Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 Bridge Crest Post Acute during CMS and state inspections, most recent first.
A facility failed to develop comprehensive care plans for several residents with identified needs. One resident had a bed rail without a care plan, another had a pressure injury and wound care without a skin plan, a third received psychotropic, anticoagulant, and anxiety meds without related care plan entries, and another had dentures and HOH/communication needs that were not reflected in the care plan or Kardex.
Failure to Provide and Document Resident Showers: Three residents had limited or no documented showers, and the EHRs did not show refusals or reasons showers were not offered. One resident said he could not remember the last shower, another said she had only received four showers since admission, and a third said it had been a while since she showered and wanted one. CNA staff said showers were offered twice weekly, but the DON could not produce documentation of completed showers or refusals.
A resident did not receive bowel interventions per the facility bowel protocol after prolonged gaps between documented BMs, and three residents did not have ordered weights obtained and documented. One resident had CHF and only one weight recorded despite daily weight orders, another resident with CHF had only one weight documented despite daily weight orders and later daily monitoring parameters, and a third resident with underweight status and a pressure ulcer had only one weight documented despite expectations for weekly weights. Staff stated the bowel protocol and weight documentation expectations were not followed.
Failure to Obtain Informed Consent Before Psychotropic Medications: The facility administered psychotropic meds to two residents without documented informed consent before initiation. One cognitively intact resident with depression and anxiety received Clonazepam and Fluoxetine before consent was documented, and another resident with borderline personality disorder received Cariprazine without a pre-administration consent in the EHR. Staff stated consent was expected before psychotropic meds were given.
Cramped Room Limited Resident Mobility: A resident admitted for rehab and noted to be cognitively intact had difficulty transferring from bed to wheelchair because a tray table blocked access, requiring staff to move it. Another resident reported the room was too small for 3 wheelchair users and that a roommate backed a wheelchair into his bed when trying to exit. The DON observed the room and said it looked cramped and probably could be set up better.
An unlocked medication cart computer was observed in the Expressions dining room displaying the PCC EHR access page with no staff in view. A resident was seated nearby and a visitor entered while the screen remained open. When an LPN and RN arrived, both agreed the screen should have been locked, and the RN secured it.
Failure to Complete AIMS Testing for Residents on Antipsychotics: The facility did not complete required AIMS assessments for two residents receiving antipsychotic medications. One resident received lurasidone daily with no documented AIMS in the EHR, and staff stated it was not done before the medication was started. Another resident received cariprazine for borderline personality disorder, but the first documented AIMS was not completed until months after the medication began, and staff confirmed it was not done on admission.
Failure to provide written bed hold notice after transfer. A resident who was alert and oriented was sent to the hospital via 911 EMTs after decreased O2 sats and no orders for breathing txs, but the EMR had no documentation of a written bed hold notice at the time of transfer or within 24 hrs. The DON and Nurse Mgr stated residents should be sent with a bed hold form, and if the transfer was emergent, Mgt and/or Social Services would handle it the next day.
Inaccurate MDS Assessment of Oral Care and Hearing Needs: A resident’s MDS incorrectly indicated no oral care devices or hearing impairment, even though the resident reported an upper partial denture plate needing repair, natural lower teeth, and HOH with a history of bilateral hearing loss. The RN/MDS nurse stated she did not think the resident had teeth or a hearing deficiency and acknowledged the MDS was coded incorrectly.
A resident’s care plan was not updated to reflect BiPAP use. The resident’s physician order documented BiPAP, but the comprehensive care plan still referenced CPAP and did not include a care plan for the BiPAP. The RCM/RN stated the care plan was never changed from CPAP to BiPAP, and the DON/RN said the BiPAP should have been care planned.
Resident-centered activities were not provided for 3 sampled residents. The facility’s activity calendars showed no bus outings, and residents reported that outings such as trips to the park or lake had stopped even though one resident’s care plan included trips/outings among preferred activities. The ADON/Activities Director stated there had been no outings on the calendar since the prior year, and the Administrator said the bus was being used by sister facilities.
Failure to obtain consent and care planning for bed rail use: A cognitively intact resident had a quarter-length bed rail on the bed, but the resident said no one discussed it with him and the EHR contained no bed rail/device consent or evaluation. The care plan also lacked any focus, goal, or intervention for the bed rail, and the RN manager and DON confirmed the required evaluation, consent, and care plan were not in place.
A resident with chronic pain and near-constant pain had a weekly Buprenorphine transdermal patch ordered for pain control, but the EMAR did not show the dose was given as scheduled. The resident reported not receiving the pain patch and rated her pain 10/10. Staff described that missing meds should be obtained from Omnicell or pharmacy and documented in the EMAR, and the DON confirmed the patch was not signed off as administered.
Medication Administration Outside Physician Order Parameters: Two residents had medications given outside physician order parameters. One resident with DM and hyperglycemia received insulin glargine despite BG readings below the hold threshold, and another resident received oxycodone outside the ordered overnight time window. The DON and RN/Resident Care Manager acknowledged the orders and the administration discrepancies.
An unlocked medication cart was observed in a dining room with no staff in view, allowing access to multiple bottles of medicine and residents' prescription medications. A resident was seated nearby and a visitor entered while the cart remained unlocked. An LPN and an RN later stated the cart should have been locked when staff stepped away, and the DCS/RN and DON/RN confirmed that medication carts are expected to be locked when no nurse is present.
A resident with chronic heel ulcers and cognitive impairment did not receive consistent wound care as ordered, with missed assessments, lack of wound documentation, and incomplete or falsely documented treatments. Staff and family observed persistent foul odor and flies, and ultimately maggots were found in the resident's wound, requiring hospitalization and antibiotic treatment. Facility leadership acknowledged multiple missed opportunities in wound care and monitoring.
The facility did not complete required background checks before hiring a nurse, and failed to conduct reference checks for multiple staff, including nursing assistants and a social service assistant. Staff were allowed to begin work without these checks, contrary to policy, placing residents at risk for abuse, neglect, and exploitation.
Two certified nursing assistants were hired and began providing care without documented verification from the nurse aide registry, as required. Personnel files lacked evidence of completed OBRA registry checks at the time of hiring, resulting in unverified staff qualifications.
A resident with complex medical and behavioral needs was transferred to a hospital and not readmitted, but did not receive a written discharge notice as required by facility policy. Staff confirmed that the required notice was not provided at the time of discharge.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist as required.
A resident with diabetes and hemiplegia developed new pressure ulcers that were not promptly reported to the provider or treated according to facility policy. Nursing staff documented the wounds and applied dressings based on nursing judgment, but did not obtain wound care orders or document treatments on the TAR for 20 days. Staff interviews revealed confusion about responsibility for notification and documentation, resulting in delayed intervention and worsening of the wounds.
