Below average — CMS composite of the measures below.
A standard survey is most likely before 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 Bridges To Home during CMS and state inspections, most recent first.
A resident with chronic respiratory failure and a tracheostomy experienced a decannulation event in which the trach flange broke, a trach tie was off, and the resident’s O2 saturation dropped before returning to baseline. Facility records and staff interviews showed that, despite a policy requiring notification of resident representatives within 24 hours of incidents or changes in condition, the resident’s representatives were not informed of this event until weeks later. A hospital note documented that the representatives reported they had not been told of the incident until much later and felt unheard and dismissed, demonstrating a failure to ensure the resident and representatives were fully informed about the resident’s health status, care, and treatment.
The facility failed to timely report an allegation of abuse/neglect after a resident on droplet precautions, ordered to remain in their room except for bathing, was directed by a senior clinical leader to be brought into common and play areas despite staff reminders about the MD order and infection policy. An RN ultimately complied, and the resident, who could understand language, was present when the leader, speaking in an elevated and agitated tone, stated they would "rather have sick babies than dead babies," a comment the facility’s investigation found implied harm and did not rule out abuse. The investigation also determined that ignoring the known MD order meant neglect was not ruled out. Although the facility’s policy and the DON required reporting such allegations to the State Agency within 24 hours, the incident was not reported until several days later, and one staff member did not report it at the time because they believed "everybody knew about it."
A resident on droplet precautions for respiratory symptoms had a physician order to remain in their room except for bathing, but an administrator directed staff to disregard the order and infection control policy and bring the resident into common areas. Staff informed the administrator of the active droplet precautions, yet the directive was repeated and followed, and the resident was present during a contentious exchange in which the administrator made a statement implying harm. The DON and administrator later acknowledged that this allegation of abuse/neglect was not investigated within the required timeframe, and the administrator did not interview the resident, the resident’s representatives, or other residents or representatives, resulting in a delayed and incomplete investigation contrary to facility policy and regulatory requirements.
A resident with respiratory symptoms and a physician’s order for droplet precautions had a care plan requiring them to remain in their room except for bathing. Despite this, the resident was observed in a common area and then taken by the Activity Director to a shared playroom, where they were supervised, although no other residents were present. The DON later stated that staff were expected to follow the care plan and that the resident should not have left the room, demonstrating a failure to implement the ordered droplet precaution care plan.
The facility did not ensure adequate dietary staffing, as only one Nutrition Services Manager was responsible for all kitchen functions, including manager, cook, and housekeeping roles. The facility assessment did not account for the number of cooks needed, despite two residents receiving oral intake in addition to tube feeding, one with frequent oral meals and another on a restricted-calorie diet. Because the Nutrition Services Manager worked every other day, meals were prepared in advance and reheated by an aide on days they were absent, rather than being freshly prepared each day. The Program Administrator confirmed that this was the only kitchen staff member, that concerns about staffing shortages and the need for a cook had been raised, and that there was no timely response from higher management.
A resident with seizures and chronic respiratory failure received an incorrect intranasal Midazolam dose during a seizure event. The RN drew up the medication at the bedside, did not verify the order at the med cart, and administered about 10 times the ordered amount. The resident was hospitalized with benzodiazepine overdose and acute on chronic hypercarbic respiratory failure, and hospital notes described the resident as somnolent, tachycardic, and requiring escalated respiratory support.
Care plans were missing for benzodiazepine, diuretic, and antibiotic use for several residents with orders for these meds. One resident had epilepsy and a UTI history with multiple antibiotic and clonazepam orders, another had hypoplastic left heart syndrome with diuretic orders, and another had seizures, UTI, and fluid/electrolyte disorders with orders for midazolam, clonazepam, diuretics, and nitrofurantoin. Staff interviews confirmed these meds were expected to be included in the care plans.
Nurse staffing information was not posted at the beginning of the nursing shift and was not placed in a prominent, readily visible location. Observations showed the Staffing Standard form was posted behind the counter at the nurse's station and was dated the prior day, and a visitor stated it was not visible. The Office Administrator said the posting was changed when they arrived at work rather than at the start of the nursing shift, while the DON/Administrator expected it to be posted daily at the beginning of the shift and visible to residents, family, and visitors.
