Below average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bremerton Trails Post Acute during CMS and state inspections, most recent first.
A resident call light system on the Cove unit was not working, and multiple residents reported they could not summon help when needed. Residents said their call lights did not illuminate or sound, some had to yell, wheel into the hallway, or wait for staff rounds, and not all residents were given bells. Staff knew parts of the system were down, but communication and response were inconsistent, and maintenance was not notified immediately.
Missed Physician-Ordered Pain Medications: Two residents did not receive ordered oxycodone on time. One resident with metastatic cancer and a femur fracture had severe pain on admission and did not receive the narcotic until the next morning, while another resident with fibromyalgia missed multiple oxycodone doses because pharmacy access issues and a new script were needed. Staff said the facility had an emergency medication dispensing cabinet, but the ordered pain meds were still not obtained as expected.
Staff failed to follow droplet precaution protocols for residents with influenza. A CNA entered rooms on droplet precautions wearing a mask, then exited, performed hand hygiene, but did not remove the mask and continued passing lunch trays in the hallway. Another CNA did the same and later stated they either forgot to remove the mask or had not noticed the droplet precaution signage. An RN exited a droplet-precaution room for a resident with influenza, performed hand hygiene, but did not remove the mask and continued administering medications while wearing the same mask. The IP confirmed that residents with influenza were on droplet precautions and that staff were expected to remove masks and eye protection and perform hand hygiene upon exiting, which did not occur.
A resident with cerebral palsy and a court-appointed guardian experienced multiple episodes of nausea, vomiting, loose stools, abdominal discomfort, fatigue, and later refusal of meals and medications, leading to changes in the care plan including close monitoring, lab testing, and IV fluid administration. Despite a facility policy recognizing court-appointed guardians as resident representatives with decision-making authority, staff did not document any notification to the guardian during these changes in condition or treatment decisions. The guardian reported not being contacted when the resident stopped eating or developed stomach issues and felt the facility did not respect the guardianship, while the DON acknowledged there were multiple missed opportunities to notify the guardian of the resident’s change from baseline.
A resident with depression, anxiety, moderate cognitive impairment, and urinary incontinence, care-planned for q2h checks and assistance with toileting, was found by a visitor to be soaking wet, unusually agitated, and reporting they had been told to wait to be changed and referred to with a derogatory remark. The visitor filed a written grievance alleging abuse/neglect related to delayed incontinence care and removal of the resident’s tablet as a consequence. Although an incident report noted that the matter was reported to the state and that the resident was not soaking wet, a CNA who actually changed the resident later reported the resident’s brief, pants, wheelchair, and socks were soaked and that the resident was acting timid and repeatedly saying they had to sit for five minutes, but this CNA was never interviewed. The DON acknowledged not investigating the resident’s behavior or interviewing this CNA, and the grievance official acknowledged the facility did not fully investigate or communicate findings and resolution to the complainant, resulting in a failure to follow the facility’s grievance policy.
A resident with dementia, respiratory failure, and heart failure developed new shortness of breath with an O2 sat of 90%, and a physician ordered transfer to the ED for tx and eval. An RN completed an SBAR, notified the MD and family, and reported to the oncoming nurse that the resident needed ED transfer and that paramedics should be contacted, then left the facility. Instead of calling 911 for this emergent respiratory distress, staff arranged non-emergent transport through a contracted ambulance service, resulting in the resident remaining at the facility for several hours without pickup until the dispatcher later instructed staff to call 911. The DON stated that 911 is expected to be used for emergent conditions and the contracted service only for non-emergent transport.
A resident with anoxic brain injury, dysarthria, and documented lack of decisional capacity alleged physical abuse and expressed fear of their identified representative, yet social services only reported the allegation to the state and did not complete an incident report, revise the care plan, or implement protective interventions. The same representative continued to be treated as the resident’s decision-maker and visited frequently, with staff noting suspicious odors of foreign substances and concerns about possible illicit substance use. Psychiatry later documented concern that the representative was providing illicit substances, and the resident was subsequently hospitalized for altered mental status and overdose, after which the representative was banned. Key staff, including the DON, unit manager, and administrator/abuse coordinator, were unaware of the initial abuse allegation, and social services did not timely explore or clarify legal decision-making authority or alternative representation for the resident.
Two residents who were dependent on staff for ADLs, including bed mobility, toileting, and eating, did not receive needed assistance with positioning, hygiene, and meals. One resident with stroke-related hemiparesis, moderate cognitive impairment, and risk for malnutrition was observed in a urine-odorous room with water and meal trays out of reach, unable to use their arms, repeatedly requesting food and fluids, while multiple staff entered and exited without timely feeding assistance or incontinence care. Another resident with severe cognitive impairment and rib and pelvic fractures was repeatedly seen slid down in bed with the head elevated, back unsupported, grimacing and whining, with their brief exposed and visible from the hallway, as staff walked by without repositioning or covering them, despite care plans indicating total dependence for bed mobility and known pain from fractures.
A resident with depression, anxiety, and moderate cognitive impairment reported that a family member had taken their personal cell phone and would not return it. The SSA documented the concern and reported it to the state agency and left a voicemail for the family member but did not initiate or conduct an investigation or attempt to locate the phone. The resident stated the phone was their only way to communicate with the outside world. The Administrator later indicated they were unaware of the allegation and that staff had not followed facility policy for handling an allegation of misappropriation of property.
A resident with chronic pain and spinal stenosis, who was cognitively intact, had physician orders for scheduled and PRN oxycodone but experienced multiple missed doses due to the medication not being available. The MAR and progress notes documented repeated instances where oxycodone was unavailable in automated dispensing systems, only partial doses were on hand, or doses were pending pharmacy delivery. The resident reported that staff frequently told them the facility had run out of oxycodone and gave varying reasons such as ordering issues, shift mix‑ups, unsigned prescriptions, and insurance problems. A medical provider stated they expected medications to be given as ordered, and the DON reported that the pharmacy had not been sending the full amount of oxycodone requested for refills.
A resident with severe cognitive impairment and a prior coccyx PU had a healed Stage II wound that later reopened and worsened to Stage III. The care plan called for weekly wound checks, off-loading, and repositioning every 2 to 3 hours, but repositioning was discontinued and not reinstated, and the resident was repeatedly observed lying on the back or at a 45-degree angle in bed. During wound care, staff used wound cleanser instead of ordered saline and did not apply ordered skin prep, while the resident reported increased pain during treatments and said the wound was getting worse.
A resident's room was found to have missing paint and protruding plaster on the ceiling, which the resident and an LPN confirmed did not meet homelike standards. Additionally, multiple residents and staff reported that a hallway exit door repeatedly slammed and set off a loud alarm, causing ongoing disturbances. Maintenance efforts to reduce the noise were unsuccessful, and residents continued to express dissatisfaction with the environment.
Two residents admitted with fractures did not receive occupational therapy (OT) evaluation and treatment as ordered due to the unavailability of an OT. Although physician orders and provider notes indicated the need for OT, therapy was delayed until an OT became available, and it was unclear if medical providers were notified of the delay. The administrator expected therapy to be provided as ordered but was unaware of the lapse.
Surveyors were not provided with complete access to resident medical records, including MAR, TAR, assessments, care plans, nutritional reports, and lab results, despite multiple requests to the Administrator and DON. The Grievance log was also outdated and missing reported grievances, and facility leadership was unable to resolve the access issues during the survey.
Failure to provide dignified and private care: An LPN left a severely cognitively impaired resident soiled and waiting for hygiene care, another LPN spoke disrespectfully to a cognitively intact resident in front of them and a staff member reportedly checked the resident’s underwear while sleeping, and staff failed to maintain privacy for a dependent resident during care with the curtain left open despite the roommate being present.
A facility failed to ensure residents with personal funds/resident trust accounts had ready access to their accounts during evenings and weekends for all 38 residents reviewed. Staff reported that access was only available when the front desk was staffed from 8:30 AM to 6:00 PM, and that residents did not have access on weekends or after hours.
Failure to Provide Quarterly Personal Fund Statements: The facility did not provide quarterly personal fund statements to residents with personal fund accounts, affecting all residents reviewed. A resident with moderate cognitive impairment said they did not receive statements, and the Revenue Cycle Manager reported statements were being issued only every 6 months instead of quarterly. The Administrator confirmed residents were not receiving the statements as expected.
A resident’s personal fund account remained open with a balance of $2,072.98 long after discharge. The Revenue Cycle Manager said the resident had been gone for over a year and the prior company had not withdrawn the money, and the Administrator confirmed the account was not closed within 30 days of transfer.
Grievances Not Logged or Resolved: The facility failed to consistently initiate, log, and resolve resident grievances. Residents raised repeated concerns in council meetings about call lights, staffing, showers, response times, food, housekeeping, and communication with the doctor, but many were not found on the grievance logs. A cognitively intact resident reported staff were not timely, another reported an LPN was not kind and described an unsettling overnight interaction, and a third cognitively intact resident with depression alleged abuse and neglect; staff said grievances were filed, but the logs and records did not reflect all of the concerns.
Psychotropic medications were not regularly monitored for side effects and target behaviors for several residents. One resident with depression had aripiprazole, sertraline, and trazodone without documented monitoring; another resident with anxiety and depression had buspirone and duloxetine without target behavior orders; a resident with anxiety and PTSD had hydroxyzine without target behavior monitoring; and two other residents with bipolar disorder, depression, anxiety, or delirium had quetiapine, trazodone, or buspirone without the required monitoring documented. Staff confirmed the missing monitoring in chart review and interviews.
MDS Communication Restorative Program Mis-coded for 3 Residents: The facility inaccurately coded a communication restorative program for three residents even though the records did not show individualized, measurable communication goals, required monitoring, evaluation, or documentation. One cognitively intact resident was coded for Yahtzee/socialization, while two other residents were coded for bible reading or bible study that staff described as staff-led reading rather than resident communication therapy. Staff could not provide documentation showing the residents’ communication levels, progress, or how the programs met RAI requirements.
A facility failed to develop, implement, and provide baseline care plans within 48 hours of admission for three new residents. One resident never received a baseline care plan, another had one started 8 days after admission, and a third had one started 4 days after admission but it was not given to the resident. The Charge Nurse/LPN and DON confirmed the baseline care plans were not provided as required.
Care conferences were not documented for several residents after MDS assessments, and multiple care plans were not updated when resident needs changed. A cognitively intact resident, a cognitively impaired resident with a POA, and another cognitively intact resident had little or no evidence of quarterly care conferences. In addition, one resident’s care plan was not updated after pills were found in a dresser, another resident’s plan was not revised after hospitalization for seizures and antidepressant discontinuation, and a resident with PTSD had no care plan addressing triggers or a preference to avoid male shower aides.
A facility failed to follow bowel protocol for four residents with several-day gaps in BM documentation, including one cognitively intact resident who reported constipation and had no PRN bowel meds or related charting. It also failed to document or promptly respond to a resident’s BG of 40 despite an order for immediate hypoglycemia treatment and repeat checks, and failed to document the events leading to another resident’s hospitalization after being found unresponsive with seizure activity.
