admission Nurse, reported that the day Resident 1 was transferred was chaotic, and the resident exhibited severe symptoms such as trying to escape and pulling out a catheter. Consequently, the decision was made to send the resident back to the emergency room. Staff A, the Administrator, confirmed that Resident 1 was not activated into the computer system, resulting in the failure to complete the necessary MDS assessments.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Everett
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Everett Transitional Care Services | 1.2 mi | ★★★★★ | 8 | 0 |
| View Ridge Care Center | 3 mi | ★★★★★ | 16 | 0 |
| Madison Post Acute | 3.6 mi | ★★★★★ | 29 | 0 |
| Mountain View Rehabilitation And Care Center | 4.5 mi | ★★★★★ | 9 | 0 |
| Marysville Care Center | 5.2 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.