Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Birch Creek Post Acute & Rehabilitation during CMS and state inspections, most recent first.
Failure to notify POA when anticoagulant was stopped: A resident with DVT/PE history, dementia, and severe cognitive impairment had an anticoagulant ordered BID and administered until it was not continued. The RN said the pharmacy refill was not filled, the on-call provider said the med was no longer needed, and the POA was not notified. The POA said they only learned of the stop after the facility called about leg swelling and stated they could have provided records showing the resident needed lifelong anticoagulation.
A resident with cancer, cognitive impairment, and declining strength experienced multiple unwitnessed falls, most occurring while attempting to toilet or move toward the bathroom, culminating in a fractured ankle requiring ED treatment. Although assessments identified fall and incontinence risks and the facility’s policy required individualized interventions, the comprehensive care plan lacked a toileting plan and did not include several interventions that were discussed in incident investigations, such as consistent wheelchair placement and frequent rounding for bathroom assistance. Staff reported relying on verbal reminders and education to use the call light, despite acknowledging the resident’s impulsivity and failure to call for help, and the resident’s bed remained furthest from the bathroom while repeated bathroom-related falls occurred without the trend being recognized or addressed in the care plan.
A resident with a history of acute urinary retention and acute kidney injury had a Foley catheter deemed permanent by the hospital, with instructions that it not be removed in the SNF. At a later urology visit, the catheter was removed, and the resident returned with no new orders documented. Facility staff did not document bladder assessments, post-void residuals, or urine output, and CNA documentation showed the resident did not void that evening. Over the next day, the resident had vomiting, poor intake, altered level of consciousness, tachycardia, hypotension, and no documented wet briefs. A bladder scan eventually showed more than 2000–2500 mL of retained urine, and a new catheter drained a large volume. The resident and a roommate reported moaning, crying out in pain, and repeatedly alerting staff that the resident was not urinating and that the catheter was not draining, while nurses documented catheter care when no catheter was in place and later had to flush and replace the catheter due to continued complaints.
Surveyors found that nurses and nurse aides did not consistently administer medications according to professional standards and facility policy. Multiple residents reported that agency nurses were slow with medications, did not fully follow instructions, and often gave routine meds late. Observations showed an LPN administering expired Humalog/Lispro insulin well past the scheduled time, an LPN giving several scheduled meds (including Tizanidine) late and all at once, and an RN attempting to give sliding-scale insulin nearly two hours late, which a resident refused after already eating. Another resident received Methocarbamol two hours late after questioning the RN, and a resident on scheduled Tramadol had doses given without timely documentation, with a discrepancy between the narcotic count and pills remaining. These events demonstrated failures in timely administration, use of non-expired medications, and immediate, accurate MAR and narcotic documentation.
A resident council reported repeated mismatches between posted menus and food actually served, including soup, omelets, and other items, along with inconsistent serving sizes and lack of notice when menu or brand changes occurred. During kitchen observation, staff served chicken thighs instead of chicken legs and used incorrect scoop sizes for side dishes; the RD identified that the wrong portion scoop was used, and the DON was unsure of the correct scoop size.
Unsafe Food Storage and Preparation Practices: Surveyors observed opened, undated, and uncovered food in the walk-in freezer and kitchen refrigerators, salad ingredients and prepared salads left out at the salad station without temperature control, and personal items in the kitchen. The cook was observed cleaning a thermometer on a dry towel between foods and working with an uncovered beard, while another staff member entered the kitchen without hand hygiene or a hair/beard net. Resident refrigerators also contained undated food, frozen nutrient drinks labeled do not freeze, and incomplete temperature logs.
Failure to monitor psychotropic medication side effects and behaviors for three residents. One resident on trazodone had no documented monitoring for adverse effects or behaviors, another resident on quetiapine had no documented orthostatic BP checks despite an order for them, and a third resident on citalopram and buspirone had no documented side effect or behavior monitoring. The DON stated the monitoring should have been done, and staff noted the behavior monitoring was missing.
The facility failed to thoroughly investigate resident accidents to rule out abuse or neglect. One resident with Parkinson's disease had a leg injury during a transfer, but the incident report lacked witness and staff statements and the CNA involved was not interviewed. Another resident with dementia had multiple unwitnessed falls, and many incident investigations did not include witness statements or interviews with assigned staff, despite the DON stating staff should be interviewed after unwitnessed falls.
Failure to Complete or Update PASSAR Screenings for Residents With Mental Health Diagnoses: The facility did not complete or update PASSAR screenings for multiple residents with MH diagnoses on admission or after new diagnoses were added. Several residents had diagnoses such as dementia, depression, schizophrenia, anxiety, bipolar disorder, hallucinations, and PTSD, yet the PASSARs were missing, incomplete, or not re-completed when the records changed.
A facility failed to develop complete care plans for 4 residents with identified care needs. One resident had oxygen therapy needs tied to heart and respiratory diagnoses, another had a chronic left foot wound, a third had an indwelling catheter with routine catheter care, and a fourth used O2 and had trazodone ordered for insomnia. The record showed missing or delayed care plan documentation for these needs, and the DON and LPN/UM acknowledged the gaps.
Respiratory care was not provided consistently for three residents with O2 needs. A resident with heart failure and respiratory disease, a resident with COPD, and a resident with COPD and chronic respiratory failure were observed receiving O2 at rates that did not match provider orders, and staff later adjusted the flow for two of them. The record also lacked orders or documentation for routine O2 tubing changes and concentrator filter cleaning, and one resident’s tubing was not dated.
Advance Directives Not Periodically Reviewed or Documented: The facility failed to periodically review and provide assistance with advance directives for two residents. One resident with Parkinson's disease and adult failure to thrive believed a durable power of attorney had been established, but the facility had not obtained the document. Another resident with MS and dementia did not have an advance directive, wanted to establish one, and later was unsure whether one existed. The SS Director stated advance directives were to be reviewed quarterly, but follow-up was not completed for either resident.
SNF ABNs were not timely or fully completed for two residents reviewed for beneficiary notification. Each resident had a NOMNC stating skilled services would end, but the corresponding ABN forms were signed much later and the Care section was left blank. The DOSS and Administrator stated the forms did not meet expectations because they were incomplete and should have been provided when the NOMNCs were issued.
A resident bathroom had a gouged floor at the entryway plus scrapes, gouges, and chipped paint on the wall, and multiple resident closets were missing doors, exposing personal items. Residents stated they wanted closet doors or were unaware they were missing, while a CNA said the issues were not entered into TELS and the Maintenance Director and DON were not aware of all of the missing doors on the hall.
MDS assessments were inaccurate for 3 residents. One resident with diabetes, dementia, COPD, and a chronic left foot wound was coded as having no wounds on the significant change MDS, while an MDSC and the DON said it should have reflected the foot lesion. Another resident with bipolar disorder and schizoaffective disorder had a level 2 PASARR on record, but the annual MDS did not show it. A third resident with stroke and heart failure was marked as receiving an anticoagulant on the annual MDS even though the medication had been discontinued, and the MDSC said it should not have been coded yes.
A resident with dementia did not have a timely care conference aligned with the MDS schedule, and the most recent conference involved only the Activities Dept. Another resident with a gastrostomy had an enteral feeding care plan that listed conflicting eating status information, including NPO and receiving a tray in addition to tube feedings, while staff stated the plan was not updated.
Failure to provide ordered wound care and follow BP medication parameters occurred for two residents. One resident with cancer had soiled, undated dressings on the wrist and hand, and the ordered wound care did not appear on the TAR. Another resident with HF and ESRD received Metoprolol and Hydralazine despite SBP being below the ordered hold parameters, and the DON stated meds were to be given according to the provider's orders.
Pressure Ulcer Care and Documentation Deficiencies: A resident admitted with hospice, dementia, diabetes, and kidney failure had a sacral stage 2 pressure ulcer, but repeated observations showed the air mattress was set at the highest pressure with a low-pressure alarm. An LPN said the mattress was rental equipment set up by the company, while the hospice RN later said the setting was in error. The facility also failed to document the ulcer’s progress, as the care plan, wound form, and weekly skin checks did not describe the sacral wound’s size, color, or drainage.
Incomplete Investigation of Resident Skin Tear: A resident with Parkinson’s disease and adult failure to thrive sustained a skin tear to the lower leg, but the facility’s incident review did not include resident or witness statements and concluded the injury came from the bed rail. A wound care note later documented the resident reported being injured while getting into a wheelchair, and the CNA involved in the transfer said they were not interviewed or asked for a statement. The DON stated the resident was not reassessed for the level of support needed for transfers.
Failure to follow an ordered fluid restriction occurred for a resident with HF and ESRD on dialysis. The resident stated they were on a fluid restriction, but the MAR showed repeated discrepancies between day/night fluid entries and total consumed amounts, and an LPN said residents with fluid restrictions did not receive water pitchers while the total amount consumed was documented in the MAR; the DON stated licensed nurses were to follow orders and document clearly.
A resident with a gastrostomy tube and diagnoses including cerebral infarction, anxiety, and depression received enteral nutrition that was not documented in accordance with provider orders. The MAR showed formula and water amounts recorded at both 10:00 AM and 2:00 PM that did not reconcile with the ordered 20-hour feeding schedule, and staff stated the machine was driving the documentation while the DON said the tube feeding should have a clear amount.
Pain management was not consistently provided for two residents. One resident with head/face and neck cancer reported constant pain, but the EHR showed only an initial pain score and no ongoing daily pain monitoring despite an order for PRN oxycodone. Another resident with heart failure, ESRD, and dialysis dependence received PRN hydromorphone frequently, but the ordered NPI was rarely documented and then not documented at all over a later review period; staff and the DON gave differing statements about where the interventions should be recorded.
A resident with anxiety disorder, dementia, and schizophrenia reported that dentures left behind when moving into the facility were never retrieved. An outside dental provider documented the resident wanted a new set of dentures ASAP, but the care plan only noted no teeth and a referral to a dentist as needed, with no documentation of the denture need. Staff were unsure whether the request was followed up, and no dental appointments were scheduled after the request.