A resident with dementia and nutritional deficiency did not consistently receive ordered meal supplements, cereal, or cut-up assistance, and staff noted the meal ticket and Kardex did not reflect the cut-up order. In addition, residents were observed not being offered drinks with meals, and two residents with ESRD and CHF repeatedly exceeded ordered fluid restrictions based on MAR and CNA documentation, with staff confirming the totals were over the limits.
A resident with depression and anxiety became increasingly tearful after an antidepressant was tapered off, but the care plan and nurse monitoring did not reflect the medication stop or the resident’s crying and request for mental health support. Another resident with PTSD reported discomfort with male shower aides due to past sexual abuse, yet the care plan did not include PTSD triggers or the no-male-caregiver preference. Resident council discussions also showed residents were emotional about mental health concerns and counseling services.
A facility failed to keep several residents’ drug regimens free from unnecessary meds by giving PRN opioids outside ordered pain-score and timing parameters, not documenting required NPIs, and not reassessing a nightly sleep med. Records showed repeated oxycodone and acetaminophen administrations without required pain criteria or NPI documentation, and staff confirmed the orders were not followed.
Food service failed to provide a palatable lunch item when a sampled chicken patty was found to be dry, difficult to chew, and lacking palatability. A CNA said the chicken was dry and hard for residents to chew, and a resident reported needing sauce to help the meat go down because it was so dry. The Dietary Mgr said he was unaware of the issue, and the DON stated meals were expected to be palatable and easy to consume.
Expired and improperly labeled food items were found in the walk-in kitchen refrigerator, including coleslaw, chicken salad, Thousand Islands dressing, and hot dogs. The Dietary Manager stated refrigerated food should be labeled right away and kept until the use-by date, and the DON stated food items were expected to be labeled accurately and discarded by the use-by date.
The facility had multiple infection control failures involving its Legionella water management program, laundry room practices, vaccination consent documentation, and EBP use. The water management plan lacked a full system diagram, complete Legionella risk areas, and documentation of testing locations; the laundry room had nonworking ventilation, soiled and clean items mixed in the area, reused microfiber rags, and a staff refrigerator present; vaccine records for several residents lacked documented education, risk/benefit review, or dated consent; and a CNA entered a resident’s room for catheter care under EBP with gloves only and no gown.
The facility failed to properly monitor antibiotic use and complete timely infection evaluations for multiple residents. An IP/ADON/LPN could not verify criteria for one resident after a hospital return, reviewed another resident only after the antibiotic course was finished, and acknowledged that two other residents did not meet Loeb or McGeer criteria despite being listed for UTI or cough/aspiration pneumonia. The DON stated infection evaluations were expected as soon as antibiotics were started.
Walk-In Freezer Door Not Closing Properly: The kitchen's walk-in freezer door had ice and frost buildup at the bottom right corner, preventing it from closing completely and leaving about a one-inch opening. The Dietary Manager said the door had been broken for about three months, kitchen staff were scraping the ice twice per shift, and the Maintenance Assistant said estimates for replacement had been obtained but no order had been made. The DON said he was aware of the issue but could not provide additional information.
The facility did not report allegations of sexual abuse and physical abuse involving two residents within the required timeframes. In both cases, staff either failed to recognize the need for immediate reporting or delayed notification to management and state authorities, resulting in late submission of mandatory reports.
Surveyors identified that two residents did not receive scheduled medications as ordered, were not promptly informed about medication unavailability, and were not properly observed during medication administration. Additionally, an insulin pen was found in a medication cart without the required open date label. These failures in medication administration, documentation, and storage did not meet professional standards and placed residents at risk.
The facility did not complete thorough abuse and neglect investigations for two residents. One resident, dependent on staff for care, alleged a CNA twisted their nipple, tickled their feet, and left them sitting in urine and stool; the investigation lacked full staff interviews, missed relevant timeline details, and did not fully address the neglect allegation. Another resident, dependent on staff for toileting hygiene, reported being left in feces for hours, but the investigation did not include all staff involved on the shift or a complete record of the follow-up review.
Failure to Provide ADL and Meal Assistance: The facility failed to ensure a resident received bathing assistance and two other residents received needed meal assistance. One resident said they had not received a shower since admission, and records did not support the documented showers. Another resident with stroke-related weakness was observed unable to open butter or a fruit cup and said breakfast assistance was often not provided. A third resident with dementia and an order for cut-up assistance was served a whole sandwich that was not cut up, and staff acknowledged the order was not reflected on the meal ticket or Kardex.
Failure to Provide and Document Resident-Centered Activities: A resident with Parkinson’s disease and severe cognitive impairment had documented activity preferences for social visits, conversation, news, gardening, outdoor activities, and other interests, but the planned activities record showed no participation. Observations found the resident sitting in a wheelchair near the nurses’ station with no stimulation, and the resident stated he enjoyed watching football and believed there were no activities. The Activities Director said documentation was not available due to technical issues, while the DON stated resident activities should be documented.
Incomplete Assessment and Monitoring of Bed Mobility Bars: A resident who was alert and oriented had bilateral bed mobility bars ordered to assist with bed mobility, but the record did not show comprehensive, ongoing, or periodic assessments for their use. The resident said the bars hurt their shoulder and that they had asked staff to remove them, while the Charge Nurse/Unit Manager/RN and DON/RN could not provide documentation of the required evaluations.
QAPI plan records were not updated with current leadership, and meeting minutes did not document staff or MD attendance. The administrator stated there was no new QAPI plan, the listed administrator was not current, and there was no sign-in sheet or minutes showing who attended the QAPI meetings.
Multiple residents did not receive timely assistance with ADLs, including dressing, hygiene, toileting, and scheduled showers, due to insufficient CNA staffing. Staff reported being unable to complete required care because of high resident assignments and call-outs, resulting in missed personal care and hygiene for several residents. The DON confirmed that care was missed when staffing was inadequate, and documentation showed no evidence that residents refused care.
Four residents did not receive medications as ordered, including missed or incorrectly timed eye drops for an eye infection, gabapentin given at improper intervals for nerve pain, and insulin administered after meals instead of before. Staff cited transcription errors, lack of follow-up, and time constraints as reasons for these medication errors.
A nurse failed to clean and disinfect a blood glucose monitor and supply container between use on two residents, did not perform hand hygiene before and after resident care, and conducted glucose testing and insulin administration in the dining room, contrary to facility protocols. The infection preventionist confirmed these actions did not follow required infection control procedures.
A resident with dementia, diabetes, and end-stage kidney failure was discharged without proper notification to outside service providers, leading to unmet care needs. The facility failed to document the discharge notification, and necessary assessments were not completed, impacting the resident's care continuity.
A resident with functional limitations and a history of using a power wheelchair for community access had their wheelchair removed after an incident, restricting their mobility and community engagement. Despite assessments showing the resident could operate the wheelchair independently, the facility did not provide alternatives, impacting the resident's socialization and mood.
A facility failed to meet professional standards by discontinuing medications without authorization and not following physician's orders for three residents. One resident missed morning medications due to an EMR error, another had critical medications discontinued without authorization, and a third did not receive daily wound care as ordered. These deficiencies led to missed treatments and discomfort for the residents.
A facility failed to follow infection control standards during wound care for a resident with MRSA. An LPN did not wear a gown and neglected hand hygiene between glove changes while treating the resident's wound, contrary to the facility's policy. The Infection Preventionist confirmed the need for gown use and proper hand hygiene.
The facility failed to ensure staff adhered to CDC guidelines for PPE use during a COVID-19 outbreak. A CNA did not change their N95 respirator after leaving a COVID-19 positive resident's room and continued to interact with other residents. Another CNA used contaminated gloves to search an isolation cart, and an Agency Licensed Nurse also failed to replace their N95 respirator. Despite training, staff actions did not align with infection control protocols.
A resident with a history of skin picking and severe cognitive impairment suffered a maggot infestation in a scalp wound due to the facility's failure to consistently assess, monitor, and provide timely wound care. Despite physician orders for treatment, there was a lack of documentation and communication regarding the wound's condition. Staff noticed a foul odor and drainage but did not report these signs to the medical provider, leading to significant physical harm.
A facility failed to maintain effective pest control, resulting in flies across all resident care units and a resident's wound becoming infested with maggots. Observations showed flies in various areas and open windows and doors without screens. Staff interviews revealed a lack of awareness and action regarding pest control and wound care, with admissions of the absence of screens and propped open doors.
The facility failed to provide sufficient licensed nurses to administer medications timely, resulting in significant delays for three residents. A resident reported inconsistencies in receiving pain medications, with morning doses scheduled for 8:00 AM being administered as late as 7:34 PM. Another resident experienced delays in bedtime medications, sometimes receiving them after midnight. A third resident reported receiving morning medications at noon and evening doses after midnight, especially when staffing was low. Staff interviews confirmed that insufficient staffing contributed to these delays.
Nonfunctioning Call Light System on Cove Unit
Penalty
Summary
The facility failed to maintain a functioning call light system in the Cove unit, including in residents’ rooms and bathroom/bathing areas. On 05/14/2026, Resident 3 and Resident 4 each reported that their call lights had not been working since the previous day. When each resident pushed the call light, the light above the door did not illuminate, there was no audible sound, and the room number did not appear on the call system panel across from the nursing station. Resident 3 said they had to wheel into the hallway to find staff, and Resident 4 said they had to yell for help because their voice was not loud enough to be heard. Additional residents on the Cove unit reported the same problem. Resident 5 said they had not had a functioning call light since about 5:00 PM the day before and had not been given a bell or other instructions for alerting staff. Resident 6 said they had been pushing the button and no one came, were told the system was down, and had not been given a bell; they said they had chronic shortness of breath and had no way of yelling loud enough. Resident 7 said they pushed the call light and no one came, later used a cell phone to contact the front desk, and eventually received a bell from staff, but said the bell could not always be heard and the wait for assistance was longer. Staff interviews showed the problem had been known before the surveyor observation, but the issue was not promptly resolved or consistently communicated. A CNA said the call light in Resident 3’s room had stopped working the day before and that the Cove unit system was still not working, with only some residents given bells because there were not enough for everyone. An LPN said the evening supervisor had discussed Resident 7’s concern and that a message was sent through the staff phone app about the Cove lights not working. The ADON said a stand-down meeting had been held and staff were told maintenance had been notified, but the ADON did not investigate how many call lights were affected or ensure all residents had a way to alert staff. Maintenance staff said they were not notified until the morning of 05/14/2026 and stated they would have responded immediately if told the prior day. The Administrator said they learned of the issue only after reading a grievance from the grievance box that morning.
