Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brookfield Health And Rehab Of Cascadia during CMS and state inspections, most recent first.
The facility failed to ensure that two residents with interest-bearing personal fund accounts received accrued interest. Record review showed $0.00 interest paid on the residents’ statements during the months reviewed, and the BOM stated both residents should have been accruing interest but did not know why they were not. The CEO stated she expected residents’ accrued interest to be in their accounts.
A resident with dementia and severe cognitive impairment was receiving Quetiapine for behavioral symptoms, but the facility did not complete the required AIMS monitoring at the expected interval. The record showed the AIMS was done on admission and then not again until about 10 months later, despite staff stating it should be completed on admission and every 6 months for residents on antipsychotics.
The facility failed to provide a written bed-hold notice to two residents at the time of hospital transfer. One resident was cognitively intact and said the facility did not discuss holding the bed after transfer for arm surgery, and the EHR had no documentation of a bed-hold notice or contact with the resident or rep. Another resident, who was alert and oriented, was transferred for vomiting, but the EHR also lacked documentation that the bed-hold policy was reviewed before or after transfer.
Inaccurate MDS coding affected three residents. One resident who was severely cognitively impaired had documented refusals of brief changes, clothing changes, showers, and peri-care, but the MDS stated he did not refuse care. Another resident receiving hospice had hospice Medicaid status and an order for hospice, yet hospice services were not identified on the MDS. A third resident was coded as taking an opioid on the quarterly MDS even though PRN tramadol was not administered during the month.
A resident admitted with depression and schizoaffective disorder had multiple significant change MDS assessments, but the EHR did not show a new Level I PASARR was completed with each change. Social Services stated PASARR screenings were completed before admission, but no new screening was done when the resident had a significant change in condition, and the state mental health authority coordinator was not notified.
A facility failed to keep care plans current for two residents. One cognitively intact resident had multiple hospice election, revocation, and discharge events documented, but the care plan was not revised to reflect hospice being stopped, restarted, or later discontinued. Another cognitively intact resident returned after vascular surgery and had sutures in the left antecubital area, but the skin care plan did not include the sutures or related interventions, and an RN and LPN acknowledged the missing update.
A resident with severe cognitive impairment and HTN had an order for amlodipine with hold parameters for SBP and HR. The EMAR showed the med was given multiple times even when the resident’s HR was below 60 bpm, and an LPN and the Resident Care Manager/LPN stated it should have been held.
Missing Orders for Suture Monitoring: A cognitively intact resident returned from the hospital after vascular intervention for dialysis access and was observed with three sutures in the left antecubital area. The EHR documented the sutures, but no physician or treatment orders were found for monitoring the sutures or the skin area, and both the RCM/LPN and CNO/RN stated such orders were expected.
A facility failed to obtain provider orders for a resident’s oxygen and BiPAP use, even though the resident was observed using both therapies and staff confirmed orders were required. The facility also failed to document weekly oxygen tubing changes and concentrator filter cleaning for another resident, despite a physician order and care plan directing those tasks.
A resident with severe cognitive impairment had repeated pharmacy recommendations for an updated AIMS test and Vitamin D lab monitoring that were not reflected in the EHR for months. The pharmacist documented multiple times that the AIMS test was overdue and that the Vitamin D level had not been drawn as requested, while an RN and an LPN later reviewed the record and could not find documentation supporting the missed lab work.
Incomplete hospice and PASARR documentation in a resident record. A resident with depression and schizoaffective disorder had hospice status changes and discharge information that were not reflected in the EHR, including missing physician orders and nursing notes that continued to show hospice after discharge. The record also lacked the completed Level II PASARR evaluation after a Level I screen triggered it.
Failure to Offer and Document COVID-19 Vaccination: A resident who was severely cognitively impaired and not up to date on COVID-19 vaccination had no EHR documentation showing education, vaccine offer, refusal, or medical contraindication. The facility policy required education and offering COVID immunization to all residents unless medically contraindicated, and the IP/RN acknowledged the vaccine was missed upon admission.