Two residents with dementia did not receive individualized care and services to address their behavioral symptoms, including wandering, exit-seeking, entering other residents' rooms, and yelling out. Care plans lacked specific interventions for these behaviors, and staff responses such as redirection and stop signs were inconsistently applied and ineffective in preventing distress to other residents.
A resident with severe cognitive impairment was found with a raised bump on the forehead and bruising on the back, but staff did not initiate an incident report or conduct a thorough investigation as required by policy. Despite reports from family and visible injuries, documentation and assessment were lacking, and the incident was not entered into facility logs. Staff interviews revealed confusion about the cause of the injuries, and the facility failed to comply with investigation and reporting requirements.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
Staff failed to promptly report suspicions of an inappropriate relationship between a staff member and a resident with complex medical needs. Multiple staff members observed or were told about concerning behavior but did not immediately notify administration, resulting in an eight-day delay before the allegation was reported and investigated.
The facility failed to store and prepare food safely, with undated and improperly labeled food items found in the kitchen, and food boxes stored on the freezer floor. Personal items were improperly placed in food preparation areas. Staff were observed not following proper hand hygiene and food temperature protocols, as confirmed by interviews with the Dietary Manager and Administrator.
The facility failed to obtain and periodically review advanced directives (AD) for three residents, denying them the opportunity to direct their healthcare. A resident with diabetes and depression had no follow-up on AD paperwork, another with a stroke and bipolar disorder had no further follow-up on durable power of attorney, and a resident with dementia had no AD documented. The Social Service Director acknowledged the lack of follow-up, and the facility administrator stated that ADs should be discussed quarterly.
The facility failed to properly screen residents with mental health disorders for additional support through the PASARR process. Several residents had PASARR forms that did not accurately reflect their diagnoses, leading to a lack of required level 2 evaluations. The Social Service Director and Administrator acknowledged these discrepancies.
The facility failed to implement baseline care plans within 48 hours for three residents, leading to unmet care needs. A resident with dementia and diabetes did not receive necessary assistance with eating, while another with heart and kidney failure lacked care plans for oral care and bed mobility. A third resident's care plan inaccurately reflected transfer needs. These oversights risked residents' quality of life.
The facility failed to develop comprehensive care plans for six residents, leading to deficiencies in addressing medical needs such as diabetic foot ulcers, ill-fitting dentures, oxygen therapy, feeding tube details, lymphedema, and ADL support. Staff interviews confirmed that care plans did not meet expectations, with outdated or missing interventions and lack of measurable goals.
The facility failed to conduct timely care planning meetings for two residents and did not update care plans for three residents, leading to discrepancies between documented care needs and actual conditions. Staff interviews confirmed these deficiencies, highlighting a failure to revise care plans to reflect current resident needs.
The facility failed to ensure a safe environment for three residents, leading to multiple falls and medication management issues. A resident with a history of falls experienced several incidents without timely interventions, resulting in serious injuries. Another resident had multiple falls without adequate interventions, and a third resident was found with medications left at their bedside without proper assessment. Staff interviews revealed expectations for immediate intervention and care plan updates were not consistently met.
The facility failed to implement an effective antibiotic stewardship program, leading to inappropriate antibiotic use for three residents. A resident was prescribed Bactrim without reviewing microbiology results, another received Clindamycin despite a negative urinalysis, and a third was on ertapenem with no growth in urinalysis. Staff interviews revealed a lack of procedures to request culture results, contributing to the deficiency.
The facility failed to document that several residents were informed about and offered influenza and pneumococcal vaccines, as required. Residents with various medical conditions, including respiratory failure, diabetes, and kidney failure, had no records of receiving education or being offered the vaccines. Interviews with the DON and Administrator confirmed this was against facility expectations.
The facility failed to document that three residents were informed about the COVID-19 vaccine and offered it, despite having significant medical conditions. Interviews with staff revealed that the lack of documentation and failure to educate and offer the vaccine did not meet facility expectations, placing residents at increased risk.
A facility failed to obtain complete informed consents for psychotropic medications for a resident with dementia, anxiety disorder, and bipolar disorder. The resident was prescribed Clonazepam and Divalproex Sodium, but the consent forms lacked critical information such as dosage, duration, and expected benefits. Interviews with staff confirmed the forms were incomplete, which did not meet facility expectations.
A facility failed to honor a resident's shower preferences, leading to the resident not receiving a shower since admission. The resident, with multiple health conditions, was able to communicate needs but reported no choice in shower scheduling. The care plan lacked shower instructions, and staff confirmed showers were scheduled with make-up days on Sundays. The DON acknowledged the deficiency in meeting resident choice expectations.
The facility failed to maintain a homelike environment in resident rooms on the 200 and 100 halls. Observations revealed torn wallpaper and deep gouges in walls behind beds, with flaking drywall on the floor. A resident reported the disrepair had been present since their arrival, and staff were aware. The Maintenance Director admitted the need for repairs had been known for months, but no timely solution was in place. The Administrator expected maintenance to complete repairs within 30 days.
A facility failed to conduct a criminal background check for a CNA, Staff F, before hire, violating their policy. Staff F was observed working with residents, including one who reported being treated rudely and experiencing pain caused by the CNA. The Administrator in Training confirmed the oversight, acknowledging it as unacceptable.
A resident with multiple health conditions reported abuse and neglect incidents to a lead aide, but these were not documented or reported to the appropriate authorities. Interviews revealed that staff were unaware of the allegations, which were expected to be reported to nurse managers and the administrator. This failure placed the resident at risk of further harm.
A resident with multiple diagnoses, including spinal stenosis, was not wearing a prescribed cervical collar for support and comfort, despite the MAR indicating its use. Observations showed the collar was not worn, and interviews revealed staff failed to educate the resident or notify the provider. The documentation was acknowledged as incorrect by the LPN and DON.
The facility failed to assist three residents with activities of daily living (ADLs), leading to deficiencies in care. A resident dependent on staff for mobility remained in bed for extended periods due to unavailable staff and a missing wheelchair. Another resident, requiring assistance with meals and mobility, was left in bed without help, contrary to their care plan. Additionally, a resident was not offered assistance with personal hygiene, specifically shaving, despite expressing a desire for it. These actions were against the expectations set by the DNS.
The facility failed to provide necessary care for two residents with non-pressure skin conditions. One resident with diabetic foot ulcers did not receive proper treatment due to incorrect application and lack of documentation. Another resident with lymphedema did not have their legs wrapped daily as prescribed, due to an error in order documentation. Staff interviews confirmed these deficiencies.
The facility failed to maintain or improve ROM for two residents. One resident, with respiratory failure and COPD, did not receive recommended restorative care after physical therapy discharge. Another resident, with cognitive deficits and diabetes, did not have a hand splint recommendation implemented. Staff were unaware of these needs, and the facility had not started a formal restorative program.
The facility failed to monitor and document fluid restrictions for two residents, leading to potential medical risks. One resident with muscle disorder and lymphedema had unrestricted access to fluids despite a fluid restriction order, while another with COPD and CHF had inconsistent fluid intake documentation. Additionally, a resident with a feeding tube did not receive required nutritional supplementation due to missing meal intake documentation. Staff interviews revealed a lack of awareness and communication regarding these care plans.
A facility failed to properly document and administer enteral nutrition for a resident with a feeding tube. The resident was supposed to receive Glucerna 1.2 calories at 65 ml per hour with water flushes, but the MAR lacked documentation for the feeding's end time and total volume. Staff interviews confirmed the deficiency, acknowledging the risk of inadequate nutrition and hydration.
The facility failed to provide proper respiratory care for three residents, with discrepancies in oxygen therapy orders and administration. One resident used an oxygen concentrator without orders, while two others received incorrect oxygen levels. Staff did not verify settings as required.
Two residents received pain medications without attempts at non-pharmacological interventions, contrary to facility orders. One resident with anxiety disorder and COPD was given Hydrocodone-Acetaminophen, while another with cervical stenosis and diabetes received tramadol. The DNS confirmed that non-pharmacological interventions should have been attempted first.
Failure to Notify POA When Anticoagulant Was Discontinued
Penalty
Summary
The facility failed to ensure that a resident and/or the resident representative were informed when a long-term anticoagulant medication was discontinued. Resident 1 had diagnoses including DVT, PE/PTE, and dementia with severe cognitive impairment. The annual MDS showed the resident was taking an anticoagulant, and the 2023 POA document showed the health care POA was effective immediately. The admission orders included an anticoagulant twice a day, and the MAR showed the medication was administered through [DATE] and then not continued. The record contained no documentation that the resident or representative was notified that the medication was not continued. Medical records showed Resident 1 had been hospitalized with a right lower extremity DVT involving the femoral veins and a right external iliac DVT. During interview, Staff D, RN, stated the pharmacy was contacted for a refill, but the order was not filled; when only two pills remained, the pharmacy said the order had expired, and the on-call provider said the resident did not need anticoagulant medication anymore and did not renew the order. Staff D stated the POA was not notified. The POA stated they were not told the medication had been stopped until the facility called about the resident’s swollen leg, and they requested the resident be sent to the hospital right away. The POA also stated they could have provided prior records showing the resident required anticoagulation therapy for life. The Administrator stated the POA should have been notified.