Missed Physician-Ordered Pain Medications
Penalty
Summary
The facility failed to provide physician-ordered pain medications for two residents. One resident was admitted with metastatic cancer and a femur fracture, had frequent pain that limited daily activities and made it hard to sleep, and had an order for oxycodone 5 mg every 8 hours as needed for pain. After admission, the resident was assessed with severe pain, received acetaminophen first, and did not receive the first dose of oxycodone until the following morning. A collateral contact stated the resident was left in excruciating pain for more than eight hours and was only given Tylenol while staff said they were unable to obtain the narcotic medication faster. The second resident had fibromyalgia and was cognitively intact, with an order for oxycodone every 4 hours for pain. The MAR and progress notes showed missed oxycodone doses because pharmacy could not provide a pull code at one time and later required a new script. The resident stated the narcotic pain medication was not available on time, was not reordered on time, and when doses were missed the resident went through withdrawals and had increased pain. Staff stated they did not know why the doses were missed and said the licensed nurse should have been able to obtain the medication from the emergency medication dispensing cabinet or contact management or the physician.
Failure to Follow Droplet Precautions for Residents with Influenza
Penalty
Summary
Facility staff failed to follow droplet precaution protocols for residents with confirmed influenza, as required by CDC guidance and the facility’s own droplet precaution signage. The facility’s sign, dated 08/10/2023, directed staff to perform hand hygiene, wear a mask and eye protection before entering a resident’s room on droplet precautions, and to remove the mask and eye protection and perform hand hygiene upon exiting. Surveyors observed that residents in specified rooms were on droplet precautions for influenza, with appropriate signage posted at the doorways. On the survey date, a CNA (Staff A) performed hand hygiene and entered a droplet-precaution room wearing a mask, then exited, performed hand hygiene, but did not remove the mask and continued passing lunch trays in the hallway while wearing the same mask. Another CNA (Staff B) similarly entered a droplet-precaution room with a mask, exited, performed hand hygiene, but did not remove the mask and continued passing lunch trays. Staff A later stated they knew they should have removed the mask after exiting but forgot. Staff B stated they understood that residents with influenza required staff to wear a mask and face shield and to remove them upon exit, but said they were not aware or did not see that the room they entered was on droplet precautions. An RN (Staff C) was observed exiting a droplet-precaution room for a resident with influenza, performing hand hygiene, but not removing the mask and then continuing to administer medications in the hallway while wearing the same mask; Staff C stated they did not think they needed to remove or change the mask upon exiting. The Infection Preventionist (Staff D) confirmed that residents with influenza were on droplet precautions and that staff were expected to remove mask and eye protection and perform hand hygiene upon exiting, and acknowledged staff did not follow facility infection control policies.
Failure to Notify Court-Appointed Guardian of Resident’s Clinical Changes
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s court-appointed guardian of significant clinical changes and care decisions, contrary to its own policy and state requirements. The facility’s policy on Resident Representatives, revised 02/2021, states that a resident representative includes a court-appointed guardian or conservator and that the facility treats the representative’s decisions as those of the resident to the extent delegated or required by the court. Resident 1, admitted with cerebral palsy, had a Superior Court guardianship letter dated 02/07/2025 indicating a guardian of person and conservator of the estate with full authority, identifying Collateral Contact 1 (CC1) as the guardian. Despite this, multiple clinical events and changes in condition were documented without any corresponding documentation that CC1 was notified. Progress notes and provider notes show that Resident 1 experienced an episode of nausea and vomiting, frequent loose stools, abdominal discomfort, bloating, worsening fatigue, generalized weakness, and later refusal of meals and medications over at least a 24-hour period, with observations that the resident appeared frailer, more fatigued, and had no energy or interest to talk. The provider developed care plans including close monitoring for deterioration, sending stool to the lab, and later initiating IV fluids for rehydration, with a plan to call family/POA for discussion. However, there was no documentation that the guardian was notified at any of these points, including when IV fluids were started. CC1 reported that they were not contacted when the resident stopped eating or developed stomach issues, and expressed that the facility did not respect their guardianship and that involvement in care planning took too long. The DON confirmed on record review that there were many opportunities to notify the guardian when the resident’s condition changed from baseline and that there was no evidence staff did so.
Failure to Thoroughly Investigate and Resolve Resident Grievance Regarding Incontinence Care and Staff Conduct
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and resolve a grievance alleging neglect and disrespect toward a resident, as required by its grievance policy. The resident had depression, anxiety, moderate cognitive impairment, occasional urinary incontinence, and required moderate assistance with toileting, with a care plan directing staff to check the resident every two hours, ask about toileting needs, and ensure they were clean and dry. A collateral contact reported arriving to visit the resident and finding them soaking wet and agitated, with behavior that was not typical for the resident. The collateral contact documented in a written grievance that the resident’s tablet was off, the resident appeared upset, and the resident reported being told they had to wait five minutes to be changed and that staff would change their “nasty *ss” in five minutes, leading the collateral contact to believe the resident had been given a consequence of no tablet and sitting in wet clothes, which they characterized as abuse/neglect and requested immediate removal of the responsible staff and a report filed. The facility documented receipt of the grievance and created an incident report indicating the matter was reported to the state agency, and that the unit manager interviewed the collateral contact and the resident, with the resident described as confused and denying being soaking wet. The incident report stated that a different nursing assistant was assigned to assist with the brief change and that the unit manager believed the resident was not soaking wet, and that the resident and collateral contact were satisfied when they left the room. However, a CNA who actually changed the resident reported that the resident’s brief was soaked through their pants onto the wheelchair and their socks were soaked, and that the resident was timid, repeatedly saying they had to sit for five minutes, and not acting like themselves; this CNA stated they were never interviewed or asked about the grievance or the resident’s condition. The DON acknowledged not interviewing this CNA or investigating the resident’s behavior and why they were upset, and the unit manager did not recall whether the collateral contact was present during follow-up and did not believe they followed up with the collateral contact regarding the grievance. The administrator, identified as the Grievance Official, stated the facility should have thoroughly investigated the grievance and discussed findings and resolution with the collateral contact, indicating the grievance process was not fully carried out in accordance with policy and WAC 388-97-0460.
Failure to Obtain Timely Emergency Transport for Resident in Respiratory Distress
Penalty
Summary
The deficiency involves the facility’s failure to obtain timely emergency medical services for a resident experiencing new-onset respiratory distress. The resident had dementia, respiratory failure, and heart failure, with severe cognitive impairment and a need for substantial assistance with activities of daily living. On the day the resident was sent to the hospital, a collateral contact observed the resident having difficulty breathing, appearing unable to get enough air, and looking as if they were sleeping or unconscious, and reported this to staff with a request to contact the doctor. An SBAR Communication Form documented that the resident was experiencing shortness of breath that had not occurred before, with an oxygen saturation of 90%. The physician was notified and ordered the resident sent to the emergency department for treatment and evaluation, and the collateral contact was notified shortly thereafter. Progress notes later documented that, despite the order for emergency department transfer, the resident was still awaiting pickup by Olympic transportation several hours later, with no estimated time of arrival. At approximately 3:30 AM, the dispatcher informed the facility that they could not provide transportation and instructed that 911 be called; only then was 911 contacted and the resident transported to the hospital via ambulance for respiratory distress. The RN caring for the resident stated they completed the SBAR, notified the physician and family, and at the end of their shift reported to the oncoming nurse that the resident needed to be sent to the emergency department for respiratory distress and that paramedics should be contacted, then left assuming 911 would be called. The DON stated that staff are expected to contact 911 for emergent conditions such as shortness of breath or respiratory distress, and that Olympic Ambulance is used only for non-emergent transport.
Failure to Provide Social Service Advocacy After Abuse Allegation and Questionable Representative
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate medically-related social services and advocacy for a resident following an allegation of abuse and concerns about the resident’s representative. The resident had an anoxic brain injury, dysarthria, moderate cognitive impairment, and was dependent on staff for activities of daily living. A hospital palliative care note documented that the resident lacked decisional capacity, had no DPOA, that the legal next of kin (CC4) did not want to be part of care decisions, and that care decisions were being deferred to another contact (CC5). CC5 accompanied the resident on admission, signed admission forms, and was listed as the primary contact in the medical record profile. On a date in February, during communication therapy, the resident reported that CC5 had done something to them, pounded their hands on their chest, recalled being hit in the back of the head by an unknown person, and stated they were sometimes afraid of CC5. A social services staff member reported this allegation to the state agency but did not complete a facility incident report, did not initiate care plan changes or interventions, and took no further action. CC5 continued to be treated as the resident’s representative, and progress notes documented CC5 at the bedside on multiple dates, including an entry noting the room smelled like foreign substances and that CC5 was seen waking the resident and then asking the nurse to administer pain medications. A psychiatry note later documented concern that CC5 was providing the resident with illicit substances and stated it would be prudent for the resident to identify a POA. Subsequently, the resident was found unresponsive, transported to the hospital, and later readmitted after altered mental status and overdose, with a provider note stating that CC5 posed a significant danger to the resident and was banned from visiting. After readmission, staff attempted to contact CC4 for consent to treat but initially reached someone who stated they were not CC4. The social service director acknowledged that, beyond reporting the initial allegation, no additional interventions were implemented, that CC5 continued to be used as the resident’s representative after the allegation, and that they had not explored legal authority for decision making following the abuse allegation or concerns about substances. The social service assistant reported they did not speak with the resident about the hospital stay or CC5 and did not complete an incident report or care plan changes after the allegation. The unit manager and DON were unaware of the initial abuse allegation, and the administrator, who served as abuse coordinator, also stated they were unaware of the allegation and that an investigation should have been initiated and a representative for the resident investigated at a minimum.
Failure to Assist Dependent Residents With ADLs, Positioning, and Eating
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary assistance with activities of daily living (ADLs), including positioning, eating, toileting, and hygiene, for residents who were unable to perform these tasks independently. Facility policy required staff to provide appropriate care and services for residents needing help with hygiene, mobility, toileting, and dining, and to identify underlying causes when cognitively impaired residents resisted care rather than assuming refusal. Despite this, observations, interviews, and record reviews showed that residents with significant physical and cognitive impairments were left without needed assistance, with call lights and essential items out of reach, and with incontinence and positioning needs unmet. One resident with depression, anorexia, stroke, hemiparesis, moderate cognitive impairment, and risk for malnutrition required substantial to maximal assistance for bed mobility, personal hygiene, dressing, and was dependent for toileting, with frequent incontinence. The Kardex directed that water and needed items, including the call light, be kept within reach, that the resident receive supervision and encouragement with eating, and that staff report refusals of food or fluids to the nurse. During a continuous observation period, the resident was found in bed in a room with a strong urine odor, with an untouched breakfast tray and water out of reach, and the call light pinned behind the head of the bed. The resident reported not having water or food for days and being unable to move their arms. Multiple staff, including a Resident Care Manager, CNAs, an LPN, and a physician, entered the room over the course of nearly two hours, acknowledged the resident’s requests for food, water, and assistance, and noted the urine odor, but assistance with eating and incontinence care was delayed. Water was repeatedly placed out of reach, the lunch tray was delivered and left without timely feeding assistance despite the resident’s repeated statements that they could not move their arms, and incontinent care and repositioning were not provided during the observation. Another resident with severe cognitive impairment, rib and pelvic fractures, and care plans indicating total dependence for bed mobility and transfers and pain related to multiple fractures was repeatedly observed lying in bed with the head of the bed elevated to 90 degrees, having slid down so that their back was unsupported by the mattress. The resident’s legs were moving, their facial expression was a grimace, and they were whining softly, while dressed in a gown with their brief exposed and visible from the hallway. Over multiple observations, staff walked by the room, glanced in, but did not enter to reposition or cover the resident. An occupational therapist later confirmed the resident was not positioned correctly, appeared uncomfortable and in pain, and noted that this position would be painful given the pelvic fractures. A CNA assigned to the resident stated they had repositioned the resident by ensuring the legs were straight and not hanging off the bed and reported that blankets had covered the resident, which conflicted with the observed condition. The Assistant DON stated an expectation that staff correctly position residents in bed and that all staff assist when they observe a resident in an uncomfortable position, which did not occur in this case.