A resident received an incorrect dosage of a blood thinner due to a transcription error, leading to hospitalization and a blood transfusion. The error was not caught by multiple staff members, including medical records, pharmacy, and nursing staff, resulting in the resident receiving ten times the prescribed amount on two occasions.
A resident with Chronic Myelomonocytic Leukemia experienced a delay in lab services due to missed and unnoted orders, leading to a critically elevated white blood cell count. Inconsistent staff responsibilities and communication contributed to the deficiency, resulting in the resident being sent to the emergency department.
The facility did not provide the required eight hours of RN supervision on three occasions, as revealed by staffing records and interviews. The Staffing Coordinator acknowledged the lack of 24-hour RN coverage, and the DON confirmed recruitment efforts and plans to submit a staffing exception.
The facility failed to conduct monthly Medication Regimen Reviews (MRR) for four residents, placing them at risk for medication-related issues. The residents were taking multiple medications, including antipsychotics and anticoagulants. The Director of Nursing acknowledged the oversight, noting that no MRRs had been conducted since April.
The facility failed to obtain timely consent for psychotropic medications for two residents. One resident with schizophrenia was prescribed Olanzapine and Clonazepam without proper consent, while another resident with dementia and depression received Seroquel and Sertraline without timely consent. Staff acknowledged that consents should have been completed prior to medication administration.
The facility failed to assist two residents with completing advance directives (ADs) and maintaining Durable Power of Attorney (DPOA) documentation. One resident was moderately cognitively impaired, and the other was alert and oriented, yet neither had an AD or documentation that an AD was addressed in their electronic health records. The facility's policy required assistance during admission, but this was not followed, as confirmed by the Social Services Director and Administrator.
A facility failed to ensure the confidentiality of a resident's medical information when a podiatrist left a progress note visible on a cart in the hallway. A registered nurse acknowledged the breach and turned the note over, while the administrator confirmed that such information should not be visible.
A facility failed to ensure a resident was free from physical restraints by placing their bed against the wall without obtaining consent. The resident, who was severely cognitively impaired, had their bed positioned this way as a fall risk intervention, but no consent was documented. The DON confirmed that consent should have been obtained.
A facility failed to provide a written Bed Hold Notice to a resident or their representative during a hospital transfer, as required by policy. The resident, who was moderately cognitively impaired, was transferred emergently, and there was no documentation of the notice being given. The DON confirmed the lack of documentation.
A resident with an indwelling urinary catheter did not have a comprehensive care plan documented in their electronic health record. Despite being alert and oriented, and having the catheter observed over several days, staff interviews revealed a lack of documentation and awareness of the resident's catheter care needs. The Resident Care Manager and Director of Nursing acknowledged the oversight, indicating a failure to adhere to facility policies.
A facility failed to update a resident's EHR to reflect their DNAR status as per the POLST form, leading to conflicting CPR orders. Staff relied on the EHR for CPR status, which was incorrect, as confirmed by a review of the POLST form and physician notes.
The facility failed to perform neurological assessments for a resident after unwitnessed falls and did not initiate bowel protocols for several residents who experienced extended periods without bowel movements. Despite having physician orders for bowel interventions, these were not administered, and there was a lack of documentation. Staff acknowledged the deficiencies in following the facility's policies.
A facility failed to obtain physician orders for a urinary catheter for a resident, as required by their policy. The resident was observed with a foley catheter, but their Electronic Health Record lacked the necessary physician's order. Staff interviews confirmed that such orders are expected to include details like catheter size and care instructions, but none were found for this resident.
A facility failed to address a resident's weight loss, risking inadequate nutrition. The resident's care plan included monitoring weight and notifying the provider of changes, but significant weight fluctuations were not reported. Staff involved acknowledged the procedure for weight loss notification, but no record of provider notification was found.
The facility did not update nurse staffing postings daily for four days, as required. Observations showed that postings from 09/07/2024 to 10/07/2024 were not updated, displaying outdated information on 10/07/2024 and 10/08/2024. Interviews with staff revealed that the overnight charge nurse was responsible for updating the postings, but this was not done, risking uninformed residents and visitors.
The facility failed to monitor targeted behaviors for a resident on psychotropic medications and did not conduct AIMS tests for two residents prescribed antipsychotics. Staff confirmed that monitoring and testing were expected but not documented.
The facility did not properly monitor medication refrigerator temperatures in the West Hall and TCU. Temperature logs were missing for several days in the West Hall, and no log was found in the TCU. Staff indicated that night shift was responsible for temperature checks, but the Director of Nursing confirmed the logs were not up to date.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with indwelling devices and wounds, as well as proper PPE protocols. A resident with a urinary catheter and another with a feeding tube lacked EBP signage and PPE at their room entrances. An LPN did not wear a gown during wound care for a resident with a pressure ulcer. Additionally, a podiatrist did not change PPE between rooms with different precautionary requirements, despite facility protocols.
The facility did not document the offer, education, or consent for Pneumococcal, Influenza, and COVID-19 vaccines for a resident, as required by their policy. The resident's electronic health record lacked information on immunization status, and the Infection Preventionist and LPN could not provide consent forms. The administrator confirmed the expectation for vaccination per policy.
A resident expressed concern about a loose bed rail, which was confirmed by staff to have significant movement, posing a risk of entrapment. The facility failed to conduct routine inspections, and although procedures existed for reporting issues, the bed rail remained loose.
Incomplete Care Plans for Bed Rails, Wounds, Medications, Dentures, and Hearing Needs
Penalty
Summary
The facility failed to develop comprehensive care plans for multiple residents with identified needs related to bed rails, pressure injury care, psychotropic and anticoagulant medication use, dental status, and hearing/communication needs. The report states that this failure affected 4 of 16 sampled residents and was identified through observation, interview, and record review. The deficiency was cited under WAC 388-97-1020(1)(2). Resident 1 was cognitively intact and had a one-quarter length bed rail on the upper left side of the bed during multiple observations. The resident stated he did not remember anyone talking to him about the bed rail and said no one discussed putting it on his bed. The comprehensive care plan did not include a focus, goal, or intervention related to the bed rail, and both the Nurse Manager/RN and the DON stated that a care plan should have been in place for the bed rail. Resident 73 was admitted with a diagnosis that included a pressure ulcer of the right buttock and was moderately cognitively impaired with a pressure ulcer present on admission. The admission nursing assessment documented a right buttock skin issue, and the December 2025 ETAR showed daily and as-needed wound care to the right gluteal pressure injury/ulcer. The comprehensive care plan did not include a focus, goal, or intervention related to skin, pressure ulcer, or injury. Staff stated that skin or wound care needs should be reflected in the care plan, and the DON stated it was his expectation that residents with a pressure injury had a care plan in place. Resident 3 was cognitively intact and was receiving lurasidone, apixaban, clonazepam as needed, and fluoxetine. The record also documented a diagnosis of generalized anxiety disorder. The comprehensive care plans did not include a focus, goal, or intervention related to psychotropic medication use, anxiety, or anticoagulant medication use. Staff stated that care plans should address psychotropic and anticoagulant medications and anxiety, and the DON stated he expected those items to be included. Resident 6 was alert and oriented and reported having a partial upper denture plate and natural lower teeth. The record did not show a care plan for the removable upper denture plate. Resident 6 also stated he was hard of hearing and used hearing aids at home, but had not brought them to the facility. The record did not show a care plan for hearing loss or communication devices. Staff stated the Kardex should show dentures or hearing devices, and the DON stated he would expect the care plan to reflect dentures, partial teeth, hearing deficiencies, and communication devices.