Failure to Implement Effective Fall and Toileting Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision, identify fall trends, and implement progressive, resident-centered interventions for a resident with multiple falls and declining strength. The facility’s own Falls and Fall Risk Management policy required staff to identify interventions related to residents’ specific risks and causes to prevent falls and minimize complications. The resident’s Care Area Assessment identified cancer-related risks for pain, falls, and ADL decline, and stated that falls and urinary incontinence would be addressed in the care plan with an objective of improvement and risk minimization. However, the comprehensive care plan did not include a urinary or ADL care plan and contained no toileting plan, despite the resident’s identified risks and prior fall history. Over a series of falls, the resident repeatedly fell while attempting to toilet or move toward the bathroom, yet the facility did not recognize or address this pattern in its investigations or care planning. The resident had multiple unwitnessed falls: next to the bed while getting up to use the restroom, in the bathroom while standing to use the toilet, and near or in the bathroom on several occasions. Incident investigations and post-fall assessments documented environmental factors such as clutter, items on the floor, water on the floor, and issues with footwear, as well as the resident’s increasing weakness, impulsivity, poor safety awareness, and poor insight into limitations. Interventions documented in investigations and risk reviews included encouraging use of the front-wheeled walker, keeping the wheelchair and walker accessible, ensuring proper footwear and non-skid socks, and providing resident education on safe transfers, ambulation, and assistive device use. However, several of these planned interventions, including placement of the wheelchair and frequent rounding/toileting assistance, were not added to or reflected in the care plan as stated. Staff interviews further showed that the resident frequently fell while trying to go to the bathroom and that staff relied on verbal education and reminders to use the call light, even though the resident often did not use it. Staff acknowledged the resident’s impulsivity and tendency to get up independently despite instructions, and one staff member stated that nursing assistants were verbally instructed to offer bathroom assistance, but this intervention was not documented in the care plan. The resident’s bed remained the one furthest from the bathroom throughout the stay, and none of the facility’s investigations identified the trend of bathroom-related falls or addressed toileting options in the care plan. Ultimately, the resident sustained a left ankle fracture after another bathroom-related fall, requiring transfer to the emergency department for evaluation and treatment, and later records documented additional fractures and a decline in condition. The surveyors concluded that the facility’s failures placed residents at risk of repeated falls and injuries.
Failure to Monitor Urinary Retention After Foley Removal Leading to Prolonged Pain
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and monitor a resident for complications associated with an indwelling urinary catheter and urinary retention, particularly after catheter removal. The resident had a history of acute kidney injury due to urinary retention, which improved after Foley catheter placement in the hospital. Hospital discharge documentation indicated the catheter was placed for acute urinary retention, was deemed permanent, and included instructions that, given the resident’s significant retention and acute renal failure, staff at the skilled nursing facility should not attempt Foley removal. The facility’s catheter care plan directed staff to empty the catheter as needed and record output in milliliters, but review of the last 30 days of documentation showed continence was not rated due to the indwelling catheter and there was no documented urinary output in milliliters on the treatment administration records. The resident had a scheduled urology appointment at which the urinary catheter was discontinued. Upon return from this appointment, nursing documentation initially indicated no new orders, and an alert note later stated the catheter was discontinued and staff were monitoring for retention or pain. However, there was no documented bladder assessment or urinary output following catheter removal. Nursing assistant documentation showed that the resident did not void on the evening shift that same day. Despite the catheter having been removed, the treatment administration record showed staff continued to document provision of catheter care on subsequent shifts when no catheter was in place. Over the next day, the resident experienced vomiting, decreased oral intake, and an altered level of consciousness, with vital signs showing tachycardia and low blood pressure, and staff documented decreased urine output. A bladder scan performed later revealed more than 2000–2500 milliliters of urine in the bladder, and an indwelling catheter was reinserted, initially draining a large volume of urine. The provider note indicated the resident had not eaten since the prior night, was unable to hold down fluids, and staff were unsure whether the resident had urinated in incontinence briefs, with no wet briefs reported since the resident’s return from the hospital after catheter removal. The provider expressed concern that the documented early-morning wet brief might not be accurate given the large bladder volume on scan and stated this should require further investigation. Subsequent notes described the resident moaning and complaining of pain, with limited urine output in the catheter bag and staff flushing and then replacing the catheter due to continued complaints. Interviews with the resident, the roommate, and staff indicated the resident was crying out and moaning in pain, the roommate repeatedly alerted staff that the resident was not urinating and that the catheter was not draining, and staff had to seek assistance to replace the catheter. Facility leadership and clinical staff later acknowledged that typical practice after catheter removal would include contacting the provider, placing the resident on alert, performing post-void residuals with bladder scans, and documenting monitoring, which was not done in this case.
Medication Administration Delays, Documentation Errors, and Use of Expired Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient nursing staff with appropriate competencies and skill sets to administer medications according to professional standards of practice, facility policy, and prescriber orders. The facility’s medication administration policy required medications to be given as prescribed, in accordance with manufacturers’ specifications and good nursing principles, with no expired medications used, and doses administered within 60 minutes of the scheduled time and documented immediately after administration. Multiple residents reported that agency nurses often gave medications late, did not read full instructions, or were slow in bringing medications, and that routinely scheduled medications were not consistently provided without residents having to ask. Surveyors observed several specific medication administration failures. For a resident with diabetes, an LPN drew up and administered Humalog/Lispro insulin from a multi-dose vial that had been opened and dated “02/16” with no year, making it expired per policy, and administered the dose nearly 1 hour and 45 minutes after it was due. Another resident with care plan instructions to receive medications as ordered had multiple scheduled medications (Gabapentin, Oxybutynin, Baclofen, and Tizanidine) that were ordered at specific times throughout the day; the LPN was observed administering all four together and acknowledged that at least one (Tizanidine) was late, while the resident reported that receiving them together at that time was typical and not at their request. For another diabetic resident, an RN checked blood sugar and prepared sliding scale Humalog/Lispro insulin almost two hours after the scheduled time; the resident refused the insulin, stating they had already finished lunch. Additional deficiencies were identified with other residents’ pain and scheduled medications. One resident with a pain care plan and an order for Methocarbamol four times daily at set times approached the cart requesting Methocarbamol and Tylenol; the RN initially stated the Methocarbamol had already been given, but then administered it two hours after it was due when the resident pointed out the scheduled timing. For another resident with a risk for pain care plan and Tramadol ordered three times daily at specific times, an LPN retrieved a PRN pain medication while the electronic record showed no 8:00 AM medications documented; the LPN stated they had given them but had not yet documented. Later, an RN prepared the 2:00 PM Tramadol dose, and review of the narcotic count showed a discrepancy between the number of pills documented and the number remaining in the card. The RN stated they had given the 8:00 AM Tramadol but had not signed it out, then signed out both the 8:00 AM and 2:00 PM doses at that time. Residents interviewed consistently reported that medications were sometimes or frequently late, that agency nurses did not always follow instructions, and that they often had to request medications that were routinely scheduled.
Menu Not Followed and Incorrect Portion Sizes Served
Penalty
Summary
The facility failed to follow menus according to Resident Council Minutes for October, November, January, and February 2026. Resident Council members reported that the menu did not always match what was served, including concerns that soup was frequently not what was listed, serving sizes varied, and food was sometimes not warm enough. Residents also requested that they be notified before changes were made to the menu or to brands such as coffee, and one meeting noted that residents frequently did not get what was on the menu, including a western omelet that was served as baked egg and cheese instead. During kitchen observation on 03/11/2026, the lunch menu listed chicken legs with 4 oz of scalloped potatoes and 4 oz of peas, but staff served chicken thighs instead of chicken legs, peas with a long-handled 4 oz scoop, and potatoes with a green-handled scoop that was not the correct portion size. The cook filled the scoop for peas only about two-thirds full. The Dietary Manager was unsure of the size of the green-handled scoop, and the Registered Dietician stated it was 2 and 2/3 oz and that the 4 oz grey-handled scoop should have been used. The Dietary Manager later stated staff were trained on portion sizes, but was unsure whether the potato scoop was correct, and the Administrator stated kitchen staff should follow designated portion sizes and the menu should be altered before publication if the facility could not purchase a product.
Unsafe Food Storage and Preparation Practices
Penalty
Summary
The facility failed to maintain sanitary food storage and preparation practices during kitchen observations and resident refrigerator reviews. During the initial kitchen tour, the walk-in freezer contained opened food items without date labels, including raw hamburger patties, breaded fish fillets, chicken tenders, fries, and hashbrowns, along with boxes of food stacked on the freezer floor and falling from the stack. The freezer also contained re-frozen food containers stacked on top of a frozen bag of soup. In the refrigerators, surveyors observed tuna salad, salad bowls, sliced tomatoes, hardboiled eggs, olives, cubed meat, and other items uncovered or without date labels, as well as a box of zucchini on the floor outside the refrigerator and personal items near the steamtable. On the second kitchen tour, staff were preparing salads with cheese, cubed meat, precut vegetables, and cottage cheese left out at the salad station without temperature controls, and prepared salads remained wrapped at the station without temperature controls for an extended period. Surveyors also observed a bag of fast food near the steamtable, a refrigerator container of hardboiled eggs uncovered and without a date, and opened freezer items left exposed to the air. The dishwasher temperature log showed the wash machine should reach 180 degrees Fahrenheit during the rinse cycle, but entries for 03/06/2026 and 03/07/2026 were below that threshold. During observation, the cook cleaned the thermometer on a dry dishcloth between foods, and later used water at the handwashing sink between temperature checks. The cook also had a beard without a net, and another staff member with hair and beard entered and moved through the kitchen without hand hygiene or a hair/beard net. Resident refrigerator observations showed the North Hall refrigerator contained frozen nutrient drinks labeled do not freeze, food items without date labels, and no temperature log. The South Hall refrigerator contained frozen nutrient drinks labeled do not freeze, multiple food items without name or date labels, food dated months earlier, grapes with white film, and a temperature log that was only for February with a single temperature entry. During interviews, the Dietary Manager and Administrator stated food should be closed, date labeled, covered, stored off the floor, and kept cold; personal items should not be in the kitchen; staff with beards should have them covered; sanitation wipes should be used between foods; and resident refrigerators should be monitored daily. The Administrator also stated maintenance should be contacted when the dishwasher was not reaching the required temperature.