A resident who was dependent for eating and moderately cognitively impaired was observed receiving meal assistance from a NA who stood next to the resident while feeding her and repeatedly left to assist other residents during the same meal. The NA said there were no stools and she had not been told to sit when feeding residents, while the RCM/LPN and CNO/RN stated staff should be seated next to residents during meal assistance to respect dignity.
The facility failed to maintain a current CLIA Waiver for low-risk lab testing such as blood glucose and COVID-19 tests. Record review showed the waiver had expired and had been lapsed for 11 months. During observation, the CEO acknowledged the posted waiver was expired, and later confirmed the renewal had not been completed.
A resident with liver and kidney disease ingested another resident's 10mg Zyprexa after a nurse left the medication unattended on the cart. The resident became unresponsive, required ICU care, and was placed on a ventilator. Staff interviews confirmed that medications were supposed to be secured and not left unattended, but this protocol was not followed in this incident.
A resident with significant medical conditions ingested a 10 mg dose of Zyprexa that was not prescribed, became unresponsive, and required hospitalization with ventilator support. The facility did not report this medication error to the State Survey Agency as required, and key staff were either advised not to report or were unaware of the incident.
Three residents with moderate cognitive impairment or mobility issues were found with bed rails or beds placed against the wall without required assessments, physician orders, or informed consent. Staff confirmed that these steps were not completed, despite facility policy requiring them for the use of restraints and bedrails.
Three medication carts were found unlocked and unattended in two hallways, with drawers accessible and no staff present. Nursing staff confirmed that carts are required to be locked when not in use, but failed to do so during the survey.
A resident who was alert and oriented was admitted without a privacy curtain in her room, and multiple observations confirmed the curtain was missing. The resident expressed ongoing concerns about her privacy, especially when using a bed pan, and reported that her requests for a curtain had not been addressed. Staff were unaware of the missing curtain and acknowledged that one should have been installed.
A resident who was alert and oriented did not have a privacy curtain installed in her room since admission, despite requesting one. She was unable to close the door herself during personal care, and staff were unaware of the missing curtain until notified during the survey.
A resident with severe cognitive impairment experienced a fall despite fall risk precautions being in place. The facility's incident investigation lacked a root cause analysis and did not determine if further interventions were needed. The CNO acknowledged that the investigation should have addressed the root cause and ruled out abuse or neglect, but this was not done.
A resident with moderate cognitive impairment had a care plan stating the bed should be against the wall with a full side rail, but repeated observations showed the bed was not against the wall and only a quarter rail was present. The care plan was not updated to reflect these changes, and staff confirmed the care plan did not match the resident's current needs.
The facility did not consistently follow physician orders for two residents: one resident was not weighed weekly as ordered, with missed and incorrect documentation, and another resident's IV bags and tubing were not labeled with the required date, time, and nurse initials during antibiotic administration, as confirmed by staff and observations.
A resident's bed was found positioned against a wall with a baseboard heater, with linens touching the heater and a plastic tub nearby, despite clear markings and signage requiring a 12-inch clearance due to fire risk. Staff interviews revealed a lack of awareness and adherence to safety protocols, and the bed's placement blocked access to the heater's controls.
A resident with COPD and acute respiratory failure was observed receiving supplemental oxygen at various flow rates, but the facility failed to document oxygen use, SPO2 measurements without oxygen, and timely tubing changes in the EHR. Staff interviews confirmed that required documentation and weekly tubing changes were not completed according to physician orders and facility protocol.
Staff did not properly don PPE when entering the room of a resident on contact precautions for conjunctivitis. Despite clear signage and physician orders, two staff members entered the room and assisted the resident without gloves or gowns, believing PPE was only needed for personal care. This misunderstanding was shared by another LPN, while the Chief Nursing Officer stated that PPE should be worn at the door for all entries.
A resident who was alert and oriented did not receive a pneumococcal vaccine despite having provided consent and having a physician's order in place. The vaccine was not documented as administered, and staff confirmed it was missed because it was not entered on the MAR as required.
The facility failed to ensure residents were free from significant medication errors, as multiple residents did not receive medications and treatments as ordered, including missed doses, late administration, and incomplete wound care, pain monitoring, and behavioral assessments. Staff confirmed that blank spaces on the MAR and TAR indicated missed or incomplete tasks.