Failure to Investigate Allegation of Misappropriated Cell Phone
Penalty
Summary
The deficiency involves the facility’s failure to investigate an allegation of misappropriation of a resident’s personal cell phone. The resident was admitted with depression and anxiety and had a Minimum Data Set (MDS) indicating moderate cognitive impairment, requiring substantial/maximal assistance for bed mobility and moderate assistance for transfers. On 02/13/2026, progress notes documented that the resident reported a family member had removed their personal phone and would not return it. The Social Service Assistant (SSA) documented a report to the state agency for possible exploitation or control of the resident’s communication device by family members. During an interview on 03/04/2026 at 9:17 AM, the SSA stated that after the resident’s allegation, they reported the concern to the state agency and left a voicemail for the family member but did not initiate or complete any investigation or attempt to locate the phone. The SSA confirmed no further action was taken beyond the report and voicemail. Later that morning, the resident stated that their family member had taken their cell phone and that they wanted it back, describing it as their only way to communicate with the outside world. The Administrator reported being unaware of the allegation and stated that staff should have initiated a grievance for a missing item and an investigation, and acknowledged that staff did not follow the facility’s policy for an allegation of misappropriation.
Failure to Ensure Continuous Supply and Administration of Ordered Pain Medication
Penalty
Summary
The deficiency involves the facility’s failure to provide physician‑ordered pain medication as prescribed for a cognitively intact resident with chronic pain and spinal stenosis. Facility policy stated that pharmacy services were available 24/7 and that residents would have a sufficient supply of prescribed medications and receive them in a timely manner. The resident had physician orders for oxycodone 10 mg six times per day and an additional 10 mg every six hours as needed for pain. The MAR for the month reviewed showed multiple missed scheduled oxycodone doses on several dates, including missed doses at midnight, early morning, afternoon, and evening times. Progress notes documented that oxycodone was not available on at least one date due to awaiting pharmacy delivery, and on another date only one tablet was available when two were ordered, with the remainder on order. Additional progress notes showed repeated unavailability of oxycodone in the automated medication storage systems (Pixis/Omnicell), with documentation that staff lacked access to the system at one point and that the pharmacy had been informed of the missing medication on another. Notes also indicated that oxycodone doses were pending pharmacy delivery on multiple occasions. During interview, the resident reported that the facility continually ran out of oxycodone, resulting in missed doses on their every‑four‑hour regimen, and described receiving various explanations from staff, including that the medication was not ordered, agency nurses did not order it, there were mix‑ups between shifts, the physician did not sign the prescription, or insurance would not cover it. A medical provider stated they expected licensed nurses to administer medications per order. The DON reported that an internal review found the pharmacy was not sending the amount of oxycodone requested for refills, though the pharmacy could not explain why.
Failure to Provide Ordered Pressure Ulcer Care and Repositioning
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met for a resident with severe cognitive impairment and maximum assistance needs who had a history of a coccyx pressure ulcer. The resident’s significant change MDS documented no current pressure ulcer but identified the resident as at risk, with interventions including a pressure-reducing device, turning and repositioning, and pressure ulcer care. A wound consultant note documented the wound had completely closed on 07/08/2025, but a later note documented the wound had increased in size and was again present for approximately 30 days. The resident’s care plan required weekly wound assessment and measurement, avoidance of positioning on the buttocks, repositioning every 2 to 3 hours for off-loading, use of pillows, education on skin breakdown prevention, and application of a topical skin protectant for incontinence. Despite this, the record showed a repositioning intervention had been discontinued on 07/11/2025 and had not been reinstated. During multiple observations in late September and early October, the resident was repeatedly found lying on the back or sitting at a 45-degree angle in bed with blankets over the body, and staff reported the resident often refused side-lying and wedges/pillows. The resident’s coccyx wound worsened from Stage II to Stage III, with the wound consultant documenting deterioration and slough development. The resident reported increasing pain during dressing changes, and a provider later ordered oxycodone PRN during treatments. During an observed wound care treatment, staff used wound cleanser instead of ordered saline, did not apply skin prep as ordered, and the nurse stated they were used to using wound cleanser and did not like skin prep. The resident later reported the wound treatment hurt badly because staff scrubbed the area, said repositioning was not offered often, and stated the wound seemed to be getting worse.
Failure to Maintain Homelike Environment Due to Room Disrepair and Excessive Noise
Penalty
Summary
The facility failed to maintain a homelike environment for its residents, as evidenced by observations and interviews regarding both the physical condition of a resident's room and the noise levels in a hallway. One cognitively intact resident pointed out multiple areas on their ceiling where paint was missing and plaster was protruding, which was confirmed by a charge nurse who noted the deficiencies did not meet expectations for a homelike setting. The resident expressed dissatisfaction with the room's appearance, indicating it affected their experience. Additionally, residents and staff reported ongoing issues with a hallway exit door that frequently slammed and triggered a loud alarm, disturbing residents in nearby rooms. Multiple residents complained about the noise, both during resident council meetings and in interviews, stating that the door slammed throughout the night and the alarm was disruptive. Observations confirmed repeated slamming and alarm sounds, with residents audibly expressing frustration. Maintenance staff acknowledged attempts to address the noise, such as installing weather stripping, but these measures were ineffective or temporary.
Failure to Provide Timely Occupational Therapy Services as Ordered
Penalty
Summary
The facility failed to provide occupational therapy (OT) services as ordered for two residents who were admitted with fractures. Both residents had physician orders for OT evaluation and treatment upon admission, and their medical provider notes indicated ongoing need for OT. However, the OT evaluations and initiation of therapy were delayed for both residents due to the unavailability of an occupational therapist at the facility. The Director of Rehabilitation confirmed that OT services were not started until several days after admission for both residents, and was unable to confirm whether the medical providers were notified of these delays. Staff interviews revealed that the occupational therapist was not available at the time of the residents' admissions, resulting in a gap between the physician's order and the actual provision of therapy services. The facility administrator stated an expectation that therapy would be provided when ordered and indicated that resources were available to obtain OT services, but was unaware that the residents did not receive timely OT evaluations and treatment as required.
Incomplete Access to Resident Medical Records and Logs During Survey
Penalty
Summary
The facility failed to provide accurate and complete access to all resident medical records during an annual recertification survey. Upon entry, surveyors requested access to the electronic health record (EHR) system and the Grievance log. Although initial access to the EHR was provided, it was incomplete and did not include essential documents such as Medication Administration Records (MAR), Treatment Administration Records (TAR), various assessments, care plans, nutritional reports, and laboratory results. Despite repeated notifications to the Administrator and Director of Nursing Services (DNS) about the incomplete access, the issue persisted over several days. The DNS indicated that the corporate office was hesitant to grant full access to all medical records. Additionally, the Grievance log provided was outdated and, even after requests for an updated version, did not include all reported grievances. The lack of timely and complete access to these records had the potential to delay the survey process and hinder the ability to address resident concerns. The events documented show a pattern of delayed and incomplete responses to surveyor requests for required documentation, as well as uncertainty among facility leadership regarding how to resolve the access issues.
Failure to Provide Dignified and Private Care
Penalty
Summary
The facility failed to ensure care and services were provided in a dignified manner for 3 of 5 sampled residents reviewed for dignity. Resident 65 was severely cognitively impaired and required maximal assistance with care. On observation, Resident 65 was yelling for help to be cleaned up while sitting on the bed wearing only a brief and shirt, with a liquid brown substance trailing from under the brief down the thigh and bed. Staff L, an LPN, walked away from the medication cart outside the room, returned a few minutes later, told the resident, "You need some attention," shut the privacy curtain, turned on the call light, and left the room. Another CNA observed the call light and asked if help was needed, but Staff L said Resident 65 could wait for the assigned CNA to return. A second CNA entered, spoke briefly with the resident, turned off the call light, and exited without providing hygiene care. Resident 65 remained without care until another CNA later returned and provided assistance. Resident 8 was cognitively intact and independent with toileting. During a hallway conversation, Resident 8 said they wanted to report a nurse for not being kind. Staff S, an LPN, stated that Resident 8 had requested eye drops and later asked for thyroid medication and Tylenol, and then said Resident 8 was rude and had memory issues in front of the resident. Resident 8 responded that the nurse needed a new job. The MAR showed no Tylenol had been given that morning or overnight. Later, Resident 8 told another LPN that a young staff member had checked their underwear while they were sleeping even though they could independently use the bathroom, and said this was unsettling and no longer felt like a safe place. Resident 12 had diagnoses of depression and anxiety and was cognitively intact but dependent on staff for cares. During an observation, Staff S was heard telling staff caring for Resident 12 to pull the curtain for privacy while the roommate was present. The roommate later stated the curtain was not pulled that morning and Resident 12 was exposed several times during care, including one time when the roommate personally closed the curtain. Resident 12 also stated they did not like the curtain being open and said, "I am laying here naked and the curtain is open."
Resident Trust Accounts Not Accessible After Hours
Penalty
Summary
The facility failed to ensure residents with personal funds/resident trust accounts had ready access to their accounts during evenings and weekends for 38 of 38 residents reviewed for personal funds accounts. During the survey, Staff T, Revenue Cycle Manager, stated that residents did not have access to their personal fund accounts after hours. Staff further reported that residents only had access when the front desk was staffed from 8:30 AM until 6:00 PM. Later the same day, Staff A, Administrator, stated that residents did not have access to their funds on weekends and after hours.
Failure to Provide Quarterly Personal Fund Statements
Penalty
Summary
The facility failed to ensure quarterly personal fund statements were provided to residents with personal fund accounts for 38 of 38 residents reviewed. Resident 60, who was readmitted to the facility and was documented on the 08/01/2025 Quarterly MDS as moderately cognitively impaired, stated on 09/23/2025 that they did not get statements. The Revenue Cycle Manager said on 09/24/2025 that statements were being given every 6 months, with the last distribution in April 2025 and the prior one in October 2024. The Administrator later confirmed that residents had not received quarterly statements and were not receiving them every month as preferred, and said that was going to change.