Failure to Monitor Psychotropic Medication Side Effects and Behaviors
Penalty
Summary
The facility failed to monitor for adverse side effects and behaviors for 3 of 5 sampled residents when reviewed for unnecessary medications. Resident 26 was admitted with diagnoses including diabetes, end stage renal disease, and dependence on renal dialysis, and was able to communicate needs. The provider ordered trazodone for insomnia, but the electronic health record showed no monitoring for adverse side effects and behaviors for the medication. During interview, the DNS stated they were not sure why there was no monitoring, but there should be. Resident 89 was admitted with diagnoses of dementia, depression, and bipolar disorder and was able to make needs known. The provider ordered quetiapine and also ordered orthostatic blood pressure monitoring every two weeks, but the medication administration record for January and February 2026 showed no documented orthostatic blood pressures. Resident 88 was admitted with diagnoses of anxiety and depression and was able to make needs known. The provider ordered citalopram and buspirone, but the record showed no documented monitoring of adverse side effects and no documented monitoring of behaviors. Staff stated Resident 88 should have had orders to monitor behaviors and adverse side effects of psychotropic medications, and the DNS stated the resident should have been monitored for adverse side effects and should have had a behavior monitor in place.
Incomplete Abuse/Neglect Investigations After Resident Injuries and Unwitnessed Falls
Penalty
Summary
The facility failed to ensure a thorough investigation to rule out abuse or neglect after resident accidents for 2 of 4 sampled residents. For Resident 5, who was admitted with Parkinson's disease and adult failure to thrive and was able to make needs known, the record showed a 02/27/2026 incident involving a superficial injury to the left lower leg. The incident report stated the resident said they accidentally bumped their leg on the bed rail, and abuse/neglect was ruled out, but the report did not include a resident statement or witness statements. The outside wound care provider's note dated 03/04/2026 documented that Resident 5 reported being injured while getting into a wheelchair. During interviews, Resident 5 described being scratched on the wheelchair during a transfer and identified Staff K, CNA, as the assisting staff member, and Staff K confirmed assisting with the transfer and stated they were not interviewed or asked for a statement as part of the investigation. For Resident 32, who was admitted with chronic lymphocytic leukemia and dementia and was unable to make needs known, the incident log showed multiple unwitnessed falls over several months. Review of the incident reports showed numerous investigations did not include witness statements and/or interviews with assigned facility staff members, including several falls on 10/05/2025, 10/11/2025, 11/12/2025, 11/24/2025, 12/17/2025, 12/18/2025, 12/21/2025, 12/22/2025, 12/24/2025, 01/01/2026, 01/21/2026, 01/25/2026, and 01/27/2026, as well as two unwitnessed falls not listed in the incident log dated 12/05/2025 and 02/14/2026. The Administrator stated staff should be interviewed after an unwitnessed fall to help rule out abuse or neglect, and the report cited WAC 388-97-0640(6)(a)(b).
Failure to Complete or Update PASSAR Screenings for Residents With Mental Health Diagnoses
Penalty
Summary
The facility failed to screen residents for additional mental health supports on admission and after changes in mental health diagnoses for 7 of 8 sampled residents reviewed for PASSAR. During interview, the Social Services Director stated residents were screened for mental health needs on admission using the PASSAR assessment, that any resident with a mental health diagnosis should have a positive PASSAR and be referred for a level two PASSAR, and that the PASSAR should be re-completed if a resident received a new mental health diagnosis. Resident 32 was admitted with dementia, depression, and violent behaviors, but a PASSAR dated 06/13/2024 showed no mental health diagnoses; a later PASSAR dated 04/21/2025 was re-completed accurately and referred for a level two PASSAR, about 10 months after admission. Resident 13 had schizophrenia listed on the diagnosis list, but a level two PASSAR dated 02/01/2022 did not include schizophrenia, and staff could not locate a re-completed PASSAR after schizophrenia was diagnosed on 04/29/2024. Resident 2 had no PASSAR completed for the 11/22/2025 admission. Resident 11 had schizophrenia on the diagnosis list, but the PASSAR dated 01/22/2026 was completed about one year after admission. Resident 88 and Resident 89 both had mental health diagnoses on the EHR, but their PASSARs completed by the admitting hospital did not include those diagnoses. Resident 9 had depression, bipolar disorder, and PTSD, but the PASSAR dated 09/18/2024 was completed by the admitting hospital and indicated a level two PASSAR was not needed because the resident was expected to stay less than 30 days.
Incomplete Care Plans for Oxygen, Wounds, Catheter Care, and Medication Use
Penalty
Summary
The facility failed to develop comprehensive care plans for 4 of 21 sampled residents when reviewed for comprehensive care plans. The deficiencies involved Resident 1’s oxygen therapy, Resident 9’s wound/skin impairment, Resident 10’s indwelling catheter, and Resident 26’s oxygen use and trazodone use for insomnia. The report states that these care needs were not accurately reflected in the residents’ care plans, and that the failure placed residents at risk of unmet care needs and potential negative outcomes. Resident 1 was readmitted with diagnoses including heart failure, respiratory conditions due to an unspecified external agent, and cerebral infarction. The resident was observed with an oxygen concentrator in the room not in use and stated they did not need oxygen at that time. The February 2026 MAR showed oxygen ordered PRN to maintain saturations greater than 92%, with documentation that oxygen was received almost every shift, and the order was later discontinued and replaced with continuous oxygen at 2 liters on the March 2026 MAR. The current care plan contained no documentation related to the resident’s oxygen therapy, and the LPN/UM and DNS stated a care plan should have been in place. Resident 9 was admitted with diagnoses including diabetes, dementia, and COPD, and was being treated for a chronic ulcer/open wound to the left foot per the February and March 2026 TARs. The current care plan included a focused plan for risk for pressure ulcers and skin impairment, but there was no documentation showing an actual skin impairment to the left foot. Resident 10 was readmitted with diagnoses including neurogenic bladder, stage 3 chronic kidney disease, and dementia, and had an indwelling catheter with catheter care documented every shift; however, the focused care plan for the catheter was not initiated until 03/09/2026. Resident 26 was admitted with diagnoses including diabetes, end stage renal disease, and dependence on renal dialysis, was observed using oxygen via nasal cannula at 2 liters per minute, and had trazodone ordered for insomnia, but the care plan dated 01/28/2026 had no directions or goals for oxygen use or antidepressant medication use.
Respiratory Care Orders and Equipment Maintenance Not Followed
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for 3 of 3 sampled residents reviewed for respiratory care. Resident 1 was readmitted with diagnoses including heart failure, a respiratory condition due to an unspecified external agent, and cerebral infarction, and was observed lying in bed receiving O2 at 1.5 liters via nasal cannula through an O2 concentrator. The resident had a provider order for continuous O2 at 2 liters to maintain saturations above 92% every shift, but the O2 flow was below the ordered rate until staff increased it during an interview. The record also showed no orders or documentation to routinely change O2 tubing or clean the concentrator filter, and the LPN/UM and DNS stated they could not locate such documentation or orders. Resident 9 was admitted with diagnoses including diabetes, dementia, and COPD, and was repeatedly observed receiving O2 at 2 liters via nasal cannula through an O2 concentrator despite a provider order for 3 liters per minute to keep saturations above 88% every shift. Staff later increased the liter flow to 3 liters during an interview. The record showed no orders or documentation to routinely change O2 tubing or clean the concentrator filter. Resident 67, admitted with COPD, cerebral infarction/stroke, and chronic respiratory failure, was observed receiving O2 at 4 liters via nasal cannula through an O2 concentrator, and the tubing was not dated. The resident had an order for continuous O2 at 2-4 liters via nasal cannula to keep O2 above 92% every shift, but the record again showed no orders or documentation for routine tubing changes or concentrator filter cleaning, and the DNS stated those orders were missing and needed to be obtained from the provider.
Advance Directives Not Periodically Reviewed or Documented
Penalty
Summary
The facility failed to periodically review and provide assistance with advance directives for 2 of 3 sampled residents, Residents 5 and 4. Resident 5 was admitted with diagnoses including Parkinson's disease and adult failure to thrive and was able to make needs known. A multidisciplinary care conference form dated 07/23/2025 showed the resident's advance directive was reviewed and assistance offered, but a progress note dated 03/11/2026 stated the resident believed a durable power of attorney had been established and the facility had not obtained the document. Resident 4 was admitted with diagnoses including multiple sclerosis and dementia and could not make needs known. A Social Service Initial Evaluation dated 12/03/2025 showed the resident did not have an advance directive but wanted to establish one, and a progress note dated 03/11/2025 stated the resident believed an advance directive existed but was unsure. Staff J, Social Services Director, stated advance directives were asked about at the initial care conference, copies would be obtained if established, information would be provided if none existed, and choices would be reviewed quarterly with care conferences. Staff J later stated Resident 5 had not had an advance directive review between 07/23/2025 and 03/11/2026 and Resident 4 had not had follow-up on the advance directive between 12/03/2025 and 03/11/2026.
SNF ABNs Not Timely or Fully Completed
Penalty
Summary
The facility failed to ensure that Skilled Nursing Facility Advanced Beneficiary Notices (SNF ABNs) were provided timely and completed as required for 2 of 3 sampled residents reviewed for Beneficiary Notification. For Resident 18, a Notice of Medicare Non-Coverage dated 10/23/2025 showed the facility informed the resident and/or representative that skilled nursing services would end on 10/27/2025. The SNF ABN for Resident 18 was dated 03/09/2025 and stated, "Beginning on 10/28/2026 you may have to pay out of pocket for this care if you do not have other insurance that may cover these costs," but the section intended to list Care was blank. The form was provided and signed by Resident 18 on 03/09/2026. For Resident 54, a Notice of Medicare Non-Coverage dated 02/13/2025 showed the facility informed the resident that skilled nursing services would end on 02/16/2025. The SNF ABN for Resident 54 was dated 03/09/2025 and stated, "Beginning on 02/17/2026 you may have to pay out of pocket for this care if you do not have other insurance that may cover these costs," but the section intended to list Care was blank. The form was provided and signed by Resident 54 on 03/09/2026. Staff J, Director of Social Services, stated both SNF ABNs did not meet expectations because the Care section had no care listed and should have been provided and signed sooner. Staff A, Administrator, stated both forms were missing listed Care and should have been provided when the NOMNCs were issued.