A resident with multiple health conditions required two-person assistance for bed mobility, as per their care plan. However, only one staff member assisted, leading to the resident falling and fracturing their femur. The incident required medical intervention, and the staff member involved was no longer employed at the facility.
A resident with multiple health conditions fell from their bed and was taken to the ER. The family was not notified until over five hours later, contrary to the facility's policy. The delay was due to an LPN's failure to inform the necessary parties promptly.
The facility failed to provide timely and complete SNF ABN and NOMNC notifications to three residents, risking inadequate information for financial decisions. Notices were either issued on the last covered day, incomplete, or missing, with staff acknowledging errors and confusion in documentation processes.
A resident with severe cognitive impairment was repeatedly observed with unkempt facial hair and a dirty beard, despite being assisted with showers. Staff acknowledged the resident was supposed to be shaved on shower days and did not often refuse care, indicating a failure in providing necessary grooming assistance.
The facility failed to ensure accurate documentation and communication of residents' code status, leading to discrepancies between POLST forms and physician orders. For several residents, the POLST indicated a DNR status, but room stickers suggested a Full Code status, causing confusion among staff about the appropriate response in emergencies.
The facility failed to follow physician orders for labeling IV and TF bags and tubing for a resident, and did not implement the bowel protocol for two residents experiencing constipation. Staff acknowledged the oversight in labeling and the lapse in following the prescribed bowel management orders.
Failure to Credit Accrued Interest to Resident Trust Accounts
Penalty
Summary
The facility failed to ensure that residents with personal fund accounts received accrued interest in those accounts for two of three sampled residents reviewed for trust fund interest accrual. Record review showed that one resident’s Resident Fund Management Service statement listed monthly interest paid as $0.00 from January through June 2026, with balances changing over time, and another resident’s statement also showed $0.00 interest paid for the months reviewed while the account balance increased and remained unchanged in later months. The report identified both residents as having money in interest-bearing accounts. During interview, the Business Office Manager reviewed the statements and stated that both residents should have been accruing interest in their accounts. She said she did not know why the accounts were not receiving interest and was unsure whether the issue was on the facility’s end or the RFMS end. The CEO also stated that she expected residents’ accrued interest to be in their accounts. The deficiency was cited under WAC 388-97-0340(3)(a).
Failure to Complete Required AIMS Monitoring for Resident on Antipsychotic
Penalty
Summary
The facility failed to complete an AIMS (Abnormal Involuntary Movement Scale) test for 1 of 5 sampled residents reviewed for unnecessary medications. Resident 51 was admitted with multiple diagnoses including dementia with other behavioral disturbances and was documented on the Quarterly MDS as severely cognitively impaired. The resident had a physician’s order for Quetiapine Fumarate 12.5 mg by mouth at bedtime and had been receiving this antipsychotic medication since 06/12/2025. Record review showed the resident’s AIMS test was first completed on admission and then not completed again until 04/01/2026, about 10 months later. During interview, the Chief Nurse Officer/Registered Nurse reviewed the record and stated AIMS tests were supposed to be completed on admission and every six months for residents on antipsychotics. The facility policy on psychotropic medications also documented quarterly review of each resident’s psychotropic regimen, including evaluation of therapeutic benefit and adverse effects.
Failure to Provide Written Bed-Hold Notice at Hospital Transfer
Penalty
Summary
The facility failed to provide a written bed-hold notice to residents and/or their representatives at the time of transfer to the hospital for 2 of 2 sampled residents reviewed for hospitalization. The facility policy stated that written bed-hold information is to be provided to the resident prior to and upon transfer for hospitalization or therapeutic leave, and that the second notice is to be given at the time of transfer or within 24 hours in an emergency transfer. The policy also stated that multiple attempts to reach the resident's representative should be documented if the representative could not be notified. Resident 39 was cognitively intact and told surveyors that after going to the hospital for surgery on the left arm, the facility did not talk to him about holding his bed. The EHR showed the resident was transferred to the hospital, but there was no documentation of a written bed-hold notice or contact with the resident or representative about bed-hold information. Resident 3 was alert and oriented and was transferred to an acute hospital after vomiting with no relief from PRN ondansetron. The EHR for Resident 3 did not contain documentation that the bed-hold policy was reviewed with the resident prior to or after transfer, and Staff B could not find a bed-hold for the resident.