A resident's MRR was not completed timely for an unnecessary medication review issue. The pharmacist identified the same BMP recommendation on consecutive MRRs, but the physician response for the earlier review was left incomplete and the response was not returned until later. Staff reported that the MRR recommendations were emailed to the Administrator, DON, and Medical Director, but the Medical Director did not respond timely and no follow-up occurred during the earlier review period.
Medication Refrigerator Temperature Not Maintained: The facility failed to keep the medication room refrigerator within the required 36 F to 46 F range and failed to maintain complete temperature logs. Records showed multiple blank entries and several readings of 49 F to 50 F. The Nurse Manager and DON acknowledged the missing documentation and stated the temperature was too high and should have been checked daily.
A resident on EBP with a trach and G-tube was suctioned in a common area by an LPN who wore gloves but no gown, despite the resident’s care plan and facility expectations for gown and gloves during direct care. In addition, a CNA was observed wearing gloves while carrying garbage through the hallway, and multiple RNs/CNAs changed gloves between suctioning, G-tube care, transfers, and other tasks without performing hand hygiene between tasks, contrary to the facility’s hand hygiene and glove-use practices.
A resident received an overdose of Midazolam when an RN administered 2 ml instead of the ordered 0.28 ml PRN dose during a seizure, and the resident was transferred to the hospital. The facility’s abuse/neglect investigation did not include witness statements, did not show whether abuse or neglect was ruled out, and did not show that the State Agency was notified. Staff later stated the investigation was not thorough and that the hospital notes showing respiratory failure secondary to the medication error would have changed the reporting decision.
Failure to Notify Ombudsman of Resident Discharge: The facility did not notify the State LTC Ombudsman of a resident’s discharge to the community, despite its Transfer and Discharge policy requiring that the Ombudsman receive a copy of the notice. Record review showed the discharge was completed and documented, but the EHR did not show Ombudsman notification. Staff interviews showed uncertainty about the process, and the SW, DON, and other staff stated they did not notify the Ombudsman of discharges or transfers.
Medication orders were not properly entered or documented before administration for two residents. An RN gave a partial dose of cholecalciferol after an LPN reported a verbal order, without checking the EMR or seeing a written order, and later documented it in the MAR. For another resident, an RN prepared a partial dose of sacubitril-valsartan, reported getting a physician order through a messenger app, and signed off in the MAR before the medication was actually administered; the EMR did not contain the order.
Failure to document COVID-19 vaccine education and status for a resident. The resident's representative was not shown to have received information about the vaccine's risks, benefits, or side effects, and the EHR did not show the vaccine was offered, accepted, or refused. The DON stated vaccines were offered per MD recommendations, but staff confirmed there was no documentation in the record.
Failure to Timely Notify Resident Representative of Significant Respiratory Event
Penalty
Summary
The deficiency involves the facility’s failure to timely inform a resident and/or their representative of a significant change in health status and treatment event. The resident was admitted with chronic respiratory failure and had a tracheostomy in place. A progress note documented that on 01/21/2026 the resident experienced a decannulation event when the tracheostomy flange broke and one trach tie was found off, during which the resident’s oxygen saturation dropped to 84% before returning to their baseline of 94%–96%. This event constituted a change in the resident’s condition and involved their respiratory support and tracheostomy management. Interview and record review showed that the facility did not notify the resident’s representatives of this decannulation incident within the facility’s stated 24-hour notification timeframe. The social worker reported receiving an email about the event after hours on 01/21/2026 but acknowledged that the resident’s representatives were not actually notified until 02/13/2026. The program administrator confirmed that facility policy required notification of the family and/or resident representatives within 24 hours of an incident and acknowledged that notification in this case was late. A hospital note dated 03/02/2026 documented that the resident’s representatives told the hospital physician they were not informed of the 01/21/2026 event until 02/13/2026 and felt unheard and dismissed. This failure to provide timely information to the resident’s representatives constituted noncompliance with WAC 388-97-0260 regarding resident rights to be fully informed of their health status, care, and treatments.