Missing Closet Doors and Bathroom Damage on 200 Hall
Penalty
Summary
The facility failed to make needed repairs to maintain a homelike environment on the 200 hall. Observation and interview showed a resident’s bathroom with a gouge in the floor at the entryway, along with two large scrapes and gouges, black scrapes, and chipped paint on the wall to the right of the sink. The resident stated they were surprised the gouge in the floor did not interfere with entering or leaving the bathroom when using a wheelchair. Additional observations showed multiple closets missing doors and exposing residents’ personal belongings. One resident’s closet was missing a door, and the resident stated they were not aware it was missing. Another room had both closets missing doors, and one resident stated they would prefer to have a closet door, while the other stated the closets had been missing for about a year and it would be nice to have doors if available. A third resident’s closet door was also missing, and the resident stated they would like to have a closet door and did not know why it was absent. A CNA stated the bathroom damage and missing closet doors had not been documented in TELS, and the Maintenance Director stated they were only aware of one missing closet door and were not aware of the other missing doors on the 200 hall. The Administrator stated these issues should have been entered into TELS and were not their idea of a homelike environment.
MDS assessments were inaccurate for wound status, PASARR status, and anticoagulant use
Penalty
Summary
The facility failed to ensure the minimum data set (MDS) accurately reflected the status of 3 of 21 sampled residents. For Resident 9, the electronic health record showed diagnoses of diabetes, dementia, and chronic obstructive pulmonary disease, and treatment records showed the resident was being treated for a chronic ulcer/open wound to the left foot. However, the significant change MDS dated [DATE] indicated there were no pressure ulcers, injuries, wounds, or skin problems. During interviews, the MDS Coordinator/LPN and the DON both stated the MDS should have been coded for the open lesion on the foot and needed to be modified or corrected. For Resident 6, the record showed diagnoses of bipolar disorder and schizoaffective disorder, and a level 2 PASARR had been completed on 07/26/2023. The annual MDS dated [DATE] indicated no level 2 PASARR was completed, and the MDSC/RN stated the resident should have been marked yes for the level 2 PASARR. For Resident 40, the record showed diagnoses of stroke and heart failure, and the annual MDS dated [DATE] indicated the resident was taking an anticoagulant medication. Provider orders showed the anticoagulant had been discontinued on 06/14/2021, and the MDSC/RN stated the resident should not have been marked yes for anticoagulant use.
Delayed care conference and inaccurate enteral feeding care plan
Penalty
Summary
The facility failed to ensure care conferences occurred timely for Resident 32 and failed to accurately reflect Resident 87’s eating status in the care plan. Staff J, the Social Services Director, stated residents were able to provide input into their plan of care through care conferences and that care conferences should occur on admission and with the MDS assessment schedule, including quarterly and with change of condition. Resident 32 was admitted with diagnoses including chronic lymphocytic leukemia and dementia and was unable to make needs known. The EHR showed the most recent multidisciplinary care conference was dated 10/02/2025 and involved only the Activities Department, with the form signed later on 12/12/2025. The MDS schedule showed a significant change MDS on 12/23/2025, and Staff J stated Resident 32 should have had a new care conference around that time. The Administrator stated the expectation was for care conferences to occur quarterly with the MDS. For Resident 87, the EHR showed diagnoses including cerebral infarction, gastrostomy, anxiety, and depression, and the resident could not communicate needs. Observations showed the resident in bed with tube feeding formula present and later being infused through the gastrostomy. The care plan for enteral feeding, dated 03/05/2026, included interventions stating the resident was NPO and also that the resident received a tray in addition to tube feedings, both dated 02/16/2026. Staff D stated Resident 87 was not NPO and the care plan was not updated. The DON stated the expectation was for care plans to be updated timely.
Failure to Provide Ordered Wound Care and Follow BP Medication Parameters
Penalty
Summary
Failure to provide wound care for Resident 2 occurred when the resident, who was admitted with diagnoses of head/face and neck cancer and was able to make needs known, was observed on 03/09/2026 pointing at bandages on the left wrist and right hand and stating that the bandages were bothering them. The bandages were undated, had hard dried drainage on them, and were soiled. Review of the EHR showed orders to monitor the left hand, cleanse with skin prep, and apply a bandage, as well as to monitor the left forearm, cleanse with skin prep, and apply a bandage, with start dates of 03/05/2026, but these orders did not appear on the treatment administration record. Staff H, an LPN, stated the resident should have had an order to cleanse and change the dressings to the right and left wrist and left elbow and did not see any such orders on the treatment administration record. Staff D, an LPN, also stated the resident should have active orders in the treatment administration record for wound care, but did not. Failure to follow provider orders for blood pressure medication parameters occurred for Resident 26, who was admitted with heart failure, end stage renal disease, and dependence on renal dialysis and was able to communicate needs. Provider orders dated 01/28/2026 directed Metoprolol ER 25 mg daily to be held when SBP was less than 110 or pulse was under 60, and Hydralazine 10 mg three times daily to be held when SBP was below 110. Review of the MAR showed Metoprolol was given on 03/04/2026 at 8:00 AM despite an SBP of 105, Hydralazine was given two times on 03/04/2026, one time on 03/08/2026, and one time on 03/11/2026 when SBP was under 110, and the February 2026 MAR showed Hydralazine was administered on seven occasions at the evening administration time when SBP was under 110. The DON stated the medications were to be administered following the orders and held per the provider's order.
Pressure Ulcer Care and Documentation Deficiencies
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met for Resident 111, who was admitted with hospice care, senile degeneration of the brain, diabetes, and kidney failure and was unable to communicate needs. The admission MDS showed the resident had a sacral stage 2 pressure ulcer. During multiple observations, the resident was lying in bed on an air mattress that was set at the highest pressure and displayed a blinking low-pressure signal. Staff D, an LPN, stated the mattress was rental equipment and was set up by the company, and Staff Q, the hospice RN, later stated the setting was in error and would contact the company. The Administrator stated the air mattress should be used according to manufacturer settings and that the low-pressure signal did not meet expectations. The facility also lacked documentation describing the progress of the pressure ulcer. The care plan dated 12/12/2025 identified a skin impairment to the right forehead and did not include a pressure ulcer or risk for one. The weekly wound evaluation form dated 12/22/2025 documented an abrasion to the right side of the forehead and did not identify the sacral pressure ulcer. Weekly skin observations completed on 12/17/2026, 12/25/2025, 01/01/2026, 01/08/2026, 01/21/2026, 01/29/2026, and 02/04/2026 did not describe the size, color, or drainage of the sacral pressure ulcer. Staff D stated pressure ulcer monitoring should be documented in the weekly skin observation with measurements and appearance, and the DON stated pressure ulcers should be assessed on admission and then weekly with measurements and appearance.
Incomplete Investigation of Resident Skin Tear
Penalty
Summary
The facility failed to protect Resident 5 from continued accident risk when it did not thoroughly investigate a skin tear incident involving the resident’s left lower leg. Resident 5 was admitted with Parkinson’s disease and adult failure to thrive and was able to make needs known. The record showed an accident and incident log entry for a superficial injury, and the care plan included a focus area for skin impairment to the left lower leg with an intervention for referral to an outside wound care provider. The incident report dated 03/03/2026 documented that Resident 5 was observed with a skin tear to the left lower leg and that the resident stated the injury occurred when [they] accidentally bumped [their] leg on the side of [their] bed railing. However, the report did not include a resident statement or witness statements. The conclusion in the report was that Resident 5 hit [their] leg on the bed rail, while the outside wound care provider’s note dated 03/04/2026 stated Resident 5 reported being injured getting into [their] wheelchair. Staff K, the CNA who assisted with the transfer, stated they were not interviewed and were not asked to provide a statement. The DON stated the facility would generally interview the resident and staff, collect statements, and review the record when a resident was injured, and also stated Resident 5 was not reassessed for the level of support required for transfer.
Failure to Follow Ordered Fluid Restriction
Penalty
Summary
Failure to implement the ordered fluid restriction occurred for Resident 26, who was admitted with diagnoses including heart failure, end stage renal disease, and dependence on renal dialysis. The resident was able to communicate needs and stated during observation on 03/08/2026 that they were on a fluid restriction because of their health condition. A provider order dated 02/18/2026 directed a 1000 ml per day fluid restriction, including breakfast, lunch, dinner, and supplements, with dietary/kitchen to provide 720 ml and nursing staff to provide up to 280 ml per day. Review of the March 2026 MAR showed discrepancies between documented total consumed amounts and the day/night entries on multiple dates, including 03/01/2026, 03/02/2026, 03/03/2026, and 03/04/2026, and this discrepancy continued through 03/11/2026. During interview, an LPN stated residents with fluid restrictions did not receive water pitchers and that the total amount consumed was documented in the MAR. The DON stated licensed nurses were to follow the orders and document clearly in the MAR.
Tube Feeding Documentation Did Not Match Ordered Amounts
Penalty
Summary
Enteral nutrition was not administered in accordance with provider orders and professional standards of practice for one resident with a gastrostomy tube. The resident was admitted with diagnoses including cerebral infarction, gastrostomy, anxiety, and depression, and could not communicate needs. On observation, the resident was in bed with tube feeding formula infusing through the gastrostomy. The provider ordered Jevity at 55 ml for 20 hours each day for a total of 1100 ml in 24 hours, with 100 ml water flushes every four hours for a total of 500 ml in 24 hours, and nurses were to document totals starting 02/17/2026. Review of the March 2026 MAR showed documentation that did not reconcile with the ordered amounts, including entries of 1050 ml formula and 300 ml water at 10:00 AM and again at 2:00 PM on multiple days, with similar documentation continuing through 03/10/2026. An RN stated the resident received nutrition for 20 hours a day and that the 10:00 AM documentation reflected the infusion amount on the machine, but could not explain why there was documentation at 2:00 PM and stated it should be zero. An LPN stated the machine was making the nurses document the amount. The DON stated the tube feeding should be administered by the orders and should have a clear amount.