Failure to Provide and Document Resident Showers
Penalty
Summary
The facility failed to ensure ADLs were provided for dependent residents, affecting 3 of 4 sampled residents reviewed for ADL care. Resident 8, who was admitted to the facility and documented on the 5-Day MDS as alert and oriented, had bathing records from 10/30/2025 to 12/09/2025 showing only one shower on 11/18/2025, 18 days after admission. The EHR did not document a shower refusal or any reason a shower was not offered during this period, and during interview on 12/09/2025 at 10:32 AM, Resident 8 said he did not remember the last time he received a shower. Resident 30, who was documented on the Quarterly MDS as alert and oriented, had no showers documented in the EHR from 11/10/2025 to 12/09/2025, and the record did not show a refusal or reason a shower was not offered. During interview on 12/08/2025, Resident 30 said she had only received four showers since admission and stated, "They make a plan for a shower, then I don't get one." Resident 50, documented on the admission MDS as moderately cognitively impaired, had one shower documented on 12/01/2025 in the EHR from 11/22/2025 to 12/09/2025, with no refusal or reason documented for showers not being offered. During interview on 12/09/2025 at 8:50 AM, Resident 50 said it had been a while since she showered and would like a shower. Staff O stated residents were offered showers twice a week and refusals were tracked, but could not confirm the last time Residents 8, 30, and 50 showered. Staff B was unable to produce documentation showing completed showers and/or refusals.
Failure to follow bowel protocol and ordered weight monitoring
Penalty
Summary
The facility failed to initiate bowel interventions for Resident 30 according to its bowel protocol. The policy stated that at the beginning of each shift the licensed nurse would review the resident bowel management report, identify residents without a bowel movement for 3 days, and follow a stepwise protocol using Milk of Magnesia, Dulcolax suppository, and then a Fleets enema if needed. Resident 30 was alert and oriented, and the bowel movement task sheet showed gaps of approximately 164 hours, 93 hours, and 243 hours between documented bowel movements. The electronic health record did not show documentation of bowel interventions from 11/18/2025 through 12/12/2025, and staff stated the expected bowel protocol was not done. The facility also failed to obtain accurate weights for Resident 12, Resident 41, and Resident 50 as ordered and as required by policy. The weight monitoring policy stated weekly weights would be documented for at least 4 weeks after admission and for residents at nutrition risk. Resident 12 had congestive heart failure and a physician order for daily weights for 4 weeks, but only one weight was documented after admission. Resident 50 also had congestive heart failure and orders for daily weights for 4 weeks, then daily weights with reporting parameters for weight gain, but only one weight was documented after admission. Resident 41 was admitted for rehabilitation services and wound care, was alert and oriented, and had a nutrition assessment documenting underweight status and a pressure ulcer. The record showed only one weight documented, and the dietitian stated Resident 41 should have been weighed weekly since admission. Staff members stated CNAs performed the weights and entered them into the chart, and the DNS stated it was his expectation that staff weigh and document residents' weights as ordered.
Failure to Obtain Informed Consent Before Psychotropic Medications
Penalty
Summary
The facility failed to obtain written informed consent before administering psychotropic medications for 2 of 5 residents reviewed for unnecessary medications. The facility policy titled, Psychoactive Medications, stated that prior to administration of psychotropic medication, consent is obtained from the resident or resident representative and that informed consent is obtained prior to initiation or dose increase. Survey review found that Resident 3, who was cognitively intact and had diagnoses including depression and generalized anxiety disorder, was prescribed Clonazepam 0.5 mg every 12 hours as needed and Fluoxetine 10 mg daily. The EHR showed Clonazepam was administered on 12/06/2025 and 12/09/2025 without documentation of informed consent, and Fluoxetine was started on 12/05/2025 with consent not documented until 12/09/2025, after the medication had already been given. Resident 4, who had a diagnosis of borderline personality disorder and was alert and oriented, had an order for Cariprazine HCl 3 mg at bedtime for clear thoughts related to the diagnosis. Review of the EHR did not show a psychotropic medication informed consent completed before administration of cariprazine. A signed informed consent form was present in the record, but it was dated 06/23/2025, about 6 months after the medication was initiated. Staff B and Staff F both stated that informed consent was expected prior to administration of psychotropic medications, and Staff B was unable to locate a consent for when the medication was started.
Cramped Room Limited Resident Mobility
Penalty
Summary
The facility failed to ensure adequate living space was available for Resident 41, who was admitted for rehabilitation services and was cognitively intact on the 5-day MDS dated 11/18/2025. During an interview, Resident 69 said he gets tired of his roommate backing his wheelchair into his bed when trying to open the room door to leave, and said the room is too small for 3 patients in wheelchairs. During observation, Resident 41 was trying to transfer from his bed into his wheelchair but could not move the wheelchair close enough because the tray table was blocking the path, requiring him to use his call light for staff to move it. Resident 41 then demonstrated difficulty getting out of the room, backing his wheelchair into the room door to close it and then rolling out from between the bed and the wall, which was obstructed by the open door. Resident 41 stated it was extremely difficult to navigate the room because of how it was arranged. The DON later observed the room and said it did look cramped and probably could be set up better.
Unsecured EHR on Medication Cart
Penalty
Summary
The facility failed to ensure residents' medical information was maintained in a manner that protected privacy and confidentiality when the Electronic Health Record (EHR) on the Number Two medication cart computer was left open and unlocked. During an observation in the Expressions dining room, the computer screen was displayed on the Point Click Care access page and no nursing or facility staff were in view of the cart. A resident was sitting about six feet away, and a visitor entered the dining room while the computer remained unlocked. After about one minute, an LPN and an RN entered the dining room. When asked about the open computer screen, the RN stated it should have been locked, and the LPN nodded and agreed. The RN then locked the screen. The Director of Clinical Services/RN stated it was her expectation that computer screens be covered, minimized, or locked when no staff were present so no one could access residents' medical records. The DON/RN also stated a computer screen should be locked when no nurse was present.