Failure to Transfer Resident Personal Funds After Discharge
Penalty
Summary
The facility failed to ensure that funds from Resident 111’s personal fund account were transferred within 30 days after discharge. A review of the personal fund account list showed Resident 111 had a balance of $2,072.98. Staff T, the Revenue Cycle Manager, stated that Resident 111 had not been at the facility for over a year and still had money in the personal fund account, and that he did not have access to the account anymore because the previous company had not withdrawn the money. Staff A, the Administrator, stated that Resident 111’s account was not closed within 30 days of transfer and said he would call the previous company to have it taken care of.
Grievances Not Logged or Resolved
Penalty
Summary
The facility failed to maintain a grievance system that ensured resident complaints were initiated, logged, addressed, and resolved in a timely manner. Review of the grievance policy showed the grievance officer was responsible for overseeing the grievance process, tracking grievances to conclusion, issuing written decisions, and maintaining a grievance log. The policy also stated that concerns should be communicated with the resident or resident representative and attempted to be resolved within five days. During review of Resident Council meeting minutes, multiple resident concerns voiced in July, August, and September 2025 were not found on the corresponding grievance logs. In July, residents reported ongoing call light issues, problems getting starches, staff shortages, a missed dental visit, and concerns about food quality and consistency. In August, residents reported staff shortages affecting showers, messages not reaching the doctor, slow response times, being left in the bathroom for over 20 minutes, staff chatting instead of answering calls, and wanting water in the room. In September, residents reported housekeeping concerns, including bathrooms not being cleaned well, excessive bleach use, and trash not being emptied. Staff H stated grievance forms were completed for concerns raised at the Resident Council meetings and given to the grievance officer, but the grievances were not on the logs and the actual forms were not provided when requested. Three sampled residents also had concerns that were not properly logged as grievances. Resident 33, who was cognitively intact, responded that staff did not respond in a timely manner on a questionnaire, but no grievance was found. Resident 8, who was cognitively intact and independent with toileting, reported that a nurse was not kind and described an overnight staff member checking their underwear while they were sleeping; staff acknowledged the concern, but no grievance was filed. Resident 12, who was cognitively intact, dependent on staff for cares, and had a diagnosis of depression, alleged physical abuse by one staff member and ongoing neglect by another. Staff reported filing grievances weekly for Resident 12 and the roommate, but the grievance log did not reflect all of the grievances described, and only one grievance form was found in the abuse investigation file. Staff B stated that if a grievance was completed, it needed to be logged within five days.
Psychotropic Medications Not Monitored for Side Effects and Target Behaviors
Penalty
Summary
The facility failed to ensure psychotropic medications were regularly monitored for side effects and target behaviors for five residents reviewed for unnecessary medication or behavioral/emotional concerns. The report states that the facility policy required monitoring for adverse consequences of psychotropic medication use, including anticholinergic, cardiovascular, metabolic, neurologic, and psychosocial effects. For one resident with moderate cognitive impairment who was prescribed aripiprazole, sertraline, and trazodone for depression, the MAR and TAR for September 2025 showed no side effect monitoring or target behavior monitoring for any of the psychotropic medications. A charge nurse confirmed the resident did not have the required monitoring, and the DNS stated the resident should have had side effect and target behavior monitoring for all psychotropic medications. A second resident with anxiety and depression, also moderately cognitively impaired, had buspirone and duloxetine ordered, but staff did not see target behavior monitoring in the chart and the DNS stated there were no orders for target behavior monitoring even though all residents on psychotropic medication should have them. A cognitively intact resident with anxiety, depression, and PTSD reported anxiety symptoms that worsened later in the day and had hydroxyzine ordered, but the MAR and TAR showed no target behavior monitoring for anxiety. Two additional residents with bipolar disorder, depressive disorder, generalized anxiety disorder, and delirium had quetiapine, trazodone, buspirone, or quetiapine ordered, yet their MARs and TARs did not show ordered or documented target behavior or side effect monitoring, and staff confirmed the monitoring was not in place.
MDS Communication Restorative Program Mis-coded for 3 Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for 3 of 3 sampled residents reviewed for the communication restorative program. The Long-Term Care Facility Resident Assessment Instrument (RAI) Version 3.0 User’s Manual stated that a communication restorative program must be individualized, planned, monitored, evaluated, and documented. Surveyors found that the residents’ restorative entries were coded as communication programs even though the documentation did not show resident-specific communication goals, measurable interventions, or evidence that the programs met the required criteria. Resident 4 was cognitively intact and coded on the Quarterly MDS as participating in a communication restorative program for 4 days during the assessment window. The resident said they were independent while playing Yahtzee. The restorative evaluation documented that Resident 4 was enjoying the communication program and socialization continued, and the care plan described meeting in the dining room to play a board game or Yahtzee up to 6 times per week for 15 minutes. Staff described the program as residents playing cards or Yahtzee independently, and the only documentation provided was a score sheet without notes showing progress toward communication goals. Facility staff stated the goal was to maintain socialization or increase socialization, and one MDS staff member said showing up and participating meant the goal was met. Resident 3 was cognitively intact and coded on the Quarterly MDS as participating in a communication restorative program for 3 days. The resident said staff read the bible to them. The initiation evaluation documented a new restorative communication program because the resident requested bible reading, and the care plan listed bible reading with staff up to 6 times per week for 15 minutes. Resident 2 was severely cognitively impaired, required maximum assistance with cares, and was coded on the Significant Change MDS as participating in a communication restorative program via bible study. The care plan stated staff would do bible study/questions per resident choice, but did not document the resident’s communication level, specific goals, how progress would be measured, or monitoring/documentation of the program. Staff confirmed the program consisted of staff reading books, magazines, or the bible to residents and said no notes were taken beyond attendance, and one staff member ultimately stated the activity was not a communication restorative program but an activity.
Baseline care plans not provided within required timeframe
Penalty
Summary
The facility failed to ensure baseline care plans were developed, implemented, and provided to residents within 48 hours of admission for 3 of 3 sampled new admissions: Resident 107, Resident 105, and Resident 78. Resident 107 was admitted to the facility, the admission MDS was still in progress, and the EHR showed no baseline care plan had been created or given to the resident. On 09/24/2025, Resident 107 stated they never received a baseline care plan 48 hours after admission. Resident 105 was admitted to the facility, and the admission MDS documented moderate cognitive impairment. The EHR showed the baseline care plan was initiated 8 days after admission, and on 09/24/2025 the resident said he did not remember receiving one. Resident 78 was admitted to the facility, the admission MDS documented severe cognitive impairment, and the EHR showed the baseline care plan was initiated 4 days after admission but was not given to the resident. Staff K, the Charge Nurse/LPN, stated residents were to receive baseline care plans within 48 hours and confirmed these three residents did not receive theirs as required. Staff B, the DON, also confirmed the baseline care plans were not provided within 48 hours.
Care conferences not completed and care plans not updated for changing resident needs
Penalty
Summary
The facility failed to ensure care conferences were held after MDS assessments for three residents. Resident 4 was cognitively intact and told the surveyor they did not think the facility was doing quarterly care conferences and could not recall the last one. Their EHR showed three completed MDS assessments in the past year, but documentation was found for only one care conference. Staff later confirmed they could only locate one documented conference for that resident. Resident 6 was cognitively moderately impaired and had a POA; the resident said they were not receiving care conferences, and the EHR showed four completed MDS assessments with no documentation of any care conferences. Resident 58 was cognitively intact and unsure whether care conferences had occurred; the EHR showed two completed MDS assessments and one in progress, but only one care conference was documented. The facility also failed to update care plans for three residents when their conditions or care needs changed. Resident 8 was observed with three white pills in a medicine cup in their dresser, which the resident identified as melatonin, but the care plan was not updated after the pills were found. Resident 12 was hospitalized after being found unresponsive and having new seizure activity, then returned with seizure medications and a seizure diagnosis added to the chart, but the care plan was not updated to reflect the new diagnosis, interventions, or goals. Resident 12’s care plan also continued to list antidepressant use even after sertraline was gradually reduced and discontinued, and it was not updated to reflect the medication changes or monitoring for recurrent depression symptoms. Resident 1 had diagnoses of anxiety, depression, and PTSD and stated their PTSD was related to past sexual abuse and that they were not comfortable with a male shower aide. Their care plan did not include a PTSD-specific plan with triggers or interventions, and it did not document the preference for no male shower aides. Staff acknowledged that a resident with PTSD should have a specific care plan and that a resident’s preference not to have male caregivers should have been included, but those details were not present in the care plan.
Missed bowel protocol, hypoglycemia response, and hospitalization documentation
Penalty
Summary
The facility failed to initiate bowel protocol interventions for four residents reviewed for constipation. The facility policy defined constipation as three or more days without a bowel movement and directed staff to begin standard bowel care, including Milk of Magnesia after eight shifts without a bowel movement, followed by a bisacodyl suppository and then a Fleet enema if needed. One resident had a documented five-day gap between bowel movements with no medication intervention recorded. Another resident had a five-day gap and received Milk of Magnesia about one day after the three-day window in the policy. A third resident had no documented bowel movement for five days after admission and no bowel medication intervention was documented. A fourth resident, who was cognitively intact and independent with toileting, reported constipation and had a five-day period without a recorded bowel movement, with no PRN bowel medications, progress notes, or alert charting related to the bowel protocol during that time. The facility also failed to ensure blood glucose levels were appropriately monitored and intervened upon for one resident with type 2 diabetes mellitus. The resident reported blood sugars were not supposed to go below 80 and stated they had been symptomatic with shakiness and falling asleep. The electronic record showed a blood glucose reading of 40, but there were no progress notes or documented interventions found. The resident had an order requiring immediate treatment for blood glucose under 70, rechecks every 15 minutes until the level reached 90 or higher, provider notification, and a protein snack afterward. Staff later stated they were not alerted to the low reading and could not find documentation of any intervention, and the blood glucose was not retaken until about six hours later. The facility also failed to document the events leading to hospitalization for one resident who had been hospitalized after being found unresponsive and having new seizure activity. The resident reported having a seizure that led to hospitalization and waking up in the ICU. The roommate reported the resident had been sleeping all night, did not wake for dinner or the visiting cat, and later had unusual hand movements in the morning. The hospital record noted the resident was found unresponsive after not following the usual bedtime routine and was minimally responsive with left-sided shaking on arrival to the ED. The facility record did not contain a progress note describing the care provided before hospitalization or the events overnight, and staff stated they could not find documentation that met expectations.