Inaccurate MDS Coding for Care Refusal, Hospice Status, and Opioid Use
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was completed accurately for Resident 46, who was admitted to the facility and was documented on the quarterly MDS as severely cognitively impaired. Behavior progress notes showed the resident refused a brief and clothing change, was verbally abusive when asked to change his shirt after wearing it for a week, and refused showers, clothing changes, and peri-care. Another behavior note documented refusal of a shower and peri-area assessment. However, the MDS dated 03/04/2026 documented that Resident 46 did not refuse care. During interview, Staff G, Social Services, stated behavior MDS assessments were coded by reviewing behavior monitoring documentation, nurses’ progress notes, and CNA documentation for key words such as refusal of care, and said Resident 46 was coded incorrectly for rejection of care. The facility also failed to identify hospice services on the MDS for Resident 14, who was admitted to the facility and was moderately cognitively impaired on the quarterly MDS. The significant change MDS showed the payer status as hospice Medicaid, and the physician’s order dated 11/30/2025 stated the resident was admitted for hospice. Staff E, the MDS nurse/RN, stated the significant change MDS was completed when the resident was admitted to hospice and acknowledged hospice services should have been identified on the MDSs. In addition, the facility coded Resident 52 as taking an opioid on the quarterly MDS even though the resident’s order for tramadol was PRN and the March 2026 eMAR showed the medication was not taken during that month. Staff E stated the MDS would need to be corrected, while Staff B stated she expected the MDS to be coded correctly to reflect the medications a resident was taking.
Failure to Notify State Mental Health Authority of Significant Change
Penalty
Summary
The facility failed to notify the state mental health authority coordinator of a significant change in physical condition for one resident reviewed for the PASARR process. The resident was admitted with diagnoses including depression and schizoaffective disorder, and a Significant Change MDS dated 04/13/2026 documented that the resident was cognitively intact. The facility policy for the PASARR process stated that when a resident who triggers a Level II PASARR has a significant change in physical or mental condition, the facility is required to notify the appropriate state mental health authority or state intellectual disability authority. Record review showed the resident had Significant Change MDS assessments on 11/17/2025, 02/17/2026, 03/05/2026, and 05/29/2026, but the electronic health record did not show that a new Level I PASARR was completed with each significant change MDS. In interview, the Social Services staff member stated that Level I PASARR screenings were completed prior to admission, and when asked whether a new PASARR screening was completed when the resident had a significant change in condition, stated that it was not completed.
Care plans not updated for hospice status changes and sutures
Penalty
Summary
The facility failed to ensure care plans were revised to accurately reflect resident care needs for 2 sampled residents. One resident was cognitively intact and had multiple hospice status changes documented in the record, including a hospice election statement showing hospice was to begin, a later hospice revocation, another hospice election statement indicating hospice was to begin again, and a hospice discharge from Peace Health Hospice. Although the resident’s care plan had been updated once after the initial hospice election, the care plan did not show revisions when hospice was discontinued, restarted, or later discontinued again. The Chief Nurse Officer/RN acknowledged that the care plan was not updated to reflect the resident’s hospice status changes. The second resident was cognitively intact and had recently returned to the facility after a hospital stay and vascular intervention for dialysis access. The resident reported having surgery on the left arm and was observed with three sutures in the left antecubital area. The EHR documented a suture to the left antecubital fossa, but the resident’s care plan for potential/actual alteration in skin/tissue, last revised earlier, did not include a focus, goal, or interventions related to the sutures or the skin condition at the left antecubital area. The Resident Care Manager/LPN stated that a resident with an incision or sutures should have a care plan for the skin area and said there should have been one for the sutures; the Chief Nurse Officer also stated the skin care plan was expected to be updated for new skin issues such as sutures.