Failure to Complete AIMS Testing for Residents Receiving Antipsychotic Medications
Penalty
Summary
The facility failed to complete AIMS testing for 2 of 5 sampled residents who were receiving antipsychotic medications. The facility policy titled, Psychotropic Medications – AIMS, revised March 2019, stated licensed staff would assess all residents receiving antipsychotic medications and Reglan on admission, prior to initiation of a new antipsychotic or Reglan, and every 6 months while receiving the medication. Resident 3 was admitted with multiple diagnoses including depression and was cognitively intact on the admission MDS dated 11/24/2025. Physician orders dated 11/17/2025 showed Lurasidone 20 mg daily, later increased to 40 mg daily on 11/26/2025 and decreased back to 20 mg daily on 12/03/2025, and the EMAR showed the medication was administered daily. The EHR did not show documentation of an AIMS test for Lurasidone. Staff A stated it did not appear an AIMS test had been completed for Resident 3, and Staff F said an AIMS test was not done prior to administration and she did not know it was supposed to be done. Resident 4 was admitted with borderline personality disorder and was alert and oriented on the quarterly MDS. A physician order dated 12/18/2024 showed Cariprazine HCl 3 mg at bedtime for clear thoughts related to borderline personality disorder, and the first documented AIMS test in the EHR was completed on 03/28/2025, 6 months after the medication was started. Staff B confirmed the first documented AIMS test was completed on 03/28/2025 and said it was not done on admission.
Failure to Provide Written Bed Hold Notice After Hospital Transfer
Penalty
Summary
The facility failed to provide a written bed hold notice at the time of transfer or within 24 hours for one sampled resident who was hospitalized. The facility’s Bed Hold Policy and Procedure, dated 08/01/2024, stated that the resident and/or resident representative is to be informed in writing upon admission, transfer, or leave of absence, and if that cannot be done at the time of transfer or discharge, the policy is to be provided within 24 hours. It also stated that if nursing is unable to provide notification at the time of transfer or discharge, the Social Services Director or designee contacts the resident and/or resident representative to notify them of the facility policy and obtain a decision. Resident 77’s record showed the resident was admitted on [DATE] and assessed as alert and oriented on the admission MDS dated 08/18/2025. Progress notes dated 09/22/2025 documented that due to decreased O2 stats and no orders for breathing treatments, the resident was sent out via 911 EMTs at 0210. Review of the electronic medical record showed no documentation of a written Bed Hold Notice at the time of transfer or within 24 hours. The Nursing Home Discharge MDS documented an unplanned discharge with return anticipated. In email correspondence on 12/10/2025, the Administrator stated that the bed hold appeared to have been missed, and in a joint interview on 12/12/2025, the DON and Nurse Manager stated that residents should be sent with a bed hold form and that if the transfer was emergent, the manager and/or Social Services would handle it the next day.
Inaccurate MDS Assessment of Oral Care and Hearing Needs
Penalty
Summary
The facility failed to accurately assess the oral care status and communication needs of Resident 6. The Quarterly MDS dated 11/23/2025 indicated the resident was alert and oriented, had no oral care devices or concerns, and had no hearing impairment or devices. However, during an interview on 12/08/2025, Resident 6 stated he had an upper partial denture plate that needed repair and that he had natural lower teeth. Resident 6 also stated he was hard of hearing and asked for the speaker to come around to the left side of the bed so he could hear better. He reported nerve damage to both ears from work around jet engines and said he had hearing aids at home but had not brought them to the facility. The electronic health record dated 05/20/2025 showed a diagnosis of hearing loss in both ears. Staff H, the RN/MDS nurse, stated she did not think Resident 6 had teeth or a hearing deficiency and said she completed the assessment and incorrectly coded the MDS. The DON stated he would expect the MDS assessment to be accurate and reflect the specific needs of residents.
Care Plan Did Not Reflect BiPAP Use
Penalty
Summary
The facility failed to ensure Resident 30’s care plan was reviewed, revised, and accurately reflected the resident’s care needs. Resident 30 was admitted to the facility and the quarterly MDS dated 11/10/2025 documented the resident was alert and oriented. A physician’s order dated 09/17/2025 documented that Resident 30 was using a BiPAP, but the comprehensive care plan initiated on 09/17/2025 did not include a care plan to address the BiPAP. During interview, Staff R, the Resident Care Manager/RN, stated residents can bring their own medical equipment, which is assessed for use and care planned, and said Resident 30’s care plan was never changed from CPAP to BiPAP. Staff B, the DON/RN, stated Resident 30’s BiPAP should have been care planned.
Resident-Centered Activities Not Provided
Penalty
Summary
The facility failed to provide resident-centered activities that incorporated resident preferences for 3 of 3 sampled residents reviewed for activities. The facility policy titled, Activity Programs, stated activities are to be based on the comprehensive resident-centered assessment and each resident’s preferences. However, review of the facility’s activities calendars from September 2024 through December 2025 did not show any resident bus outings. Resident 7, who was admitted to the facility and was alert and oriented per the Quarterly MDS dated 11/14/2025, stated in interview that there was a bus but it was not being used and that it would be nice to just get out. Resident 14, who was admitted to the facility and was alert and oriented per the Quarterly MDS, had a care plan dated 09/10/2025 documenting interests including Bingo, reading on a tablet, cards, family visits, word-search and crossword puzzles, listening to Old Country music, pet visits, trips/outings, walking, and watching old shows and action on TV; in interview, Resident 14 stated the facility used to provide bus rides to the park but had not done so for about a year. Resident 62, who was admitted to the facility and was alert and oriented per the Quarterly MDS, stated in interview that the facility used to go on outings, sometimes to the lake, but not anymore. Staff N, Activities Director, stated there had not been outings on the activities calendar since September 2024, and Staff A, Administrator, stated the bus previously used was being used by the Oregon facilities.
Failure to Obtain Consent and Care Plan for Bed Rail Use
Penalty
Summary
The facility failed to obtain a Bed Rail/Bed Enabler and Device Consent and Evaluation for one sampled resident who had a one quarter length bed rail on the upper left side of the bed. The resident was admitted to the facility and the admission MDS dated 11/14/2025 showed the resident was cognitively intact. During observations on 12/09/2025 and 12/10/2025, the bed rail remained in place, and the resident stated he did not remember anyone talking to him about the bed rail and later said no one talked to him about putting a bed rail on his bed. He also said the bed rail was on the bed when he was admitted. Review of the resident’s EHR showed no Bed Rail/Bed Enabler and Device Consent and Evaluation related to the bed rail. The resident’s comprehensive care plan, initiated 11/10/2025, did not include a focus, goal, or intervention related to the bed rail. Facility policy stated that residents and/or representatives are to be provided risks and benefits of restraint or enabler/device use and consent obtained prior to implementation, and that the care plan and Kardex are to be updated for device use. Staff F, the Nurse Manager/RN, stated residents using assistive devices like bed rails needed an evaluation, consent, and care plan, and after reviewing the record said these were not present. Staff B, the DON/RN, stated it was his expectation that an evaluation, consent, order, and care plan be in place for bed rails on a resident’s bed.