Missed meal interventions and fluid restriction failures
Penalty
Summary
The facility failed to provide ordered nutrition interventions for a resident with unspecified dementia and nutritional deficiency. The resident’s enhanced diet order included whole milk, extra butter, sauce, gravy, dessert instead of fruit, ice cream or magic cup, cereal with all meals, double fruit or dessert, and cut-up assistance. During multiple meal observations, the resident’s delivered meals were missing ordered items, including cereal, ice cream or magic cup, an additional cookie, and extra gravy. Staff acknowledged that the resident’s meals were not consistently plated according to the ticket and that the cut-up assistance order was not reflected on the meal ticket or Kardex. The facility also failed to maintain adequate hydration for residents who were observed not receiving beverages with meals. One resident reported going to the dining room for lunch and not being given anything to drink. On another observation, two residents’ lunch trays were delivered without beverages, and neither staff member asked if they wanted something to drink. Staff later stated that hydration should be offered throughout the day, including at meals, and confirmed that the observed lack of beverages at lunch did not meet expectations. The facility failed to follow fluid restriction orders for two residents with significant cardiac and renal diagnoses. One resident with end-stage renal disease and chronic heart failure had an 1800 ml fluid restriction, with specific amounts assigned to nursing and dietary each shift and meal. Review of MAR and CNA task documentation showed multiple days when the documented intake exceeded the restriction, and the resident reported receiving only apple juice with dinner and having to get water from a roommate. Another resident with end-stage renal disease on dialysis and heart failure had a 1200 ml fluid restriction, yet documentation repeatedly showed intake above the ordered limit across many days. Staff confirmed that the documented totals exceeded the prescribed restrictions.
Failure to Address Residents’ Mental Health and Trauma-Related Needs
Penalty
Summary
The facility failed to provide appropriate treatment and services for residents with mental health diagnoses and psychosocial needs, including a resident with depression, anxiety, and muscle weakness who became increasingly tearful after an antidepressant was reduced and then discontinued, and a resident with anxiety, depression, and PTSD whose trauma-related preferences were not reflected in the care plan. The report also identified concerns related to resident council discussions about counseling services and residents’ emotional needs. One resident was admitted with depression and anxiety and later had an antidepressant gradually reduced and discontinued after a GDR attempt. After the medication was stopped, the resident was observed and heard crying repeatedly, stating they needed something, could not handle what was going on, and wanted to talk to a mental health provider. The resident also reported crying for days and wanting to restart antidepressants. Although staff acknowledged the resident had become more tearful and had discussed restarting the medication, the care plan was not updated to reflect the discontinuation, recurrent depression risk, or monitoring needs, and licensed nurse behavior documentation did not reflect the resident’s crying or depression-related behaviors despite CNA documentation of frequent crying. A second resident with PTSD reported discomfort with male staff providing showers because of past sexual abuse. The resident raised this concern during a resident council meeting, and the grievance record documented that a male aide was the only one available on some shower days and that the shower was not rescheduled. The resident’s care plan did not include a specific PTSD plan, triggers, or the preference to avoid male caregivers, and staff interviews confirmed this information was not included even though staff agreed it should have been. In addition, during the resident council meeting, residents were emotional about mental health concerns and not feeling heard or valued, and the administrator discussed volunteer counseling services, but later stated he did not remember that discussion.
Unnecessary Medication and Pain Management Deficiencies
Penalty
Summary
The facility failed to ensure residents’ drug regimens were free from unnecessary drugs by administering pain medications outside ordered parameters, failing to document non-pharmacological interventions (NPIs), and failing to reassess the necessity of certain medications. The deficiency involved multiple residents reviewed for unnecessary medication and pain management, including residents with cognitive impairment, chronic pain, and insomnia-related medication use. For one resident with severe cognitive impairment and maximum assistance needs, oxycodone was administered multiple times when the documented pain score did not meet the ordered range of 6-10, and several doses were also given outside the ordered 6-hour timeframe. The record also showed multiple oxycodone administrations with no NPIs documented, despite a physician order requiring repositioning, relaxation, diversional activities, and redirection before pain medication. Staff interviews confirmed the medication was given outside order parameters and that NPIs should have been attempted and documented. For another resident with mild cognitive impairment, oxycodone orders were written for different pain ranges, but the MAR showed doses given when pain scores were outside the ordered parameters, including times when the pain score was 0 or 4. Staff confirmed the order parameters were not followed and that the medication should not have been given outside those parameters. A third resident was found with melatonin tablets in a medicine cup in the room after the medication had been ordered nightly, and the record review found no sleep monitor or reassessment of the medication’s necessity documented. Two additional residents also had pain medication given without the required documentation or use of NPIs. One resident with chronic pain syndrome received oxycodone 18 times for pain scores from 0 to 5 even though the order was for pain scores 6-10, and no NPIs were ordered. Another resident had acetaminophen ordered as needed along with an order for NPIs, but the pain record showed multiple pain scores with either no acetaminophen given or acetaminophen given without any NPI documentation, and the MAR area for NPIs was left blank. Staff interviews confirmed NPIs should have been attempted and documented for these residents.
Food Not Palatable or Easy to Chew
Penalty
Summary
Food and drink were not ensured to be palatable, attractive, and at a safe and appetizing temperature during lunch service. On 09/24/2025 at 12:46 PM, the test/sample lunch tray included a chicken patty, potato wedges, carrots, and coleslaw, and the chicken patty was sampled and found to be difficult to chew and lacked palatability. During an interview the same day, a CNA stated the chicken patty served for lunch was dry and difficult for residents to chew. Later that day, Resident 107 stated the lunch meat was dry and that sauce had to be poured on it to help it go down because it was so dry. The Dietary Manager stated he was not aware the chicken was difficult to chew and said he would address it by doing an in-service on baking times. The DON stated meals were expected to be palatable and easy to consume for residents.
Expired and Improperly Labeled Food Items in Walk-In Refrigerator
Penalty
Summary
The facility failed to ensure food items were labeled and dated when opened in 1 of 1 walk-in kitchen refrigerators. During observation, surveyors found expired, opened items in the refrigerator, including a plastic Tupperware container of coleslaw labeled with a use-by date of 07/10/2025, a plastic Tupperware container of chicken salad labeled with a use-by date of 09/18/2025, a plastic container of Thousand Islands dressing labeled with an open date of 06/17/2025, and a plastic Ziplock bag containing several hot dogs labeled with a use-by date of 09/06/2025. The facility policy stated refrigerated foods are to be labeled, dated, and monitored so they are used by their use-by date, frozen, or discarded. The Dietary Manager stated food placed into refrigerators should be labeled right away and kept until the use-by date, and the DON stated food items in the refrigerators were expected to be labeled accurately and discarded by the use-by date.
Infection Control Deficiencies in Water Management, Laundry Practices, Vaccination Consent, and EBP
Penalty
Summary
The facility failed to ensure infection control practices met professional standards in several areas, including its Water Management Program, the laundry room, vaccination consent documentation, and enhanced barrier precautions. Review of the facility’s Legionella Water Management Program showed the written plan did not include a detailed description or diagram of the water system showing receiving, cold water distribution, heating, hot water distribution, and waste. The plan also did not fully identify all areas where Legionella could grow or document controls for those areas. During interviews, the Maintenance Director was unable to provide documentation showing where monthly Legionella testing had been performed, could not produce a flow diagram of the water system, and described controls only in limited terms. The Administrator acknowledged the expectation that the program should have included the missing elements and documentation. In the laundry room, observations showed the ceiling ventilation/fan was not working in either the soiled linen room or the main laundry room. Three soiled linen containers were present in the main laundry room, and a clean storage container with linen was located in the corner between the soiled linen room and the washing machines. Staff touched a dirty linen container lid while opening the clean linen cover. Cleaning supplies and two stacks of microfiber rags were on top of a washing machine, and one stack appeared moist and wrinkled; the Laundry Aide stated all of the rags were clean and confirmed the rags were being reused. Pillows were also observed on top of the washing machine, and a staff mini refrigerator with cups and coffee creamers was present in the laundry area. Staff interviews confirmed items should not be stored on washing machines, rags should not be reused, the laundry room should be spotless, the room should not contain a staff refrigerator, and the ceiling ventilation should be working. Vaccination records showed incomplete documentation of education and consent for multiple residents. One resident’s flu vaccine record stated no education was provided, another resident refused pneumococcal and COVID vaccines with no education documented, and two residents had vaccine audit forms showing consent for flu and COVID vaccines without dates listed. The Infection Preventionist stated staff were responsible for educating residents, but described the process as mainly telling residents the vaccines were recommended and asking for consent. She acknowledged that risk and benefits were not documented and that Vaccine Information Statements were not routinely provided at the time of consent. An LPN stated nurses reviewed admission paperwork and asked residents if they wanted vaccinations, but did not provide the VIS form. For enhanced barrier precautions, a CNA was observed entering a resident’s room with EBP signage posted for catheter care but wore gloves only and did not wear a gown while emptying the resident’s catheter bag and assisting with ice. The CNA stated gowns were not available in the correct size, and the Infection Preventionist confirmed that catheter emptying required both gown and gloves.
Antibiotic Stewardship Reviews Were Not Completed or Documented for Multiple Residents
Penalty
Summary
The facility failed to ensure antibiotic stewardship practices met professional standards for 3 of 3 months reviewed, involving the antibiotic line list used to track and review antibiotic use. The facility was using Loeb criteria to determine when antibiotics were likely indicated and McGeer criteria for definitive infection criteria, but the infection preventionist/ADON/LPN stated that antibiotic use should be reviewed for validity, that the provider should be notified if criteria were not met, and that an antibiotic timeout should occur 48-72 hours after antibiotics were started. The same staff member also stated infection evaluations should be completed before antibiotics were initiated and that the line list should include comprehensive symptoms. For one resident, the line list showed symptoms beginning before a hospital stay and an antibiotic course after return to the facility, but the infection preventionist could not find documentation that the resident was reviewed for antibiotic use or that criteria were met. For another resident, the line list listed a UTI with no other symptoms, but the urine sample had been collected earlier and the antibiotic stewardship note was completed after the antibiotic course was already finished; the staff member later stated the resident was asymptomatic, did not meet McGeer or Loeb criteria, and no provider conversation or staff education occurred. For a third resident, the line list showed a UTI with no symptoms or urine results, and for a fourth resident the line list showed cough/aspiration pneumonia with a negative x-ray; the staff member acknowledged there was no criteria evaluation for the UTI case and that the resident with cough did not meet criteria for antibiotic use. The DON stated the expectation was that infection evaluations be completed as soon as antibiotics were started and that the infection preventionist should investigate whether residents really needed antibiotics.
Walk-In Freezer Door Not Closing Properly
Penalty
Summary
The facility failed to ensure the kitchen's walk-in freezer was in good working condition. On 09/22/2025 at 10:05 AM, the freezer door was observed to have ice and frost buildup at the bottom right corner, which prevented the door from closing completely and left an opening of approximately one inch. The same condition was observed again on 09/23/2025 at 10:05 AM, with the freezer door still not shut completely because of the ice buildup. In interview, the Dietary Manager stated the freezer door had been broken for about three months and had been like that "forever," and that kitchen staff were scraping the ice twice per shift while also maintaining temperature logs for the freezer and refrigerator. The Maintenance Assistant stated the facility had received a few estimates for replacement, but no order had been made. The DON stated he had been aware of the issue but could not provide additional information regarding freezer door replacement.