Physician Order for Amlodipine Not Followed
Penalty
Summary
The facility failed to follow a physician’s order for Resident 51, who was admitted to the facility and had a Quarterly Minimum Data Set dated 03/12/2026 documenting severe cognitive impairment and a diagnosis of hypertension. The physician’s order, dated 11/20/2025, directed amlodipine besylate 5 mg orally for hypertension with parameters to hold the medication if systolic blood pressure was below 100 or heart rate was below 60 bpm. Record review showed Resident 51’s heart rate was below 60 bpm on multiple dates in February, March, April, and May 2026, including 57, 54, 59, 55, 55, 56, 58, 58, and 55 bpm. Despite those values, the February through May 2026 EMAR documented that amlodipine besylate 5 mg was administered on each of those dates. During interviews, an LPN stated the medication was expected to be held if systolic blood pressure or heart rate was below the ordered parameters, and the Resident Care Manager/LPN reviewed the record and stated licensed nurses should have held amlodipine besylate when Resident 51’s heart rate was below 60 bpm.
Missing Orders for Suture Monitoring
Penalty
Summary
The facility failed to obtain physician and/or treatment orders for skin and/or wound care for Resident 39, who was cognitively intact and had been readmitted after a hospital stay for vascular intervention for dialysis access (fistula/catheter revision). The resident’s EHR admission note documented the readmission status post vascular intervention, and a health status note documented a suture to the left antecubital fossa. However, the record did not show physician and/or treatment orders for monitoring the sutures or the skin condition to the left antecubital area. During interview and observation, Resident 39 was seen lying in bed with three sutures in the antecubital area of the left arm and stated he thought they should be coming out soon. Staff H, the Resident Care Manager/LPN, stated that if a resident had a skin issue such as an incision or sutures, there would be physician orders for wound care and/or monitoring the skin area, and acknowledged that no orders were seen for monitoring the sutures. Staff B, the CNO/RN, also stated she expected physician and treatment orders were in place to monitor the sutures.
Missing oxygen and BiPAP orders; oxygen tubing not changed as ordered
Penalty
Summary
The facility failed to obtain physician orders for oxygen and BiPAP use for Resident 39. Resident 39 was cognitively intact, was on oxygen therapy, and used a non-invasive mechanical ventilator. During observation, a BiPAP machine was seen on the resident’s nightstand and an oxygen concentrator was in the room, and the resident stated he used the BiPAP at night and sometimes used oxygen. On another observation, the resident was lying in bed with oxygen running at 1.5 lpm by nasal cannula and said he used the BiPAP the previous night. Review of the electronic health record showed no physician order related to oxygen or BiPAP use, and staff stated orders were required for both therapies. The Resident Care Manager reviewed the record and said the orders did not get put back in after the resident returned from the hospital. The facility also failed to change oxygen tubing as ordered for Resident 60. Resident 60 was moderately cognitively impaired and was on oxygen therapy. The resident was observed in bed with oxygen turned on and reported using oxygen regularly but could not recall when the tubing was last replaced or the concentrator serviced. The physician order directed staff to change oxygen/nebulizer tubing and clean the concentrator filter every week, and the care plan also directed weekly tubing changes and filter cleaning. Review of the electronic health record from April 2026 through June 2026 showed no documentation that the oxygen tubing was exchanged or the concentrator filter was cleaned as ordered. Staff stated these tasks were supposed to be documented on the MAR, but documentation could not be found.
Pharmacy Recommendations Not Addressed for AIMS Testing and Vitamin D Labs
Penalty
Summary
The facility failed to ensure monthly pharmacy review recommendations were addressed for Resident 51, who was admitted to the facility and was documented on the Quarterly Minimum Data Set dated 03/12/2026 as severely cognitively impaired. Pharmacy review records from December 2025 through April 2026 repeatedly identified that an updated AIMS test was needed because the last documented test had been completed on 06/13/2025, but the resident’s EHR did not show an updated AIMS test during the December 2025, February 2026, or March 2026 pharmacy reviews. The March 2026 pharmacy note stated this was a repeat recommendation since December and that the pharmacist could not locate a current AIMS test in the EHR. Pharmacy review records also requested a Vitamin D blood level for Resident 51 in February 2026, but the EHR did not show results at that time or in March 2026. The March 2026 pharmacy note stated that the provider had signed to draw the lab on 2/10/2026, but no labs were noted as drawn and clarification was requested. A later pharmacy review in April 2026 again requested Vitamin D blood levels, and the EHR showed the level was drawn on 04/21/2026, about 2 months after the initial request. During the 06/04/2026 interview and record review, Staff B stated AIMS tests were supposed to be completed on admission and every six months for residents on antipsychotics, reviewed the resident’s EHR and pharmacy recommendations, and Staff H said they were unable to find documentation that the resident refused the blood draw.