Failure to Timely Report Alleged Abuse/Neglect Related to Droplet Precautions
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of abuse and/or neglect to the State Agency within the required timeframe, as mandated by facility policy and state regulations. The facility’s Abuse and Neglect Prevention and Reporting policy, revised in February 2026, states that all suspected, alleged, or actual cases of abuse or neglect, including injuries of unknown origin, must be thoroughly investigated and reported according to state and federal regulations, with reporting required within 24 hours. Staff B, the DON, and Staff A, the Program Administrator, both acknowledged that an allegation of neglect related to a resident’s physician‑ordered droplet precautions occurred on 02/16/2026 but was not reported to the State Agency until 02/23/2026, outside the required timeframe. Resident 1 had a physician order dated 02/11/2026 for droplet precautions due to runny nose and increased secretions, requiring the resident to remain in their room and only leave for bathing. On 02/16/2026, an incident occurred in which Staff D, the Associate Executive Director for Clinical Operations, instructed Staff C, the Activity Director, and Staff E, an RN, to disregard the physician’s droplet precaution order and the facility’s infection policy by bringing the resident out of their room into the common area and later into a shared playroom. Both Staff C and Staff E informed Staff D that the resident was on droplet precautions, but Staff D insisted the resident be brought out of isolation. Staff E ultimately complied, and the resident, who could understand language, was present during a verbal interaction between Staff D and Staff C. During this interaction, when Staff C objected and offered to don PPE and remain in the resident’s room instead of bringing the resident into the community areas, Staff D responded, “I would rather have sick babies than dead babies.” The facility’s investigation documented that this statement implied harm to the resident and that abuse was not ruled out. The investigation further concluded that, because a physician’s order was known and there was no reason not to follow it, others were placed at risk and the neglect allegation was not ruled out. Staff C later stated in interview that they knew taking the resident, who was not wearing a mask, into the common area was against the physician’s order and did not report the incident because “everybody knew about it.” Staff B and Staff A both confirmed in interviews that the allegation should have been reported to the State Agency in a timely manner as required by the facility’s policy and the Purple Book guidelines, but it was not.
Failure to Timely and Thoroughly Investigate Alleged Abuse/Neglect Related to Droplet Precautions
Penalty
Summary
The deficiency involves the facility’s failure to timely and thoroughly investigate an allegation of abuse and neglect related to a resident on droplet precautions. Facility policy and the Purple Book guidelines require that all alleged incidents of abuse, neglect, mistreatment, injuries of unknown source, or exploitation be thoroughly investigated, with an initial investigation completed within 24 hours and a full investigation within five days of the incident. Despite these requirements, an allegation arising from an incident involving a resident with a physician’s order for droplet precautions was not investigated within the required timeframe. The resident had a physician order dated 02/11/2026 for droplet precautions due to runny nose and increased secretions, specifying that the resident was to remain in their room and could leave only for bathing. On 02/16/2026, the resident was taken out of their room and remained in the facility’s common area and later in a shared playroom. According to the incident investigation report, the Associate Executive Director for Clinical Operations (Staff D) instructed the Activity Director (Staff C) and an RN (Staff E) to disregard the physician’s droplet precaution order and the facility’s infection policy, and to bring the resident out of isolation. Staff C and Staff E each informed Staff D that the resident was on droplet precautions, but Staff D insisted the resident be brought out, and Staff E ultimately complied. The resident, who was reported to understand language and repeat what staff say, was present during a verbal interaction in which Staff D stated, “I would rather have sick babies than dead babies,” and the investigation document noted that abuse and neglect could not be ruled out. Interviews showed that the Director of Nursing (Staff B) and the Program Administrator (Staff A) acknowledged that the allegation of neglecting the physician‑ordered droplet precautions occurred on 02/16/2026, but the investigation was not completed until 02/25/2026. Staff B stated they were in the facility when the incident occurred, that the Program Administrator was on leave, and that the investigation was delayed until the Program Administrator returned, contrary to the policy requiring investigation within 24 hours. Staff A confirmed responsibility for the investigation, acknowledged the delay, and stated they were not able to rule out abuse and neglect. Staff A also stated they did not interview the resident, the resident’s representatives, or other residents or their representatives to assess potential harm or impact, despite knowing that the resident could understand and repeat language. This failure to initiate and complete a timely and thorough investigation, including appropriate interviews, constituted noncompliance with the facility’s abuse and neglect investigation policy and applicable regulations.