Failure to Timely Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to report allegations of abuse within the required timeframes for two residents. For one resident with anxiety and post-traumatic stress disorders, a CNA documented that the resident claimed to have received nude photos from staff and to have had romantic relationships with several staff members. The Director of Nursing and the Administrator were unaware of these allegations until they read the progress notes the following day. The Director of Nursing acknowledged that this was an allegation of sexual abuse and should have been reported immediately to management and the state agency, but it was not reported until after the delay was discovered. For another resident with depression, anxiety, and muscle weakness, the resident reported physical abuse by a CNA and neglect by another CNA to an Activities Aide, who then notified the Administrator and Assistant Director of Nursing. The facility's investigation into the abuse allegation began the same day, but the mandatory report to the state was not submitted until the following afternoon, exceeding the 24-hour reporting requirement. The Assistant Director of Nursing stated they did not initially report the allegation because they did not believe it constituted abuse or neglect, and the Director of Nursing believed the next-day reporting was within the appropriate timeframe.
Failure to Meet Professional Standards in Medication Administration and Documentation
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice in several areas, as evidenced by observations, interviews, and record reviews. For one resident with hypertension and heart failure, there were multiple instances where a prescribed medication, eplerenone, was not administered as scheduled. The Medication Administration Record (MAR) showed blank entries and missed doses without corresponding documentation or progress notes explaining the omission. The resident was not promptly informed about the unavailability of the medication, and there was a lack of timely communication with the provider and pharmacy regarding the medication's status. Staff interviews confirmed that documentation and resident notification were not completed as expected. Another resident, who was cognitively intact, was found to have three melatonin pills in their dresser drawer, despite documentation indicating the medication had been administered on six nights. This indicated that the resident had not taken the medication as intended on three occasions. Staff interviews revealed that the expectation was for nurses to observe residents taking their medications and ensure they had fully swallowed them before leaving the room, which did not occur in this case. Additionally, during a medication cart review, an insulin pen was found in a medication cart without an open date labeled, as required by facility policy. Staff confirmed that insulin pens are to be dated when first used, and the absence of a date meant the insulin could not be verified as safe for use. These failures in medication administration, documentation, and storage practices did not meet professional standards and placed residents at risk.
Incomplete Abuse and Neglect Investigations
Penalty
Summary
The facility failed to ensure abuse and neglect investigations were thorough and complete for two residents. For one resident, who was admitted with depression, anxiety, and muscle weakness and was dependent on staff for cares, the resident alleged physical abuse by a CNA and neglect by another CNA. The resident reported that one CNA twisted their right nipple and laughed, and also that the CNA had previously tickled their feet while they were sleeping. The resident also reported being left too long in urine and stool by another CNA over the weekend. The resident became tearful during interviews, and the roommate reported having witnessed the CNA tickling the resident’s feet on multiple occasions and hearing the resident tell the CNA not to touch them. The investigation for this resident was incomplete. The file showed the abuse allegation was ruled out based on staff schedules, but no additional comments were found addressing the neglect allegation. The investigation reviewed only two named staff schedules for two dates and did not include other relevant dates, including a prior weekend when staffing logs showed one CNA assigned to the resident’s room and the other CNA nearby. No general CNA interviews were conducted, no other staff interviews were found regarding the foot-tickling allegation, and the roommate’s concerns were not documented as a separate witness statement in the investigation file. Staff involved in the investigation acknowledged that some parts were missing and that they had not completed general interviews they should have done. For the second resident, who was cognitively intact and dependent on staff for toileting hygiene, the resident reported lying in feces for several hours while waiting for the call light to be answered. The facility’s investigation included sample resident interviews, an administrator statement, an incident report, and a DNS progress note, but it did not include additional staff interviews from the shift in question. A CNA assigned to the resident later provided a statement, but another CNA who had assisted was not included in the investigation. Additional documents such as a call light audit and inservice summary were later provided separately, and the DNS stated that additional evening staffing review, sample staff interviews, and a resident follow-up existed, but those items were not included in the investigation record available at the time reviewed.
Failure to Provide ADL and Meal Assistance
Penalty
Summary
The facility failed to ensure residents were assisted with activities of daily living, including bathing and meal preparation assistance, for 3 of 6 sampled residents reviewed for ADLs and choices. The report states that this failure placed the residents at risk for poor hygiene, embarrassment, diminished self-image, weight loss, and a decreased quality of life. Resident 107 was admitted to the facility and, during interviews, said they had not received a shower since admission and wanted their fingernails clipped. Although the EHR documented showers on multiple occasions, review of the Shower folder, Shower binder, and Skin Assessment sheets showed no documentation to support that Resident 107 had received a shower. Staff K, the Charge Nurse/Unit Manager/LPN, said residents were assigned shower days and should receive showers twice a week, but after reviewing the records could not confirm the resident had been showered. Staff B, the DNS, said Resident 107 should have been offered a shower on their assigned days. Resident 12, who had hemiplegia and hemiparesis following a stroke and was dependent on staff for cares with meal set-up or clean-up assistance, was observed with unopened butter and a lidded fruit cup they could not open or see. Resident 12 said they were frequently not assisted with breakfast. Staff M and Staff D both stated the resident should have been assisted with set-up and opening items. Resident 55, who had unspecified dementia, nutritional deficiency, and severe cognitive impairment, had an order for cut-up assistance, but during lunch their ham and grilled cheese sandwich was served whole and was not cut up. Staff KK said they did not believe the resident required cut-up assistance because it was not on the ticket, and Staff B acknowledged the order should have been noted on the meal ticket and Kardex but was not.
Failure to Provide and Document Resident-Centered Activities
Penalty
Summary
The facility failed to provide resident-centered activities that incorporated Resident 78’s preferences. Resident 78 was admitted with Parkinson’s disease and the 5-day MDS dated 09/08/2025 documented severe cognitive impairment. The Activities Preferences assessment dated 09/09/2025 showed the resident enjoyed social visits, conversations, news, gardening, outdoor activities, and other activities of interest. The care plan revised 09/10/2025 included interventions to invite the resident to social activities, offer snacks between meals, provide opportunities to keep up with the news, and provide opportunities to participate in favorite activities. Review of the Planned Activities task from admission did not document any participation in activities. Observations on 09/22/2025, 09/24/2025, 09/26/2025, and 09/29/2025 showed Resident 78 sitting in a wheelchair across from the nurses’ station, awake or sleeping, with no stimulation. During an interview on 09/22/2025, the resident said he enjoyed watching football and planned to watch a game later that day, and stated, “As far as I know, there are no activities.” The Activities Director said she was unable to document residents’ participation due to technical issues and stated she charted on paper and in progress notes, but could not provide documentation of Resident 78’s participation. The DON stated resident activities should be documented.
Incomplete Assessment and Monitoring of Bed Mobility Bars
Penalty
Summary
The facility failed to comprehensively assess the use of bedrails/side rails for Resident 67, who was admitted to the facility and was documented on the Quarterly MDS dated 06/30/2025 as alert and oriented. The facility policy, Bed Safety and Bed Rails, Revised 2022, stated that bed rails or side rails are prohibited unless criteria for use have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. A physician's order dated 12/06/2024 directed bilateral bed mobility bars to assist with bed mobility, but the resident's electronic health record did not show documentation of comprehensive, ongoing, and periodic assessments for the mobility bars. During observation on 09/22/2025 and again on 09/25/2025, Resident 67 was seen in bed with mobility bars in place. The resident stated the bars hurt their shoulder because the bed was not wide enough and said they did not want them; the resident also stated they had asked staff to remove the mobility bars since December 2024. Staff D, the Charge Nurse/Unit Manager/RN, said standard practice was to obtain consent and evaluate a resident for the use of bed mobility bars, but could not provide documentation showing periodic evaluations were completed for Resident 67. Staff B, the DON/RN, stated he expected mobility bars to be used only with consent, evaluations, and follow-ups, but also could not provide documentation of completed periodic mobility bars evaluations.
QAPI Plan Not Updated With Current Leadership or Attendance Documentation
Penalty
Summary
The facility failed to show evidence that its Quality Assurance and Performance Improvement (QAPI) program plan was reviewed and updated with current leadership. Record review of the QAPI Plan showed annual review dates of 12/01/2022 and 12/01/2023, but the document listed committee members and an administrator name that was not the current administrator. The current administrator stated that there was no new QAPI plan and that the listed information was old. Review of the QAPI meeting minutes showed no record of which staff were present and no documentation that the medical director attended the meetings. The administrator also stated there was no updated QAPI plan and no sign-in sheet or documentation in the minutes showing staff or medical director attendance.
Failure to Provide Sufficient Nursing Staff for Resident Care Needs
Penalty
Summary
The facility failed to provide competent and sufficient nursing staff to meet the personal care needs of multiple residents, as evidenced by direct observations, interviews, and record reviews. Several residents did not receive timely assistance with activities of daily living (ADLs) such as dressing, personal hygiene, toileting, and bathing, as outlined in their care plans. For example, one cognitively intact resident reported waiting since early morning for assistance with getting up and having their brief changed, with staff repeatedly turning off the call light without providing care. Another resident, who was cognitively impaired, was observed multiple times lying in bed in soiled conditions, with a strong odor of urine in the room, and their call light on the floor. Staff assigned to these residents admitted to not having provided complete care due to time constraints and high workload. Additional residents were affected by missed showers and inadequate personal hygiene. One resident reported not receiving scheduled showers because staff stated they were short-staffed and did not have time. Staff confirmed that due to insufficient staffing, they were unable to complete showers and could only provide brief changes and respond to call lights. Another resident expressed frustration at not receiving oral care and having to wait hours for assistance, attributing these delays to staff being too busy. Staff interviews corroborated that the high resident-to-staff ratio prevented them from delivering all required care, especially when scheduled staff called out and replacements were not available. The Director of Nursing acknowledged that the expectation was for nursing assistants to provide comprehensive morning and evening care, including oral care, personal hygiene, and showers as scheduled. However, the DON also stated that when staffing was inadequate, care could be missed despite efforts to have management assist or call in additional staff. Documentation reviewed for the affected residents did not indicate that care was refused by the residents, further supporting that the deficiencies were due to insufficient staffing rather than resident choice.