Incomplete hospice and PASARR documentation in resident record
Penalty
Summary
Resident 7, who was admitted with diagnoses including depression and schizoaffective disorder and was documented as cognitively intact on the significant change MDS dated 04/13/2026, had inaccurate and outdated hospice documentation in the medical record. The record showed a hospice benefit revocation dated 02/11/2026, but the EHR did not contain an updated physician order discontinuing hospice services. The record also contained a hospice election statement dated 02/26/2026 indicating hospice was to begin, yet there was no updated physician order showing hospice services were restarted. In addition, the hospice care plan was initiated on 11/12/2025 and later documented as resolved on 04/17/2026, but the EHR still did not show documentation or a physician order discontinuing hospice services. Further review showed Peace Health Hospice documentation that Resident 7 was discharged from hospice on 04/25/2026, but the EHR still lacked a physician order to discontinue hospice. Nursing progress notes from 04/25/2026 through 05/23/2026 continued to document that Resident 7 was on hospice when he was not. A health status note dated 05/23/2026 documented that staff called PH hospice to confirm the resident’s hospice status and learned the resident had been off hospice since 4/25/26. The record also showed a Level I PASARR dated 10/08/2025 identifying serious mental illness and triggering a Level II PASARR evaluation, but the EHR did not contain the completed Level II PASARR evaluation; the CEO later provided a copy of the Level II evaluation/determination dated 03/05/2026 and stated it had not been placed in the EHR.
Failure to Offer and Document COVID-19 Vaccination
Penalty
Summary
The facility failed to offer the COVID-19 vaccine and failed to provide documentation of education regarding the vaccine’s risks, benefits, and potential side effects for Resident 52. Record review showed the resident was admitted to the facility and, on the Quarterly Minimum Data Set dated 03/18/2026, was documented as severely cognitively impaired and not up to date on COVID-19 vaccination. The resident’s EHR did not contain documentation that education was provided or that the COVID-19 vaccine was offered, declined, or found to be medically contraindicated. The facility policy titled, COVID Vaccination for Residents, revised 09/25/2025, stated the facility would continue to provide education about COVID-19 vaccines and offer vaccination to all residents within the facility, and that each resident should be offered COVID immunization unless medically contraindicated. During interview, the Infection Preventionist/RN stated vaccinations, including COVID-19, are addressed upon admission and acknowledged that Resident 52’s COVID-19 vaccination was missed and should have been offered upon admission. The CNO/RN also stated she expected the COVID-19 vaccination was offered upon admission.
Dining Assistance Did Not Preserve Resident Dignity
Penalty
Summary
The facility failed to provide eating assistance in a manner that promoted resident respect and dignity for one resident who was dependent for eating and moderately cognitively impaired. The resident’s quarterly MDS dated 03/11/2026 indicated dependence with eating, and the care plan dated 04/06/2026 documented that the resident required 1 staff member for eating and 1:1 assistance with meals. During observation on 06/02/2026, a NA assisted the resident with eating while standing next to the resident on the resident’s left side. The NA repeatedly moved away from the resident to assist other residents at the same meal, including handing pizza to an unidentified male resident, placing another resident’s plate, cup, and utensils on a tray, and bringing pudding to the resident. The NA stated there were no stools to sit on and that she had not been told staff should sit when feeding residents. The RCM/LPN and CNO/RN stated staff assisting residents with meals should be seated next to the resident to respect dignity.