Failure to Follow Droplet Precaution Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to implement a comprehensive, person-centered care plan for a resident who was placed on droplet precautions. The facility’s policy required the IDT to develop and implement such a care plan. A physician’s order dated 02/11/2026 directed that the resident be on droplet precautions due to respiratory symptoms, including a runny nose and increased secretions, and specified that the resident was to remain in their room and could leave only for bathing. The resident’s care plan, printed on 03/25/2026, reflected these orders, stating that the resident was recovering from respiratory symptoms, was on droplet precautions, and was to remain in their room except when leaving for bathing. Despite these orders and the care plan, an incident investigation report dated 02/25/2026 documented that on 02/16/2026 the resident was observed outside their room in the facility’s common area and later in a shared playroom. The investigation showed that the physician’s order for droplet precautions and room restriction was not followed. During an interview, the Activity Director stated they observed the resident in the common area and, following instructions, took the resident to the shared playroom and supervised them there, noting that no other residents were present in either area at that time. In a separate interview, the DON stated they expected staff to follow residents’ care plans, including droplet precaution care plans, and confirmed that the resident should not have left their room.
Insufficient Dietary Staffing Resulting in Lack of Freshly Prepared Meals
Penalty
Summary
The facility failed to ensure sufficient dietary support personnel were available to carry out food and nutrition services, as identified through observation, interview, and record review. The facility assessment revised on 01/13/2026 did not plan for the number of cooks needed to meet food and nutrition service requirements. Physician orders showed that one resident was to take meals orally four times daily, and another resident had a restricted diet of 60 calories per day. Both residents received some oral intake in addition to tube feeding, with one resident on a plan to gradually discontinue tube feeding and the other receiving oral food for pleasure feeding. On 03/05/2026, the Nutrition Services Manager reported working alone in the kitchen and being responsible simultaneously for the duties of Dietary Manager, cook, and kitchen housekeeping. This staff member stated they prepared meals in advance for the following day because they only worked every other day, resulting in residents not receiving freshly prepared meals daily and having their meals reheated by an aide when the Nutrition Services Manager was not present. The Program Administrator confirmed that there was only one staff member assigned to the kitchen, acknowledged that this staff member had raised concerns about kitchen staffing shortages and the need for a cook, and stated that higher management had not provided a timely response to requests to hire additional dietary staff.
Incorrect Midazolam Dose Given During Seizure Event
Penalty
Summary
The facility failed to ensure that one resident was free from a significant medication error when Midazolam was administered in an incorrect dose. Resident 4 had diagnoses that included chronic respiratory failure with hypercapnia, seizures, and other lung disorders, and had an order for Midazolam 5 mg/mL intranasal PRN for seizures, with instructions to give 0.28 mL (1.4 mg) and half the dose in each nostril for a seizure lasting longer than four minutes. On 04/17/2025, Resident 4 had seizure-like activity with very high heart rate and respiratory rate, oxygen desaturation, and required rescue medication. The nurse administered intranasal Midazolam, and the clinical note later documented that 2 mL had been given instead of the ordered 0.28 mL. The note stated that the Director of Nursing was notified immediately and 911 was called for transport to the hospital. The resident left the facility still requiring oxygen and with elevated respiratory and heart rates. Hospital records showed the resident was evaluated for seizure/overdose and was diagnosed with benzodiazepine overdose and acute on chronic hypercarbic respiratory failure. The emergency department note stated the resident had received the incorrect seizure rescue dose of Midazolam, and the PICU note described the resident as initially somnolent and critically ill with acute on chronic hypercarbic respiratory failure. Interviews with staff showed the administering RN acknowledged not checking the order at the medication cart, drawing up the medication at the bedside, and giving almost 10 times the ordered amount. Other staff and the DON stated the resident had been hospitalized for the incorrect dose of Midazolam and that the medication rights should have been followed.