Failure to Administer Medications per Physician Orders and Guidelines
Penalty
Summary
The facility failed to administer medications according to physician orders and established guidelines for four residents, resulting in significant medication errors. For one resident with a history of bacterial conjunctivitis, the prescribed Maxitrol eye drops were not documented as administered, and a subsequent order for Polytrim eye drops was not resumed after a cancelled ophthalmology appointment, despite ongoing infection. Staff confirmed that transcription errors and lack of follow-up with the provider led to the resident not receiving the required medications as ordered. Another resident, who was prescribed gabapentin three times daily for nerve pain, did not receive the medication at appropriate intervals. The medication was administered at inconsistent times, sometimes with less than the recommended six-hour interval between doses. Staff acknowledged that the medication schedule should have been adjusted to ensure proper spacing, as advised by the facility's pharmacist, but this was not done. Two additional residents with diabetes were prescribed Lispro insulin to be administered before meals. Observations showed that both residents received their insulin injections after they had finished eating, contrary to physician orders. Nursing staff attributed the delay to time constraints, and facility leadership confirmed that medications should be given as ordered. These failures in medication administration were directly observed and confirmed through interviews and record reviews.
Failure to Maintain Infection Control During Glucose Monitoring and Insulin Administration
Penalty
Summary
Staff failed to maintain proper infection control practices during blood glucose monitoring and insulin administration. A registered nurse used a blood glucose monitor on one resident, placing the device and used supplies into a plastic container without cleaning or disinfecting the monitor or the container afterward. The nurse also did not perform hand hygiene after removing gloves and before proceeding to care for another resident. The same glucose monitor and plastic container were used for another resident without cleaning or disinfecting between uses. The nurse also failed to perform hand hygiene before donning gloves and administering care to the second resident. Supplies, including the insulin pen and alcohol wipes, were placed back into the same uncleaned container after use. The infection preventionist confirmed that the facility's protocol required the glucose monitor to be cleaned with disinfecting wipes per manufacturer instructions, and that alcohol wipes were insufficient for disinfection. The infection preventionist also stated that hand hygiene should be performed before and after all resident care and that the plastic container should be cleaned after removing dirty supplies. Additionally, glucose testing and insulin administration were performed in the dining room, which was not in accordance with facility procedures. These actions and inactions were observed and confirmed through interviews and record review.
Failure in Discharge Planning and Notification
Penalty
Summary
The facility failed to ensure proper discharge planning for a resident, identified as Resident 8, who was discharged to home without necessary notifications to outside service providers. Resident 8, who was moderately cognitively impaired and required assistance with daily activities, was discharged without the completion of a required assessment by an outside service provider. The facility's social services department had a protocol for weekly meetings with outside services to discuss potential discharges, but there was no documentation of notification for Resident 8's discharge, which was reportedly communicated verbally only. Collateral Contact 2, an outside service provider, was unaware of the discharge and unable to complete an assessment to resume care services at home. Additionally, Collateral Contact 1 reported no care conferences or discussions about the discharge, and the resident's caregiver was not being paid due to incomplete paperwork. The facility's administrator acknowledged that a form should have been used to notify outside services of the pending discharge, but it was not utilized for Resident 8.
Failure to Accommodate Resident's Mobility Needs
Penalty
Summary
The facility failed to accommodate the mobility needs of a resident, who was cognitively intact and used a power wheelchair due to functional limitations in their extremities. Following an incident where the resident used their power wheelchair defensively against another resident, the facility removed the power wheelchair and provided a manual one, which the resident could not propel independently. This action restricted the resident's ability to access the community, affecting their routine activities such as visiting their girlfriend and shopping, which they previously did using the power wheelchair. Despite a power mobility assessment indicating the resident could operate the power wheelchair independently, the facility did not allow its use outside the facility. Staff members, including the Activity Director and Social Service Director, acknowledged the resident's previous community outings and expressed no concerns about their ability to navigate the community. However, no alternative transportation or plans were arranged to assist the resident in maintaining their community activities, leading to a decline in the resident's mood and socialization opportunities.
Medication and Care Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice, as evidenced by the discontinuation of medications without authorization and failure to follow physician's orders for three residents. Resident 1, who was admitted with complex medical conditions and heart disease, did not receive their prescribed morning medications on the day following their readmission. This was due to an error in the electronic medical record (EMR) where the medication orders were not confirmed, leading to the omission of the medications. Staff involved were aware of the issue but failed to rectify it in a timely manner, and the Director of Nursing was not informed of the missed medications until much later. Resident 2, who had diagnoses including respiratory failure and diabetes, experienced unauthorized discontinuation of critical medications such as insulin, pain medication, and potassium. These medications were discontinued in the EMR without authorization from a medical provider, leading to the resident experiencing pain and not receiving necessary insulin for several days. Additionally, Resident 2 requested a humidifier for their oxygen due to discomfort, but this request was not fulfilled, resulting in continued discomfort and nosebleeds. Resident 3, diagnosed with dementia and multiple pressure ulcers, did not receive daily wound care as ordered by their physician. The wound dressing was not changed for several days, and staff falsely documented that the care had been completed. This oversight was only discovered when a collateral contact noticed the unchanged dressing. The facility's failure to adhere to physician orders and properly document care resulted in a lack of necessary medical treatment for the residents involved.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to adhere to infection control standards during wound care for a resident on enhanced barrier precautions (EBP). The facility's policy required staff to wear gowns and gloves when performing wound care on residents with wounds, such as those with methicillin-resistant staphylococcus aureus (MRSA). However, during an observation, a Licensed Practical Nurse (LPN) was seen entering the resident's room, performing hand hygiene, and donning gloves without wearing a gown. The LPN removed the resident's wound dressing, cleansed the wound, discarded the dressing and gloves, but failed to perform hand hygiene before putting on new gloves and applying a clean dressing. The resident involved had been admitted with diagnoses including MRSA and had physician orders indicating the need for EBP due to wounds and MRSA in their eye. The facility's policy also required hand hygiene to be performed after removing gloves and before donning new gloves during wound care. The Infection Preventionist and Assistant Director of Nursing confirmed that the staff should have worn a gown and performed hand hygiene after removing the old dressing and gloves, highlighting the deviation from the established infection control protocols.
Non-compliance with PPE Protocols During COVID-19 Outbreak
Penalty
Summary
The facility failed to ensure that three out of six staff members adhered to CDC guidelines for using personal protective equipment (PPE) when caring for residents with confirmed COVID-19 infections. Staff A, a Certified Nursing Assistant (CNA), entered a COVID-19 positive resident's room wearing appropriate PPE but did not remove the N95 respirator after exiting the room. Instead, Staff A proceeded to the nurse's station and later passed trays to other residents without changing the respirator. Similarly, Staff C, another CNA, exited a COVID-19 positive resident's room without changing the N95 respirator and used gloves from the room to search an isolation cart, potentially contaminating it. Staff D, an Agency Licensed Nurse, also failed to replace the N95 respirator after leaving a COVID-19 positive resident's room. The facility's Director of Nursing and the Float Infection Control Licensed Nurse confirmed that the expectation was for staff to remove all PPE, including the N95 respirator, after leaving a COVID-19 positive room and to perform hand hygiene before donning new PPE. Despite this, the staff did not comply with these protocols, which were intended to prevent the spread of COVID-19 within the facility. The report indicates that all staff had been trained on the correct usage of PPE, yet the observed actions did not align with the established guidelines.
Failure to Monitor and Treat Scalp Wound Leads to Maggot Infestation
Penalty
Summary
The facility failed to consistently assess, monitor, and provide timely wound care for a resident with a scalp wound, leading to a maggot infestation. The resident, who was severely cognitively impaired and dependent on staff for transfers, had a history of skin picking and was at risk of infection. Despite having physician orders for antibiotic ointment and ammonium lactate solution to be applied to the scalp wound, there was a lack of documentation and monitoring of the wound's condition from early August 2024 onwards. The wound specialist's last documented assessment was on July 30, 2024, and subsequent weekly skin evaluations failed to document the status of the scalp wound. Staff members reported noticing a foul odor and drainage from the wound, but these signs were not communicated to the medical provider. On September 2, 2024, emergency services were called when the resident was found with a maggot-infested scalp wound, indicating a severe lapse in wound care and monitoring. Interviews with staff revealed that the licensed nurses did not follow the facility's wound care policy, which required weekly monitoring and documentation of wounds. The facility's infection preventionist noted the presence of flies in resident care areas due to open windows without screens, which may have contributed to the infestation. The lack of proper wound care and failure to notify the medical provider of changes in the wound condition resulted in significant physical harm to the resident.
Pest Control Deficiency Leads to Resident Wound Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a significant deficiency involving the presence of flies across all four resident care units. Observations revealed flies in various locations, including hallways, doorways, and light fixtures, as well as open windows and doors without screens, which facilitated the entry of flies into the facility. The facility's policy on pest control emphasized the responsibility of staff to report pests immediately and take steps to prevent harm, but this was not effectively implemented. A resident with medically complex conditions and dementia was found with a maggot-infested wound on their scalp, indicating a severe lapse in wound care and pest control. The resident was dependent on staff for care and had a severe cognitive impairment. Staff interviews revealed a lack of awareness and action regarding the resident's wound care and the presence of flies, with staff acknowledging the absence of screens on windows and the propping open of doors. The facility's maintenance director admitted to the presence of flies and the lack of screens, while the director of clinical operations highlighted the need for wound care and preventative measures to reduce flies.
Medication Administration Delays Due to Insufficient Staffing
Penalty
Summary
The facility failed to ensure sufficient licensed nurses were available to administer medications timely for three residents, leading to delays in medication administration. Resident 1, who was cognitively intact, reported inconsistencies in receiving medications on time, particularly for pain management. The Medication Administration Audit Report for Resident 1 showed significant delays, with morning medications scheduled for 8:00 AM being administered as late as 7:34 PM on some days, and evening medications scheduled for 7:00 PM being administered after midnight. Resident 2, also cognitively intact, expressed frustration over receiving bedtime medications inconsistently, sometimes after midnight. The audit report for Resident 2 indicated similar delays, with medications scheduled for 7:00 PM being administered as late as 12:52 AM. Resident 3 reported not receiving morning medications until noon and evening medications after midnight, especially when staffing was low. The audit report confirmed these delays, with morning medications scheduled for 8:00 AM being administered as late as 8:25 PM. Interviews with staff revealed that the facility often operated with insufficient nursing staff, particularly during night shifts, which contributed to the delays in medication administration. Staff C, a Resident Care Manager, acknowledged that having only two nurses and a medication tech made it challenging to administer medications on time. The Director of Nursing, Staff B, confirmed the discrepancies in medication administration times and attributed them to a shortage of licensed nurses, acknowledging that the facility did not have enough staff to meet residents' needs timely.
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What surveyors actually found near you
We read the 1,185 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Bremerton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Belmont Terrace | 0.1 mi | ★★★★★ | 22 | 0 |
| Port Washington Post Acute | 2 mi | ★★★★★ | 15 | 0 |
| Washington Veteran Home-retsil | 2.8 mi | ★★★★★ | 19 | 0 |
| Life Care Center Of Port Orchard | 4.7 mi | ★★★★★ | 20 | 0 |
| Avamere Rehabilitation At Ridgemont | 4.8 mi | ★★★★★ | 16 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.