Pain Management Not Consistently Monitored or Documented
Penalty
Summary
Safe, appropriate pain management was not provided for two residents who required pain services. Resident 2 was admitted with diagnoses of head/face and neck cancer and was able to make needs known. During observation, Resident 2 was lying in bed with bandages to the right ear and stated, "It hurts all the time." The initial nursing assessment documented pain at an 8 out of 10 on 11/22/2025, but no other pain assessments were found in the EHR. No orders or documentation were found showing that Resident 2's pain level was monitored daily, even though an order for oxycodone as needed for pain levels of 4 to 10 was in place starting 11/23/2025. Resident 26 was admitted with diagnoses including heart failure, end stage renal disease, and dependence on renal dialysis, and was able to communicate needs. Provider orders included hydromorphone every six hours as needed for severe pain and an order for non-pharmacological intervention to be offered and documented every shift. The February 2026 MAR showed hydromorphone was administered 27 days of the month, but NPI was documented only four days out of 28. The MAR from 03/01/2026 through 03/11/2026 showed hydromorphone was administered on all 11 days, and no NPI was offered or documented. Staff stated that NPI was documented in the MAR in a separate box, and the DNS stated the interventions were to be documented in the MAR.
Failure to Promptly Provide Denture Care
Penalty
Summary
The facility failed to promptly provide denture care for Resident 13, who was admitted with anxiety disorder, dementia, and schizophrenia and was able to make needs known. Resident 13 stated during interview that their dentures had been left in their rental when they moved into the facility and there was no way to retrieve them. An outside dental provider’s preventative report dated 06/05/2025 documented that Resident 13 wanted to enroll to obtain a new set of dentures and that, based on clinical need, it was ASAP. The care plan, initiated 11/23/2021, noted that Resident 13 had no teeth and included an intervention to refer to a dentist as needed, but there was no documentation of the resident’s need for dentures. Staff O, the ADON, stated they were unsure whether the denture request had follow-up and later stated the facility did not follow up on Resident 13’s request for dentures. Staff V, the transportation aid, stated they scheduled dental follow-up appointments for residents and that Resident 13 had no dental appointments after 06/05/2025. Staff B, the DON, stated residents needing dentures would be referred to a dentist as soon as the facility was aware and that dental services should be provided at the time the resident requests it.
Failure to Provide Individualized Dementia Care and Behavioral Interventions
Penalty
Summary
The facility failed to provide appropriate treatment and services to two residents diagnosed with dementia who exhibited behavioral symptoms, including wandering, exit-seeking, entering other residents' rooms, and yelling out. For one resident with encephalopathy and non-Alzheimer's dementia, the care plan did not specifically address exit-seeking behaviors, sundowning, or times of increased behaviors, despite repeated incidents of elopement, wandering into other residents' rooms, and taking belongings. Documentation showed frequent refusals of medication and care, but these refusals were not addressed in the care plan. Staff interventions were limited to redirection and the use of stop signs on doors, which were inconsistently applied and not always effective in preventing the resident from entering other rooms or taking items. Multiple progress notes and interviews with staff and other residents confirmed ongoing issues with the resident's behaviors, including distress caused to peers when the resident entered their rooms, sat on their beds, or took personal items. The care plan did not include individualized interventions to prevent the resident from entering other rooms or address the removal of belongings. Staff and residents reported that the use of stop signs was inconsistent, and redirection was not always successful in mitigating the behaviors. The facility's policies required an interdisciplinary approach and person-centered care planning, but these were not fully implemented for this resident. For the second resident with dementia, the care plan addressed some behaviors such as fidgeting and restlessness but did not include targeted interventions for frequent yelling out, which was documented in progress notes and behavior monitoring. The yelling out caused distress to roommates and other residents, as confirmed by interviews. There was no evidence of a detailed assessment or individualized interventions for this behavior in the clinical record. The facility did not ensure that care plans were updated to reflect the residents' current behavioral needs, nor did it implement comprehensive strategies to mitigate the adverse effects of dementia-related behaviors.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to implement its abuse prohibition policy by not thoroughly investigating an injury of unknown origin for a resident with severe cognitive impairment. The resident, who required substantial assistance with bed mobility and transfers, was observed with a raised bump on the forehead and bruising on the back. Documentation showed that the resident was on alert charting and neuro checks following a reported fall, but there was no documented assessment of the forehead bruise, and the incident was not entered into the facility's incident logs. Interviews with collateral contacts revealed that the resident reported falling out of bed and being picked up by a man, but staff interviews indicated that no male staff were working at the time and that the resident was confused and cognitively impaired. Despite these reports and visible injuries, staff did not initiate an incident report or conduct a comprehensive investigation as required by facility policy and state guidelines. The staff focused on determining whether a fall had occurred rather than treating the injuries as incidents of unknown origin requiring thorough investigation. The facility's failure to promptly initiate and thoroughly conduct an investigation into the resident's injuries, as well as the lack of documentation and incident reporting, resulted in noncompliance with both facility policy and state regulations. The absence of a root cause analysis and failure to identify all contributing factors left the injuries unexplained and unaddressed according to established procedures.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Timely Report Alleged Abuse by Staff
Penalty
Summary
The facility failed to identify and timely report an allegation of potential abuse involving a resident with complex medical needs who was cognitively intact and required assistance with activities of daily living. Staff observed and became aware of suspicious interactions between a staff member and the resident, including being found together behind locked doors in the therapy gym when it was closed and unscheduled for therapy. Despite these observations and suspicions, staff did not immediately report the concerns to facility leadership as required by policy. Instead, one staff member confronted the staff involved and discussed the situation with other staff, while others who heard about the suspicions did not report them because they had not personally witnessed inappropriate behavior. The delay in reporting resulted in the administrator being notified of the concern eight days after the initial suspicion was identified. Interviews confirmed that multiple staff members were aware of the situation or had been told about it but failed to report the suspicion of abuse in a timely manner, as required by facility policy and state regulations. The failure to promptly report the allegation placed residents at risk and did not ensure immediate intervention or investigation.
Food Safety and Hygiene Deficiencies in Kitchen
Penalty
Summary
The facility failed to store and prepare food in a manner that prevents foodborne illness, as observed during a survey. A large undated ham was found in the kitchen refrigerator, along with diced turkey, diced ham, and opened hotdogs labeled only with the month and year, and shredded cheese labeled with a past date. Food boxes were improperly stored on the floor of the kitchen freezer. Personal items such as headphones and a cell phone charger were found on a counter in the kitchen, which also contained food items like peanut butter and condiments. These observations indicate a lack of adherence to proper food storage and labeling protocols. Additionally, the Dietary Manager, Staff BB, and Dietary Aide, Staff CC, were observed not following proper food safety and hygiene practices. Staff CC was seen turning off the water with bare hands after performing hand hygiene and failing to perform hand hygiene after returning from the dining room. Staff BB was observed placing trays of hamburgers and fish on the tray line without taking their temperatures to ensure they were safe for consumption. Interviews with Staff BB and the Administrator confirmed that these practices did not meet the facility's expectations for food safety and hygiene.
Failure to Obtain and Review Advanced Directives
Penalty
Summary
The facility failed to obtain and periodically review advanced directives (AD) for three residents, denying them the opportunity to direct their healthcare in the event they become unable to make decisions. Resident 22, who was admitted with diagnoses including diabetes and depression, had AD paperwork provided to a family member, but there was no documented follow-up. Resident 43, admitted with a stroke and bipolar disorder, had an attempt to contact a family member for durable power of attorney, but no further follow-up or periodic review was documented. Resident 77, with dementia and dysphagia, had no AD documented, and there was a lack of follow-up with the resident's spouse. Interviews with the Social Service Director (SSD) revealed that follow-ups on AD paperwork were not conducted as required. The SSD acknowledged that Resident 43's AD should have been reviewed quarterly, and there was a failure to follow up with Resident 77's spouse. The facility administrator stated that the expectation was for ADs to be discussed at every quarterly care conference, which was not adhered to in these cases.
Deficiency in PASARR Screening for Mental Health Disorders
Penalty
Summary
The facility failed to ensure that residents with mental health disorders were properly screened for the need for additional mental health support through the Preadmission Screening and Resident Review (PASARR) process. This deficiency was identified in five out of nine sampled residents. For instance, Resident 77, who was admitted with diagnoses including dementia with psychosis, anxiety, and insomnia, had a PASARR form that did not reflect these active diagnoses, and a level 2 PASARR was not required. Similarly, Resident 95, diagnosed with PTSD, anxiety, and depression, had a PASARR form that only marked anxiety, and no level 2 PASARR was required. Resident 103, with major depressive disorder, had two PASARR forms that did not indicate depression, and thus, no level 2 PASARR was required. Additionally, Resident 22, who was admitted with depression, had a level 1 PASARR that did not mark any serious mental illness indicators, and no level 2 PASARR was indicated. Resident 26, diagnosed with anxiety disorder and bipolar disorder, had a level 1 PASARR that did not mark anxiety disorder as a serious mental illness, and no level 2 evaluation was indicated. The Social Service Director acknowledged the discrepancies in the PASARR forms and stated that these did not meet expectations. The Administrator also confirmed that the PASARR forms for the residents were incorrect.