Care plans missing for benzodiazepine, diuretic, and antibiotic use
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for 4 of 7 residents reviewed for comprehensive care plans. The deficiency involved residents receiving benzodiazepines, diuretics, and antibiotics, but their care plans did not include those medications or related monitoring needs. The report cited WAC 388-97-1020(1) and identified that the facility's policy on comprehensive assessment and care planning required review of physician orders and medication and treatment records. Resident 7 had orders for midazolam and clonazepam, furosemide and spironolactone, and cephalexin and azithromycin, but the care plan did not show benzodiazepine, diuretic, or antibiotic use. During record review, the NAC stated she did not think those medications should be included and did not know if it was a requirement. The DON stated that benzodiazepine, diuretic, and antibiotic use were expected to be included in the care plan. Resident 1 had diagnoses including epilepsy and a history of UTI and had July 2025 MAR orders for clonazepam, cephalexin, nitrofurantoin, erythromycin ethylsuccinate, tobramycin-dexamethasone, and ciprofloxacin-dexamethasone, but the comprehensive care plan did not show a care plan for benzodiazepine or antibiotic use. Resident 6 had hypoplastic left heart syndrome and an order for spironolactone and hydrochlorothiazide, but the comprehensive care plan did not show a care plan for diuretic use. Resident 4 had diagnoses including seizures, UTI, and disorders of electrolyte and fluid balance, with orders for midazolam, clonazepam, hydrochlorothiazide, furosemide, and nitrofurantoin, but the care plan did not show benzodiazepine, diuretic, or antibiotic use.
Nurse Staffing Information Not Posted at Start of Shift or in Visible Location
Penalty
Summary
The facility failed to ensure the nurse staffing information posting was posted at the beginning of each shift for 3 of 4 days and failed to ensure the posting was in a prominent location readily accessible to residents, representatives, and visitors. Review of the facility policy titled Staff Postings showed that staffing was to be posted daily in a readable format in a prominent location in the facility, and that the DON or designee was to post the required information daily at the beginning of each shift. Observations on 07/30/2025 at 9:28 AM, 07/31/2025 at 8:14 AM, and 08/01/2025 at 7:57 AM showed the nurse staff posting form labeled Staffing Standard was dated the prior day and posted on the wall at the nurse's station behind the counter. During a joint observation and interview on 08/01/2025 at 8:05 AM, CC2 stated they did not know about the nurse staffing information posting and said it was not very visible. Staff Q, Office Administrator, stated they posted the staffing information when they came to work at 8:30 AM and that they did not come in at 5:45 AM to post it at the beginning of the nursing shift. The Administrator stated the staffing information was expected to be posted daily at the beginning of the shift and in a prominent place visible to residents, family, and visitors, but also stated it was always at the nurse's station.
Delayed Physician Response to MRR Recommendation
Penalty
Summary
The facility failed to ensure that Medication Regimen Review (MRR) was completed for one resident reviewed for unnecessary medications. Resident 6 had a May 2025 MRR dated 05/30/2025 and a June 2025 MRR dated 06/27/2025, and both reviews included the same recommendation to check a BMP. The May 2025 MRR showed that the Physician/Prescriber Response was not completed. During interview and record review, Staff E, Nursing Assessment Coordinator, stated that the pharmacist emailed MRR recommendations to Staff A, the Administrator, Staff B, the DON, and Staff N, the Medical Director, and that Staff N was expected to complete and return the responses. Staff E stated that Staff N did not send the completed recommendations for April 2025 and May 2025 until June 2025 and did not respond timely. Staff E also stated that no one had followed up with Staff N in April or May 2025. Staff B stated that the expectation was for the pharmacist to provide the MRR recommendations and for Staff N to provide responses and recommendations, and acknowledged that Resident 6's May 2025 MRR recommendation was completed late.