Routine Pain Patch Not Administered as Ordered
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when the facility failed to ensure a routine pain medication was acquired timely for Resident 53. Resident 53 was admitted with diagnoses including chronic pain. Her Quarterly MDS dated 11/12/2025 documented that she was alert and oriented and was almost constantly in pain, which occasionally interfered with her day-to-day activities. A physician order dated 10/02/2025 directed Buprenorphine Transdermal Patch 20 mcg/hr to be applied weekly in the evening every Thursday for chronic pain and removed per schedule. The EMAR did not show the patch was administered on Thursday 12/04/2025 as scheduled. During an interview on 12/09/2025, Resident 53 stated she did not receive her Buprenorphine pain patch the previous week and had not received it since, and she rated her pain as 10/10. Staff L stated that if a medication was not available in the cart, the nurse would pull it from Omnicell or call the pharmacy for immediate delivery, and the missed medication would be documented in the EMAR with follow-up by the oncoming nurse. Staff B reviewed the EMAR and confirmed Buprenorphine was not signed off as administered, stating it was his expectation that if a medication was not available, the EMAR would be signed off, the provider notified, and staff would coordinate with pharmacy for delivery.
Medication Administration Outside Physician Order Parameters
Penalty
Summary
The facility failed to administer medications as directed by physician orders for 2 of 5 residents reviewed for unnecessary medications. One resident had a diagnosis of type 2 diabetes mellitus with hyperglycemia and was ordered insulin glargine 17 units subcutaneously in the morning, with instructions to hold for blood glucose less than 100. The December 2025 EMAR showed the insulin was administered on 12/07/2025 with a blood glucose of 82, on 12/08/2025 with a blood glucose of 82, and on 12/09/2025 with a blood glucose of 86. During interview, the DON reviewed the order and EMAR and stated the insulin was given outside the hold parameters and that staff should have held the medication and notified the provider. Another resident had an order dated 07/30/2025 for oxycodone to be given only between 9:00 PM and 6:00 AM for pain not relieved by scheduled medication. The MAR showed oxycodone was administered on 12/01/2025 at 10:48 AM, 12/08/2025 at 2:25 PM, and 12/09/2025 at 12:53 PM, which was outside the ordered time parameters. The RN/Resident Care Manager stated the order indicated oxycodone should only be administered during the permitted hours and said the nurses must not have been reading the entire order for the directions. The DON later stated he was not aware of the discrepancy and expected nurses to follow physician orders.
Unlocked Medication Cart Left Accessible
Penalty
Summary
The facility failed to secure medications in 1 of 4 sampled medication carts, identified as the Number Two medication cart, during an observation and interview on 12/10/2025 at 2:43 PM. The cart was observed unlocked in the Expressions dining room, with no nursing or facility staff within view. The drawers of the unlocked cart could be opened, and multiple bottles of medicine and residents' prescription medications were accessible. A resident was sitting alone about six feet away from the cart, and a visitor walked into the dining room while the cart remained unlocked and no staff were present. After about 1 minute, Staff D, an LPN, and Staff E, an RN, entered the dining room. When asked about the practice for locking a medication cart when it was not in view, Staff D said the cart should have been locked and was not because they were changing nursing shifts. Staff D stated he had the keys to the cart. Staff E said the cart should have been locked when they stepped away from it. Staff C, the DCS/RN, stated it was her expectation that medication carts be kept locked when no staff were present and within view of the cart. Staff B, the DON/RN, said a medication cart should be locked when no nurse was present.
Failure to Provide Consistent Wound Care and Monitoring Resulting in Maggot Infestation
Penalty
Summary
The facility failed to consistently assess, monitor, and provide wound care treatments as ordered for a resident with existing pressure ulcers. Upon admission, the resident had chronic ulcers on both heels, osteomyelitis, and vascular dementia, and was cognitively impaired. The initial skin assessment documented the presence of pressure wounds, but there was no evidence that wound photographs or measurements were taken during the resident's stay, despite facility policy requiring such documentation. Nursing staff did not consistently complete or document daily wound care treatments as ordered by the physician, with several days lacking signatures or indicating refusals without further follow-up. Multiple staff interviews and record reviews revealed that wound dressings were frequently soaked, malodorous, and not changed as required. Staff reported that nurses on certain shifts did not have access to the camera for wound documentation, and that wound care was sometimes signed off as completed by one nurse but not actually performed. The resident's family and therapy staff noted a persistent foul odor and the presence of flies in the resident's room. On one occasion, a nurse signed off on all treatments for a medication cart but did not perform them, expecting other nurses to complete the tasks, which did not occur. The resident's condition deteriorated, and maggots were discovered in the left heel wound during a dressing change, prompting immediate hospitalization. Hospital records confirmed the presence of maggots and noted that the wounds appeared uncared for, with necrotic tissue and excessive drainage. The resident required removal of maggots and antibiotic treatment for the infected wounds. Facility leadership acknowledged missed opportunities for wound evaluation, daily rounding, and ensuring that wound care standards were upheld during the resident's transition and stay.
Failure to Complete Background and Reference Checks Prior to Staff Hire
Penalty
Summary
The facility failed to implement its abuse prohibition policy and procedures by not ensuring that required background checks and reference checks were completed prior to the hire dates for several staff members. Specifically, one licensed nurse was hired and began working before a background check was conducted, and five staff members, including nursing assistants, a social service assistant, and a staffing coordinator, were hired without evidence of reference checks being completed beforehand. The facility's policy requires background checks to be conducted and prohibits the employment of individuals with findings of abuse, neglect, exploitation, or related disciplinary actions. Record reviews confirmed the absence of background and reference checks in the personnel files of the affected staff. Interviews with the Human Resource Director and the Administrator confirmed that staff were allowed to begin work prior to the completion of these checks, contrary to facility policy and regulatory requirements. This lapse in procedure placed residents at risk for abuse, neglect, exploitation, and misappropriation of property.