Failure to Implement Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for three residents, leading to unmet care needs. Resident 30, who was admitted with diagnoses including colon cancer, dementia, and diabetes, was unable to make their needs known and required assistance with eating. However, the baseline care plan did not include necessary care areas for activities of daily living (ADLs) such as assistance with eating, oral care, hygiene, bed mobility, or dressing. This oversight was highlighted during an interview where it was noted that staff removed the resident's meal tray without providing assistance. Resident 103, admitted with congestive heart failure, kidney failure, and diabetes, was also dependent on staff for ADLs and unable to communicate needs. The baseline care plan lacked provisions for oral care and bed mobility, only addressing transfer needs. Staff interviews revealed that the facility's new care plan library did not automatically include ADLs, and the admission nurse failed to create a comprehensive baseline care plan. Resident 215, with end-stage renal disease and other conditions, had a baseline care plan that inaccurately reflected their transfer needs due to an oversight in updating the care plan. These deficiencies placed residents at risk for unmet care needs and decreased quality of life.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop comprehensive care plans that accurately reflected the current medical status and needs of six residents, leading to deficiencies in care. Resident 22, who had diabetic foot ulcers, did not have a care plan that addressed the actual skin impairment and necessary wound treatment, despite having a provider's order for iodine application. Staff interviews confirmed that the care plan did not meet expectations as it failed to document the resident's wounds and necessary interventions. Resident 26's care plan lacked documentation regarding ill-fitting dentures and the need for a denturist consultation, despite the resident's complaints and family awareness. Additionally, the cognitive/dementia care plan for Resident 26 did not include measurable goals, which was acknowledged by staff as not meeting expectations. Similarly, Resident 36's care plan included an outdated intervention for oxygen administration, which was no longer ordered, and lacked details about the resident's feeding tube, such as location, type, and size. Resident 70's care plan was outdated, as it included interventions for a palm guard and elbow orthotic that had been discontinued due to resident refusal. The care plan also inaccurately included interventions for a restorative program that the facility did not have. Resident 64's care plan failed to address lymphedema and the application of ACE wraps, which were not being applied as ordered. Lastly, Resident 77's care plan did not provide comprehensive instructions for activities of daily living, despite the resident's dependency on staff for care, and was not developed within the expected timeframe after admission.
Deficiencies in Care Planning and Documentation
Penalty
Summary
The facility failed to conduct timely care planning meetings for two residents, as evidenced by the lack of care conferences for these individuals. Resident 22, who was admitted with diagnoses including diabetes and depression, expressed a desire for a care conference involving a family member, but the facility was unable to contact the family member and did not proceed with the conference. Similarly, Resident 36, admitted with conditions such as diabetes and COPD, did not have a documented care conference, despite the facility's expectation for quarterly meetings. These omissions were acknowledged by the Social Service Director and the Administrator, who confirmed that the facility's expectations were not met. Additionally, the facility failed to update care plans for three residents, leading to discrepancies between documented care needs and actual conditions. Resident 30's care plan included an intervention for catheter management, despite the catheter having been removed per provider orders. Resident 88's care plan also inaccurately reflected the presence of a urinary catheter, which had been discontinued. Furthermore, Resident 77's care plan indicated ongoing isolation for COVID-19, although observations showed no isolation measures in place. These inconsistencies were confirmed by staff interviews, highlighting a failure to revise care plans to reflect current resident needs.
Failure to Implement Fall Interventions and Medication Management
Penalty
Summary
The facility failed to maintain a safe environment for three residents, leading to multiple falls and medication management issues. Resident 22, who had a history of falls and medical conditions such as diabetes and peripheral vascular disease, experienced several falls, including one that resulted in serious injuries requiring hospitalization. Despite these incidents, the facility did not implement new fall interventions promptly, as evidenced by the lack of immediate action following a fall on January 6, 2025, and subsequent falls. Interviews with staff revealed that there was an expectation for immediate intervention and care plan updates after each fall, which were not consistently met. Resident 5, who was independent and had conditions like diabetes and chronic kidney disease, also experienced multiple falls without timely or adequate interventions. The care plan for Resident 5 did not reflect new interventions after falls on January 31, 2025, and February 20, 2025. Although an intervention for a grab bar was suggested after a fall on March 1, 2025, it was not implemented by the time of observation in mid-March. Staff interviews highlighted a lack of communication between nursing and therapy departments, contributing to the failure to implement necessary safety measures. Resident 45, with diagnoses including diabetes and cognitive deficit, was found with medications left at their bedside without a proper self-medication administration assessment or order. This practice was against the facility's expectations, as confirmed by staff interviews, which indicated that residents should have an assessment and order before self-administering medications. The failure to assess and plan for self-medication administration placed Resident 45 at risk for medication errors.
Failure in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, which led to inappropriate and unnecessary use of antibiotics for three residents. Resident 418 was prescribed Bactrim for a urinary tract infection upon returning from the hospital, but there was no review of microbiology results and susceptibilities. Resident 419 was prescribed Clindamycin for a UTI despite a negative urinalysis, and there was no documentation of a review for microbiology results or antibiotic stewardship. Resident 420 received ertapenem for a suspected UTI related to kidney stones, but hospital documentation showed no growth in urinalysis results, and there was no review for microbiology results or antibiotic stewardship. Interviews with facility staff revealed a lack of procedures to request culture results for residents prescribed antibiotics at the hospital. The Infection Preventionist/Registered Nurse admitted to not requesting culture results, while the Director of Nursing Services expected the infection preventionist to review new antibiotic orders and cultures for susceptibility. This discrepancy in expectations and actions contributed to the facility's failure to effectively monitor and manage antibiotic use, placing residents at risk for potential adverse outcomes.
Failure to Document Vaccine Education and Offerings
Penalty
Summary
The facility failed to ensure and document that four out of five sampled residents were informed about the benefits and risks of influenza and pneumococcal vaccines, and whether they had the opportunity to receive these vaccines unless medically contraindicated, refused, or already immunized. This deficiency was identified through interviews and record reviews, which revealed that Residents 87, 27, 92, and 78 did not have documentation in their electronic health records (EHR) indicating they received education on the vaccines or were offered, provided, refused, or already received the vaccines. Resident 87, admitted with acute respiratory failure, asthma, and diabetes, had no documentation of education or vaccine status. Resident 27, with diabetes and encephalopathy, also lacked documentation of education or vaccine status. Similarly, Resident 92, with liver disease and kidney failure, and Resident 78, with gout and weakness, had no records of being informed or offered the vaccines. Interviews with the Director of Nursing Services and the Administrator confirmed that it was the facility's expectation to provide such education and documentation upon admission and annually, which was not met in these cases.
Failure to Educate and Document COVID-19 Vaccination for Residents
Penalty
Summary
The facility failed to ensure and document that three residents were informed about the benefits and risks of the COVID-19 vaccine and had the opportunity to receive it unless medically contraindicated, refused, or already immunized. This deficiency was identified during a review of the electronic health records (EHR) of Residents 87, 27, and 92. Each of these residents had significant medical conditions, such as acute respiratory failure, diabetes, encephalopathy, liver disease, and kidney failure, and were capable of making their needs known. However, there was no documentation in their EHRs indicating that they received education on the COVID-19 vaccine or were offered the vaccine. Interviews with facility staff, including the Director of Nursing Services and the Administrator, revealed that it was the facility's expectation that all residents be provided education on the risks and benefits of the COVID-19 vaccine and be offered the vaccine upon admission and annually. The staff acknowledged that the lack of documentation and failure to educate and offer the vaccine to Residents 87, 27, and 92 did not meet their expectations. This oversight placed the residents at an increased risk of COVID-19 infections and deprived them of the knowledge needed to make informed decisions regarding their health.
Incomplete Informed Consents for Psychotropic Medications
Penalty
Summary
The facility failed to obtain complete informed consents for psychotropic medications for a resident, identified as Resident 26, prior to administering the medications. Resident 26, who had diagnoses of dementia, anxiety disorder, and bipolar disorder, was prescribed Clonazepam and Divalproex Sodium. However, the informed consent forms for these medications were incomplete. The form for Clonazepam, dated 02/21/2024, lacked details such as dose/frequency, duration, medication category, diagnosed condition, clinical indication, expected benefits, and possible side effects. Similarly, the consent form for Divalproex Sodium, dated 04/22/2021, was missing information on the specific condition to be treated, expected benefits, and the proposed course of the medication. Interviews with facility staff, including a Licensed Practical Nurse/Unit Manager and the Director of Nursing Services, confirmed that the informed consent forms for Resident 26 were not filled out completely, which did not meet the facility's expectations. This oversight placed the resident or their legal representatives at risk of not having sufficient knowledge to make informed decisions regarding the use of these medications, potentially affecting the resident's quality of life.
Failure to Honor Resident Shower Preferences
Penalty
Summary
The facility failed to honor the shower preferences of Resident 216, who was readmitted with diagnoses including bipolar disorder, heart failure, spinal stenosis, and morbid obesity. The resident was capable of communicating their needs but reported not having a choice regarding shower times. The care plan initiated on 03/01/2025 did not include instructions or preferences for showers. During an interview, the resident stated that they had not received a shower since their admission on 03/01/2025, as the only option given was to accept or decline a shower, with no alternative arrangements if they were unwell or busy. Staff L, an LPN/Unit Manager, confirmed that showers were scheduled, and make-up days were on Sundays. The Director of Nursing Services acknowledged that the situation did not meet expectations for resident choice.
Failure to Maintain Homelike Environment in Resident Rooms
Penalty
Summary
The facility failed to provide a homelike environment in resident rooms on two of its hallways, specifically the 200 and 100 halls. Observations conducted on multiple dates revealed that the wall behind the head of the bed in Resident 65's room on the 200 Hall had torn wallpaper and deep gouges, with flaking drywall accumulating on the floor. Resident 65 reported that the wall had been in disrepair since their arrival three weeks prior, and staff were aware of the issue. Similarly, observations in two rooms on the 100 Hall showed walls behind the head of the beds with torn wallpaper and deep gouges. During interviews, the Maintenance Director acknowledged that the rooms had needed repair for months, but the facility lacked a timely solution. The Administrator stated that the expectation was for maintenance staff to complete weekly rounds, enter needed repairs into the system, and complete repairs within 30 days. This deficiency was noted under WAC 388-97-0880(1).
Failure to Conduct Background Check for CNA
Penalty
Summary
The facility failed to complete a criminal background check prior to hiring a Certified Nursing Assistant (CNA), identified as Staff F, which is a violation of their policy titled 'Background Screening Investigations' dated 03/27/2024. This policy mandates that employees cannot work in positions involving direct contact with patients until a criminal background check is completed. Staff F was hired on 09/05/2024, but their employee file lacked documentation of a completed background check. During an interview, the Administrator in Training, Staff C, acknowledged that the background check for Staff F was not conducted, which was deemed unacceptable. Additionally, Resident 216 reported that Staff F was rude and caused them pain by pushing hard on their hip, leading them to scream. Observations confirmed that Staff F was working in the same hallway as Resident 216 during the day shifts on 03/10/2025 and 03/11/2025.