Medication Refrigerator Temperature Not Maintained
Penalty
Summary
The facility failed to maintain proper temperature for 1 of 1 refrigerator used for medication storage, the Medication Room Refrigerator. The facility policy titled, Storage of Medication, required medications and biologicals to be stored properly according to manufacturer or provider pharmacy recommendations, with refrigerated items kept between 36 and 46 degrees Fahrenheit and temperature logs maintained to verify temperatures remained within accepted limits. Review of the refrigerator temperature logs showed multiple blank entries and multiple temperatures above the required range, including 50 F on several dates and 49 F on one date. During interviews, Staff C, the Nurse Manager, stated the refrigerator temperature should be checked daily and acknowledged that some entries were missing and that 50 F was too high. Staff C also stated there was no documentation showing what was done when the temperature was 50 F. Staff B, the DON, stated staff were expected to check the medication refrigerator temperature daily, that the expected range was 36 F to 46 F, and that missing entries meant they did not have a way to go back and determine the temperature.
EBP, Hand Hygiene, and Glove Use Failures During Resident Care
Penalty
Summary
The facility failed to ensure Enhanced Barrier Precautions were followed for a resident with a tracheostomy and G-tube who was identified in the care plan as requiring EBP. During observation, the resident was in the dining/activity room in a wheelchair with mucous and secretions coming from the tracheostomy and from the left side of the mouth. A LPN suctioned the resident in the common area after performing hand hygiene and applying gloves, but did not wear a gown while providing the suctioning care. The facility policy stated that EBP is used for high-contact resident care activities, including device care or use. The resident’s record showed an intervention to maintain Enhanced Barrier Precautions. In interview, the LPN stated that for residents on EBP they used gown and gloves when providing care such as transfers, personal care, and when accessing devices like a tracheostomy or G-tube, but also stated that in a common space they did not need to wear a gown because of dignity issues. The nurse manager stated that staff were to use PPE, including gown and gloves, anytime they provided direct patient care for residents on EBP and expected a gown to be worn when suctioning the resident in the dining/activity room. The facility also failed to ensure proper hand hygiene and glove use during resident care and garbage disposal. One CNA was observed walking in the hallway wearing gloves while carrying a garbage bag from a resident room toward the dining/activity room and basement stairs. An RN caring for a resident with a tracheostomy and G-tube repeatedly removed gloves and applied new gloves during suctioning, G-tube dressing care, skin care, and transfer activities without performing hand hygiene between tasks. Another RN suctioned a resident and then continued care after changing gloves without hand hygiene. A staff member assisting with another resident’s G-tube, wheelchair belt, headphones, and Hoyer lift transfer also did not change gloves or perform hand hygiene between tasks. Staff interviews confirmed that hand hygiene should have been performed between glove use and between different tasks, and the DON stated staff were expected to perform hand hygiene before and after glove use and between different tasks.