Failure to Verify Nurse Aide Registry Status Prior to Employment
Penalty
Summary
The facility failed to ensure that nursing assistants were properly screened through the nurse aide registry (OBRA) prior to providing care to residents. Specifically, two certified nursing assistants were hired without documentation in their personnel files confirming that OBRA registry checks had been completed. This was confirmed through both interview and record review, which revealed that the required registry verification was missing for both staff members at the time of their hiring. The absence of these checks meant that the facility did not verify whether the nursing assistants were qualified and eligible to provide care before they began working with residents.
Failure to Provide Written Discharge Notice
Penalty
Summary
The facility failed to provide a written notice of discharge for one resident who was reviewed for transfer and discharge requirements. According to the facility's policy, a written notice of transfer or discharge must be given 30 days prior to the event unless there is an immediate threat to health or safety. Record review and staff interviews confirmed that no written discharge notice was provided to the resident at the time of discharge. The Social Service Director acknowledged that a written notice was not given. The resident involved was cognitively intact, able to make her own decisions, and required moderate assistance with activities of daily living. She had ongoing and active substance use, including nicotine, methamphetamines, and methadone, which led to complex and unstable medical conditions. The resident exhibited behaviors such as leaving the facility and returning in a compromised state, declining care, and inconsistent eating, resulting in medical interventions for diabetes-related events. The facility determined that her needs exceeded their capacity and arranged for her transfer to a hospital, after which she was not readmitted. The lack of written discharge notice was confirmed through interviews with facility staff and collateral contacts.
Failure to Provide Required Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Timely Address and Treat New Pressure Ulcers
Penalty
Summary
The facility failed to address a newly developed pressure ulcer for a resident with significant medical conditions, including diabetes with polyneuropathy and hemiplegia following a stroke. The resident required substantial assistance with activities of daily living and repositioning. On discovery of open wounds and areas of concern on the resident's right buttock and heel, nursing staff documented the findings and applied dressings per nursing judgment, but did not notify the provider, obtain wound treatment orders, or document the interventions on the Treatment Administration Record (TAR) as required by facility policy. No progress notes or physician orders for wound care or pressure reduction modalities were entered for 20 days after the wounds were first identified. Multiple staff interviews revealed confusion and lack of clarity regarding responsibility for provider notification, order acquisition, and documentation. Some staff believed it was the responsibility of the wound nurse or Resident Care Manager, while others stated it was the responsibility of the nurse who identified the wound. The delay in obtaining appropriate wound care orders and implementing pressure reduction interventions resulted in the deterioration of the resident's wounds, with the wounds becoming unstageable by the time they were properly assessed and treated.
Significant Medication Error Due to Incorrect Dosage Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the case of a resident who received an incorrect dosage of a blood thinner medication. The resident, who had been admitted with diagnoses including hemiplegia and transient ischemic attack, was prescribed Enoxaparin 30 mg/0.3 ml to be administered subcutaneously once daily. However, due to an error in transcribing the hospital discharge orders, the medication administration record incorrectly indicated a dosage of 300 mg/3 ml, leading to the resident receiving ten times the prescribed amount on two consecutive days. This error resulted in the resident developing multiple hematomas and requiring hospitalization and a blood transfusion. The error occurred due to multiple oversights in the medication administration process. The Director of Nursing Services acknowledged that the error was missed by several staff members, including medical records personnel, the pharmacy, and the nurses responsible for administering the medication. The medical records staff member who entered the orders was not familiar with the correct dosage of Lovenox and did not flag the discrepancy for further review. Additionally, a Licensed Practical Nurse admitted to activating all orders without thoroughly checking them due to being busy, and the Resident Care Manager, who was still in training, did not review the orders until after the error was discovered.
Failure to Provide Timely Laboratory Services
Penalty
Summary
The facility failed to provide timely laboratory services for a resident who was readmitted with Chronic Myelomonocytic Leukemia, a condition characterized by an overproduction of white blood cells. Hospital discharge orders required a Complete Blood Count (CBC) and Basic Metabolic Panel (BMP) to be completed by a specific date, but these were not noted or completed as required. Subsequent physician orders for lab draws were inconsistently followed, with some lab results missing from the resident's medical record. A critically elevated white blood cell count was eventually identified, but the necessary repeat analysis was not ordered promptly. The deficiency was further compounded by unclear processes and responsibilities among staff for implementing and overseeing lab orders. Interviews with staff revealed inconsistencies in who was responsible for entering and verifying lab orders, as well as ensuring their completion. Despite discussions in clinical meetings about missed labs, the orders were not consistently followed through, leading to a delay in identifying the resident's critically elevated white blood cell count. This delay resulted in the resident being sent to the emergency department with increased swelling and discomfort, and the resident did not return to the facility.
Failure to Provide Required RN Supervision
Penalty
Summary
The facility failed to provide at least eight hours of Registered Nurse (RN) supervision for three out of thirty days, specifically on 09/29/2024, 10/05/2024, and 10/06/2024. This deficiency was identified through interviews and record reviews, which included the Aging and Long-Term Support Administration (ALTSA) Staffing Pattern and the facility's Daily Nurse Staffing Forms. These documents revealed that there was no RN on duty for all three shifts (day, evening, and night) on the specified dates. During an interview on 10/11/2024, the Staffing Coordinator, Staff T, acknowledged that the facility did not always have 24-hour RN coverage and mentioned ongoing recruitment efforts. Additionally, the Director of Nursing Services, Staff B, confirmed attempts to recruit RNs using online hiring services and indicated plans to submit an exception for staffing.
Failure to Conduct Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist completed a monthly Medication Regimen Review (MRR) for four out of five sampled residents. This deficiency was identified during interviews and record reviews, which revealed that the facility did not conduct monthly pharmacy MRRs for the months of June, July, August, September, and October 2024. The absence of these reviews placed residents at risk for delays in necessary medication changes, adverse side effects, and receiving medications without the required pharmacist oversight. The residents involved were alert and oriented, and were taking multiple medications, including antipsychotics, antidepressants, hypnotics, anticoagulants, diuretics, opioids, antianxiety medications, and hypoglycemics. The Director of Nursing Services acknowledged the oversight, stating that the facility had not received any monthly pharmacy MRRs since April 2024. This lapse in procedure was a direct violation of the facility's policies and procedures, as well as regulatory requirements.
Failure to Obtain Timely Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were informed and provided consent before administering psychotropic medications. This deficiency was identified for two residents. Resident 41, who was diagnosed with schizophrenia, was prescribed Olanzapine and Clonazepam. The consent for Olanzapine was obtained 47 days after the medication was started, and there was no documented consent for Clonazepam. Staff E, a Resident Care Manager and RN, acknowledged that consents should have been completed prior to starting these medications. Similarly, Resident 3, who had diagnoses of dementia and depression, was prescribed Seroquel and Sertraline. The consent for these medications was signed 22 days after they were initiated. Staff B, the Director of Nursing Services, confirmed that it was her expectation that consents should have been obtained on the day the orders were initiated. This oversight placed residents at risk of not being fully informed of the risks and benefits before making decisions about their medications.