Failure to Report Allegation of Abuse
Penalty
Summary
The facility failed to identify and report an allegation of abuse involving Resident 216, who was readmitted with diagnoses including bipolar disorder, heart failure, spinal stenosis, and morbid obesity. Resident 216, who was able to communicate their needs, reported an incident where a certified nursing assistant was rude and pushed hard on their hip, causing them to scream. Additionally, Resident 216 reported not receiving incontinent care the previous night, resulting in urine on the floor by morning. These concerns were communicated to the lead aide but were not documented in the facility's incident and grievance log. Interviews conducted revealed that the staff, including the Licensed Practical Nurse/Unit Manager and the Administrator, were unaware of Resident 216's allegations. Staff L stated that staff were expected to report such concerns to nurse managers, the state reporting hotline, and the administrator. However, the allegations were not reported, which was acknowledged as unacceptable by Staff A, the Administrator. This oversight placed Resident 216 at risk of further abuse, psychological distress, and diminished quality of life.
Failure to Follow Provider's Order for Cervical Collar
Penalty
Summary
The facility failed to follow the provider's order for a resident, identified as Resident 215, who was reviewed for professional standards of care and services. Resident 215 was admitted with diagnoses including end-stage renal disease, spinal stenosis in the cervical region, diabetes, and urine retention. The resident was capable of communicating their needs. Observations from March 10 to March 14, 2025, showed that Resident 215 was not wearing the prescribed cervical collar, which was intended for support and comfort. Despite this, the medication administration record (MAR) indicated that the cervical collar was signed off as used by multiple nurses from March 9 to March 12, 2025. Interviews revealed that the staff were supposed to educate the resident on the use of the neck collar and notify the provider if it was not used. Staff L, a Licensed Practical Nurse/Unit Manager, acknowledged that the documentation in the MAR was incorrect, as it should not have been signed when the collar was not used. The Director of Nursing Services, Staff B, also confirmed that the documentation did not meet expectations.
Failure to Assist Residents with ADLs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for three residents, leading to deficiencies in care. Resident 43, who was dependent on staff for mobility due to a stroke and other conditions, expressed a desire to get out of bed more frequently but believed there were not enough staff. Despite having a wheelchair, it was unavailable due to repairs, and staff only assisted the resident out of bed for appointments. Observations showed the resident remained in bed for extended periods, and staff did not prioritize the resident's request to get up, contrary to the Director of Nursing Services' (DNS) expectations. Resident 30, diagnosed with cancer, dementia, and diabetes, required assistance with meals and mobility. However, staff failed to assist the resident with eating, and the resident remained in bed throughout the day without repositioning, as outlined in their care plan. Additionally, Resident 88, who had a cognitive communication deficit and diabetes, was not offered assistance with personal hygiene, specifically shaving, despite expressing a desire to be shaven. The care plan lacked interventions for grooming, and staff did not offer shaving during morning care or showers, contrary to the DNS's expectations.
Failure to Provide Proper Care for Non-Pressure Skin Conditions
Penalty
Summary
The facility failed to provide necessary care and services for two residents with non-pressure skin conditions. Resident 22, who had diabetes, peripheral vascular disease, and atrial fibrillation, was not given proper treatment for diabetic foot ulcers. The treatment administration record showed an order to apply iodine to scabs on the third toes of both feet, but the treatment was incorrectly applied to the right second toe. Weekly skin checks and wound evaluations were not documented as required, and new wounds were discovered without proper documentation or clarification of treatment orders. Staff interviews confirmed that the treatment and documentation did not meet expectations. Resident 64, diagnosed with a disorder of muscle, lymphedema, and difficulty walking, did not receive the prescribed daily leg wrapping for edema management. Observations confirmed that the resident's legs were not wrapped, and the medication administration record showed no documentation of the treatment being applied. Staff interviews revealed that the order was incorrectly entered as requiring no documentation, leading to the treatment not being performed as expected. The Director of Nursing Services acknowledged that the orders were not followed as directed by the provider.
Failure to Maintain or Improve Range of Motion for Residents
Penalty
Summary
The facility failed to provide appropriate treatment or services to maintain or improve the range of motion (ROM) for two residents, leading to a deficiency in care. Resident 80, who was admitted with acute respiratory failure and chronic obstructive pulmonary disease, had impairments in both upper and lower extremities. Despite a recommendation for a restorative program following the discharge from physical therapy, Resident 80 did not receive any restorative care outside of daily activities. Interviews with staff revealed a lack of awareness and implementation of the recommended restorative program, which was only recently initiated. Resident 88, admitted with cognitive communication deficit and diabetes, was observed with a curled left hand and dry skin, unable to move their fingers. Although a hand splint was recommended and fitted to improve functional grasp, there was no provider order or care plan entry for its use. Staff interviews indicated a lack of awareness and implementation of the hand splint recommendation, and the resident confirmed they did not wear the splint. The facility had not yet started a formal restorative program, and the therapy recommendations were not incorporated into the care plan, failing to meet the facility's expectations.
Failure to Monitor Fluid Restrictions and Nutritional Supplementation
Penalty
Summary
The facility failed to monitor and accurately document fluid restrictions for two residents, Resident 64 and Resident 82, which placed them at risk for medical complications. Resident 64, who was admitted with diagnoses including muscle disorder and lymphedema, was observed with multiple sources of fluids at their bedside, despite having a provider's order for a fluid restriction of 2000 ml per day. The care plan specified no fluids at the bedside and required monitoring and documentation of fluid intake, but there was no documentation of fluid intake in the nutrition task. Staff interviews revealed a lack of awareness and communication regarding the resident's fluid restriction. Similarly, Resident 82, diagnosed with COPD and CHF, was observed with a full water pitcher and other drinks at their bedside, despite a fluid restriction order of 2000 ml per day. The medication administration record showed inconsistent documentation of fluid intake, and the nutrition task lacked documentation of fluids consumed with meals. Staff interviews indicated that the resident was not included on the fluid restriction list, and the assigned nurse was unaware of the fluid restriction order. Additionally, the facility failed to follow provider's orders for nutritional supplementation for Resident 36, who had a feeding tube and was diagnosed with diabetes and COPD. The resident's diet order included a regular diet and enteral feed supplementation if oral intake was less than 50% at meals. However, documentation showed missing meal intake percentages and no record of the required bolus supplement administration. Staff interviews confirmed the inconsistency in meal intake documentation and the lack of supplementation, which did not meet the facility's expectations.
Deficiency in Enteral Nutrition Administration and Documentation
Penalty
Summary
The facility failed to administer enteral nutrition to Resident 36 in accordance with the provider's orders and professional standards of practice. Resident 36, who was admitted with diagnoses including diabetes, COPD, and required a feeding tube, was supposed to receive enteral feedings of Glucerna 1.2 calories at 65 ml per hour with 60 cc water flushes every four hours via a PEG tube. The feedings were to start at 7:00 PM and end at 7:00 AM, totaling 780 ml in 24 hours. However, the medication administration records (MAR) for March 2025 did not include documentation for when the feeding was stopped or the total amount of feeding provided in a 24-hour period. Interviews with staff revealed that the documentation did not meet expectations. Staff X, an LPN, confirmed the feeding schedule, but the MAR lacked areas to document the feeding's end time and total volume administered. Staff H, an LPN/Unit Manager, and Staff B, the Director of Nursing Services, acknowledged the deficiency in documentation, stating that it should have included both the start and stop times and the total amount of feeding provided. This oversight placed Resident 36 at risk for inadequate nutrition and hydration.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for three residents. Resident 36, who had a history of COPD, was observed with an oxygen concentrator in their room despite having no active orders for oxygen therapy. The resident used the oxygen concentrator at their discretion, which was not in accordance with any physician's orders. Staff interviews revealed that the oxygen concentrator should not have been in the resident's room, and there were no parameters set for monitoring oxygen saturation levels or guidelines for when to notify a provider. Resident 5, who had diagnoses including congestive heart failure, was observed receiving oxygen at a rate of three liters per minute, contrary to the physician's order of two liters per minute. Staff were signing off on the administration of oxygen without verifying the correct setting. Similarly, Resident 82, with COPD, was receiving oxygen at two liters per minute instead of the ordered three liters per minute. Staff interviews confirmed that the oxygen settings were not being checked as required, leading to discrepancies in the administration of oxygen therapy.
Failure to Provide Non-Pharmacological Interventions Before Pain Medication
Penalty
Summary
The facility failed to provide non-pharmacological interventions for two residents, leading to the administration of unnecessary medications. Resident 26, who was readmitted with anxiety disorder, high blood pressure, and COPD, received Hydrocodone-Acetaminophen multiple times without documented attempts of non-pharmacological interventions prior to administration. The Director of Nursing Services (DNS) acknowledged that non-pharmacological interventions should have been offered before administering as-needed pain medication, and the lack of documentation did not meet expectations. Similarly, Resident 88, admitted with severe cervical stenosis with myelopathy and diabetes, received tramadol for pain on several occasions without attempts at non-pharmacological interventions, despite an existing order to do so. The medication administration records marked these interventions as not applicable, which the DNS confirmed did not align with the facility's expectations. This oversight placed the residents at risk for unnecessary medication use and potential side effects.
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Illustrative
What surveyors actually found near you
We read the 1,014 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Tacoma
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Orchard Park Health Care & Rehab Center | 0.5 mi | ★★★★★ | 45 | 0 |
| Agility Health And Rehabilitation | 1.4 mi | ★★★★★ | 24 | 0 |
| Alaska Gardens Health And Rehabilitation | 1.9 mi | ★★★★★ | 20 | 1 |
| Park Rose Care Center | 2.6 mi | ★★★★★ | 0 | 0 |
| Avalon Healthcare - Tacoma | 3.5 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.