Failure to Thoroughly Investigate Medication Error for Possible Abuse or Neglect
Penalty
Summary
The facility failed to ensure staff followed and implemented its abuse and neglect policies and procedures during the investigation of a medication error involving Resident 4. The facility’s policies stated that allegations of abuse or neglect must be thoroughly investigated, including interviews with the alleged victim, alleged perpetrator, witnesses, and others with knowledge of the event, and that suspected abuse or neglect must be reported to the Administrator, state agency, adult protective services, and other required agencies. The Purple Book guidance also stated that medication errors that may be abuse or neglect must be reported to the Department and law enforcement. Resident 4 had a seizure and was given an overdose of Midazolam when Staff F, a RN, administered 2 ml instead of the ordered 0.28 ml PRN dose. The resident was transferred to the hospital after the overdose. The facility’s investigation document stated that Staff F misread the order and bottle label, and that another staff member later checked the bottle label against the EMR order and found them to match. The investigation also noted that the resident did not show the expected side effects of depressed HR and RR, although the resident’s HR was in the 200s and RR was in the high 80s. The investigation listed four witnesses or employees involved, but it did not include witness statements, did not show what interventions were implemented to prevent recurrence, and did not show whether staff were trained on any changes. The investigation also did not show that the State Agency was notified or that abuse or neglect was ruled out. Staff B stated the investigation was not very thorough and that witness statements should have been included to determine all aspects of what happened. Staff B also stated that, after reviewing the hospital notes showing acute on chronic respiratory failure secondary to the Midazolam overdose, the Medication Error Decision Tree would have led the facility to report and log the incident.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman of a resident discharge, as required by its Transfer and Discharge policy and WAC 388-97-0120 (5)(a). Resident 11 was admitted to the facility and later discharged to the community, with the discharge documented on the Minimum Data Set and the face sheet showing the discharge date. Review of the resident’s electronic health record did not show that the Ombudsman was notified of the discharge. The facility’s policy titled Transfer and Discharge, dated July 2022, stated that prior to a facility-initiated transfer, the resident would be notified in writing by Social Services or designee and that the State Ombudsman Office would be sent a copy of the notice. During interviews, Staff O stated they were not sure whether the Ombudsman was notified and said they had notified the State about residents’ discharges. Staff E stated they did not know of any Ombudsman notification process for discharge or transfer, Staff B stated they did not know if such notifications were sent, and Staff P stated they did not notify the Ombudsman of discharges or transfers and instead notified residents’ insurance and the State.
Medication orders were not entered or documented before administration
Penalty
Summary
The facility failed to ensure medications were documented and physician orders were entered before administration for 2 residents. The facility policy for receiving and documenting physician orders stated telephone or verbal orders were to be entered into the EMR, double checked by an RN or LPN, and then sent to the on-call physician for signature. The medication pass policy stated medications were to be administered under physician orders and documented in the electronic MAR immediately after administration. For one resident, the July 2025 MAR showed an order for cholecalciferol 2.5 ml daily, but during observation an RN drew up 1.2 ml because the bottle was empty and the refill had not been received. An LPN told the RN that a one-time order had been obtained for 1.2 ml, but the RN was not shown a written order and did not check the EMR before administering the dose. The RN later documented in the MAR that 1.2 ml had been given per verbal order due to medication unavailability, and the DON stated the nurse who communicated with the physician was expected to enter the order in the EMR and administer the medication. For another resident, an RN prepared multiple medications and drew up 3.9 ml of sacubitril-valsartan after stating there was not enough for the full ordered dose of 5.6 ml. The RN stated a physician was contacted through a messenger application and gave an order to administer 3.9 ml, but the RN had already signed off on the medications in the MAR before administration. The EMR did not show a physician order for the 3.9 ml dose, and the DON stated the order should have been entered and medications signed off after administration.
Failure to Document COVID-19 Vaccine Education and Status
Penalty
Summary
The facility failed to ensure that the resident's representative was provided information about COVID-19 vaccination, including the risks, benefits, and potential side effects, and failed to document whether the vaccine was accepted or refused in the medical record for one resident reviewed for COVID-19 immunizations. Resident 5 was admitted to the facility, and review of the hospital immunization record did not show that the resident received the COVID-19 vaccine or that it had been declined. Review of Resident 5's EHR did not show documentation that the COVID-19 vaccine was offered or that the representative was educated on the risks and benefits of the vaccine. Staff E, the Nurse Assessment Coordinator, stated there was no documentation showing the representative was offered the vaccine and said there should be documentation in the EHR when a vaccine is declined or not medically appropriate. Staff B, the DON, stated that COVID-19 vaccines were offered to residents per doctor's recommendations.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Shoreline
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Richmond Beach Rehab | 1.9 mi | ★★★★★ | 23 | 0 |
| Fircrest Nursing Facility | 2.3 mi | ★★★★★ | 25 | 0 |
| Avamere Rehabilitation Of Shoreline | 2.6 mi | ★★★★★ | 12 | 0 |
| Edmonds Post Acute | 2.7 mi | ★★★★★ | 60 | 0 |
| Pine Ridge Post Acute | 2.9 mi | ★★★★★ | 18 | 0 |
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