Failure to Address Advance Directives for Two Residents
Penalty
Summary
The facility failed to have procedures in place to assist residents with completing advance directives (ADs) and obtaining and maintaining Durable Power of Attorney (DPOA) documentation for two residents. Resident 3, who was moderately cognitively impaired, was admitted to the facility, and their electronic health record (EHR) did not show an AD or documentation that an AD was addressed since admission. Similarly, Resident 9, who was alert and oriented, also did not have an AD or documentation that an AD was addressed in their EHR since admission. The facility's policy on advance directives, dated August 1, 2018, indicated that assistance would be provided during the admission process if a resident wished to formulate an AD. However, the facility did not adhere to this policy. Staff X, the Social Services Director, stated that ADs were addressed during the initial admission care conference and a few days later, but typically only documented if residents declined. The Administrator, Staff A, confirmed that it was her expectation to address ADs per facility policy but was unable to provide further documentation of ADs being addressed for the two residents.
Failure to Maintain Resident Medical Information Confidentiality
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' medical information, specifically for Resident 258. During an observation, Staff S, a podiatrist, was seen providing care to Resident 258 in their room. However, Staff S left multiple papers on a cart in the hallway, with the top paper being a Podiatric Progress Note that displayed Resident 258's medical information. This information was visible to anyone passing by in the hallway. Staff R, a registered nurse, acknowledged that resident information should not be visible and turned the progress note over to conceal it. Staff A, the administrator, also confirmed that resident medical information should not be visible to others and should be turned over to maintain confidentiality.
Failure to Obtain Consent for Bed Placement as Restraint
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints, as evidenced by the case of Resident 38. Resident 38, who was admitted to the facility and assessed as severely cognitively impaired, was found to have their bed placed against the wall with a floor mat on the side not against the wall. This setup was intended as a fall risk intervention, as Resident 38 had previously attempted to get out of bed and fallen. However, there was no consent found in the electronic health records for the bed being placed against the wall, which is considered a form of restraint. The Director of Nursing Services confirmed that consent would typically be obtained for such an arrangement.
Failure to Provide Bed Hold Notice
Penalty
Summary
The facility failed to provide a written Bed Hold Notice to a resident or their representative at the time of transfer to a hospital, as required by their policy. This deficiency was identified during a review of the facility's records and interviews with staff. The facility's Bed Hold Policy mandates that residents or their representatives be informed in writing about the bed hold policy upon admission, transfer, or leave of absence, and if not possible at the time of transfer, within 24 hours. However, for a resident who was moderately cognitively impaired and transferred emergently to an acute care hospital, there was no documentation of a Bed Hold Notice being provided. The Director of Nursing Services confirmed the absence of such documentation.
Failure to Develop Care Plan for Resident with Urinary Catheter
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with an indwelling urinary catheter, which was necessary to address the resident's care needs. Resident 28, who was alert and oriented, was admitted and readmitted to the facility with a foley catheter. Despite this, the resident's electronic health record did not document a care plan for the catheter. Observations over several days confirmed the presence of the catheter, yet no care plan was in place. Staff interviews revealed a lack of awareness and documentation regarding the resident's catheter care needs. A Certified Nursing Assistant indicated that care needs are typically communicated through the Kardex and care plan, but the care plan for the catheter was missing. The Resident Care Manager and RN acknowledged the absence of the care plan, stating it should have been included. The Director of Nursing Services also confirmed that it was expected for care plans to address residents with foley catheters, highlighting a gap in the facility's adherence to its own policies.
Discrepancy in CPR Orders and POLST Form
Penalty
Summary
The facility failed to ensure that the physician's orders in the Electronic Health Record (EHR) accurately reflected a resident's wishes for Cardiopulmonary Resuscitation (CPR) status as documented in the Physician Orders for Life Sustaining Treatment (POLST) form. This discrepancy was identified for a resident who was alert and oriented, and whose POLST form clearly indicated a Do Not Attempt Resuscitation (DNAR) status. However, the EHR contained conflicting orders to attempt CPR, which was inconsistent with the resident's documented wishes and the physician's progress notes that confirmed a DNAR status. Staff interviews revealed that registered nurses relied on the EHR to determine a resident's CPR status. The error was discovered when a Resident Care Manager reviewed the POLST form and found it contradicted the EHR orders. The Director of Nursing Service acknowledged that the physician orders should have matched the POLST form, highlighting a failure in the facility's process to ensure that residents' advance directives were accurately reflected in their medical records.
Failure to Conduct Neurological Assessments and Initiate Bowel Protocols
Penalty
Summary
The facility failed to conduct ongoing neurological assessments for a resident after experiencing multiple unwitnessed falls. Resident 38, who was severely cognitively impaired, had several unwitnessed falls over a period of time, yet no neurological assessments were documented in the electronic health record (EHR) or fall investigations. The Director of Nursing Services confirmed that neurological assessments should be initiated and completed after such incidents, and any refusal by the resident should be documented. Additionally, the facility did not adhere to its bowel management policy for several residents. Resident 10, who was alert and oriented, went over 96 hours without a bowel movement, yet the prescribed bowel protocol was not initiated. Similarly, Resident 11 experienced significant delays between bowel movements on two occasions, with no initiation of the bowel protocol as per physician orders. The facility's records showed a lack of documentation and administration of necessary bowel interventions. Residents 28 and 41 also experienced extended periods without bowel movements, with no documentation of bowel interventions being initiated. Despite having physician orders for PRN constipation medications, these were not administered, and there was no record of refusals. Staff members acknowledged the lack of documentation and administration of bowel protocols, which should have been initiated after three days without a bowel movement.
Failure to Obtain Physician Orders for Urinary Catheter
Penalty
Summary
The facility failed to obtain physician orders for a urinary catheter for Resident 28, who was one of the two sampled residents reviewed for urinary catheter use. Resident 28 was admitted and readmitted to the facility with an indwelling catheter, as documented in the Medicare - 5 day Minimum Data Set assessment. However, a review of Resident 28's Electronic Health Record revealed the absence of a physician's order for the indwelling foley catheter, which is necessary to ensure proper catheter care and management. Observations over several days confirmed that Resident 28 had a foley catheter bag hanging on the left side of the bed frame. Interviews with facility staff, including a Licensed Practical Nurse, a Resident Care Manager and Registered Nurse, and the Director of Nursing Services, revealed that it was the facility's expectation and policy that residents with foley catheters should have physician orders detailing catheter size, care instructions, and other relevant details. The absence of such orders for Resident 28's catheter was acknowledged by the staff, indicating a lapse in following the facility's policy and procedures.
Failure to Address Resident's Weight Loss
Penalty
Summary
The facility failed to identify and address weight loss for one resident, placing them at risk for inadequate nutrition and diminished quality of life. Resident 3 was admitted to the facility and was alert and oriented according to the Admission Minimum Data Set assessment. The resident's nutrition care plan aimed to maintain adequate nutritional status through stable weight, with interventions including obtaining weights as ordered and reporting significant changes to the physician and responsible party. However, the electronic health record showed fluctuating weights for the resident, with significant weight loss not being reported to the provider. Staff I, a Resident Care Manager and LPN, stated that they would notify the dietician and provider if a resident was losing weight, but Staff B, the Director of Nursing Services and RN, could not find any provider notification of the resident's weight loss in the EHR.
Failure to Update Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to ensure that nursing hours were accurately posted daily for four out of thirty days reviewed. This deficiency was identified through observation, interview, and record review. Specifically, the nurse staff postings from 09/07/2024 to 10/07/2024 were examined, and it was found that on 10/07/2024 and 10/08/2024, the postings still displayed the date 10/04/2024 with a census of 67. Interviews with Staff T, the Staffing Coordinator, and Staff B, the Director of Nursing Services, revealed that the overnight charge nurse was responsible for updating the postings over the weekend, but this was not done. This failure placed residents, their representatives, and visitors at risk of not being fully informed about the current staffing levels and census, as the postings were not updated as required.
Failure to Monitor Psychotropic Medication Use and Conduct AIMS Tests
Penalty
Summary
The facility failed to monitor targeted behaviors for a resident who was prescribed psychotropic medications, which is necessary to evaluate the effectiveness and necessity of such medications. Resident 3, who was diagnosed with dementia and depression, was not monitored for targeted behaviors as expected by the facility's protocol. The Director of Nursing Services confirmed that residents should be monitored every shift for behaviors related to psychotropic medication use, but this was not documented in Resident 3's electronic health record. Additionally, the facility did not complete the Abnormal Involuntary Movement Scale (AIMS) test for two residents who were prescribed antipsychotic medications. Resident 3 was prescribed Seroquel and Sertraline, and Resident 41 was prescribed Olanzapine, yet there was no record of an AIMS test being conducted for either resident. Staff members acknowledged that an AIMS test should be completed upon admission and when a new antipsychotic medication is started, but this was not done, as confirmed by the Director of Nursing Services and the Resident Care Manager.
Failure to Monitor Medication Refrigerator Temperatures
Penalty
Summary
The facility failed to ensure proper monitoring of medication refrigerator temperatures in two sampled units, the West Hall and the Transitional Care Unit (TCU). On October 9, 2024, it was observed that the temperature log for the medication refrigerator in the West Hall medication room was missing entries for October 3, 4, and 5, 2024. Additionally, on October 10, 2024, the medication refrigerator in the TCU medication room was found without a temperature monitoring log, and Staff K, an LPN, was unable to locate it. Staff K mentioned that the night shift was responsible for checking the refrigerator temperatures. On October 11, 2024, Staff B, the Director of Nursing Services, confirmed that it was expected for refrigerator temperatures to be checked twice daily, but acknowledged that the temperature log for the West Hall medication room was not up to date.
Failure to Implement Enhanced Barrier Precautions and Proper PPE Use
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for three residents who required them due to their medical conditions. Resident 28, who had an indwelling urinary catheter, was observed multiple times without EBP signage or personal protective equipment (PPE) at the entrance of their room. Similarly, Resident 13, who had a feeding tube, also lacked EBP signage and PPE at their room entrance during several observations. Staff C, the Infection Preventionist, acknowledged that EBP had not been implemented in the facility, despite the residents' needs. Resident 107, who was being treated for a Stage 3 pressure ulcer, also did not have EBP signage or PPE at their room entrance. During wound care, Staff U, an LPN, failed to wear a gown, which is a requirement under EBP for wound care. Staff U later admitted to forgetting to wear a gown during the procedure. The Director of Nursing Services expected that residents requiring EBP, such as Residents 28 and 13, would be placed on precautions, but this was not the case. Additionally, the facility failed to ensure proper donning and doffing of PPE by staff. Staff S, a podiatrist, was observed wearing the same gown and respirator while moving between rooms with different precautionary requirements, without changing PPE as indicated by the signage. Staff C and the Administrator confirmed that staff should follow the signage instructions for PPE use, but Staff S did not adhere to these protocols, potentially compromising infection control measures.
Failure to Document Vaccine Education and Consent
Penalty
Summary
The facility failed to ensure that residents were offered, educated, and provided with the risks and benefits of Pneumococcal, Influenza, and COVID-19 vaccines, as evidenced by the case of one resident. The facility's policy, revised in February 2022, required that the risks and benefits of vaccines be reviewed with residents or their representatives, and that vaccine declinations and reasons be recorded in the resident's medical record. However, for Resident 15, who was alert and oriented upon admission, there was no documentation in the electronic health record regarding their immunization status or any offer or education about the vaccines. Staff C, the Infection Preventionist and LPN, acknowledged the absence of consent forms for Resident 15, despite the expectation that such documentation should exist. The facility administrator also confirmed the expectation that residents be vaccinated according to the facility's policies.
Failure to Inspect and Maintain Bed Rails
Penalty
Summary
The facility failed to conduct routine inspections of beds and bed rails, leading to a deficiency involving a resident's bed. Resident 106, who was alert and oriented, expressed concern about the looseness of their bed rail, which they initially felt made them feel safe. Upon inspection, the bed rail was found to have six to eight inches of movement, indicating it was loose. Staff L, a Resident Care Manager and LPN, confirmed the looseness of the bed rail. Staff B, the Director of Nursing Services and RN, mentioned that nurses were aware of the procedure to report bed rail issues through the TELLS system, and some nurses knew how to tighten them. Staff Q, the Maintenance Director, also confirmed the looseness and noted that the gap exceeded the entrapment zone, posing a risk of entrapment and injury.
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Illustrative
What surveyors actually found near you
We read the 542 citations issued within 25 miles in the last 12 months — including the 4 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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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Vancouver
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Oaks At Timberline | 1 mi | ★★★★★ | 15 | 0 |
| Vancouver Specialty And Rehab Care | 4.4 mi | ★★★★★ | 29 | 0 |
| Hudson Bay Health And Rehabilitation | 4.5 mi | ★★★★★ | 14 | 0 |
| Salmon Creek Post Acute & Rehabilitation | 4.5 mi | ★★★★★ | 27 | 0 |
| Marquis Piedmont Post Acute Rehab | 5.7 mi | ★★★★★ | 13 | 0 |
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