Expired CLIA Waiver License
Penalty
Summary
The facility failed to maintain a current Clinical Laboratory Improvement Amendments (CLIA) Waiver, also referred to as a Medical Test Site Certificate of Waiver License, for performing simple, low-risk tests such as blood glucose checks and COVID-19 tests. Record review showed the facility’s CLIA Waiver had an expiration date of [DATE] and had been in a lapsed status for 11 months. During an observation and interview on [DATE] at 2:25 PM, Staff A, the Chief Executive Officer, pointed to the CLIA Waiver posted on the wall and stated that it was expired and that she would look for the current license and provide it to the survey team. In an email interview on [DATE] at 12:07 PM, Staff A stated that she confirmed with the Business Office Manager that the renewal for the CLIA Waiver had not been completed.
Resident Harm from Unattended Medication Error
Penalty
Summary
A significant medication error occurred when a resident with liver cirrhosis and stage 3 kidney disease ingested a 10mg Zyprexa pill that was not prescribed to them. The medication, intended for another resident, was left unattended in a cup on top of the medication cart by a licensed nurse who had stepped away. The resident took the medication while at the cart for their own bedtime medications. Shortly after, the resident became unresponsive, began mumbling incoherently, and was transferred to the emergency room, where they required intensive care and mechanical ventilation for several days. Interviews with staff revealed that standard procedures required medications to be kept locked in the cart and not left unattended, and resident identification was to be verified before administration. However, in this incident, the medication was left accessible, and the nurse provided inconsistent accounts of the event. The facility's medication error report identified the root cause as the medication cup being left on the cart. The incident was not immediately communicated to the facility's CEO, and the resident's family was notified only after the resident was found unresponsive.
Failure to Report Serious Medication Error Resulting in Hospitalization
Penalty
Summary
The facility failed to report a significant medication error to the State Survey Agency as required. A resident with liver cirrhosis and stage 3 kidney disease, who was unable to participate in their assessment, ingested a 10 mg tablet of Zyprexa that was not prescribed to them while receiving medications at the medication cart. The resident subsequently became unresponsive and began to mumble incoherently, prompting the nurse to notify the physician, who ordered a transfer to the emergency room. The resident was hospitalized and required ventilator support in the intensive care unit for three days. The facility's incident log confirmed the event and documented that the state hotline was not notified. During interviews, the Interim DNS stated that regional staff advised the incident did not require reporting, so it was not reported. A newly appointed Interim DNS later stated that the medication error should have been reported, and the CEO was unaware of the incident. The failure to report the serious medication error delayed appropriate oversight and investigation.
Failure to Assess and Document Use of Bed Rails and Bed Placement as Restraints
Penalty
Summary
The facility failed to ensure that bed placement and the use of bed side rails were properly assessed, physician ordered, and accompanied by informed consent for three residents who were reviewed for physical restraints. Specifically, for one resident with moderate cognitive impairment, a quarter rail was observed on the bed during multiple observations, but there was no evaluation assessment, consent, or physician's order documented in the electronic health record. For another resident with hemiplegia and hemiparesis following a stroke, the bed was consistently observed with one side against the wall, yet there was no related assessment, consent, or physician's order. A third resident, also moderately cognitively impaired, was found with the bed against the wall and was unaware of the reason; again, no evaluation, consent, or physician's order was found in the record. Staff interviews confirmed that the expected process was not followed, as both the Resident Care Manager (LPN) and the Chief Nursing Officer (RN) acknowledged that evaluation assessments, consents, physician orders, and care plans should have been in place for the use of bed rails or beds placed against the wall. The facility's own policy requires these steps for the use of restraints and bedrails, including assessment, care planning, physician order, and informed consent, none of which were documented for the affected residents.
Medication Carts Left Unlocked and Unattended
Penalty
Summary
Surveyors observed that three out of four medication carts on the 200 Hall and 300 Hall were left unlocked and unattended, allowing drawers to be opened without staff supervision. At the time of observation, no staff were present in the hallway, and the carts contained medications, including controlled substances. Staff members, including a Registered Nurse and an LPN, acknowledged that medication carts are supposed to be locked when unattended, confirming that the carts should not have been left unsecured. These findings were based on direct observation and staff interviews during the survey.
Failure to Provide Privacy Curtain for Resident
Penalty
Summary
A resident who was alert and oriented was admitted to the facility and, upon admission, did not have a privacy curtain installed in her room. Observations on multiple occasions confirmed the absence of a privacy curtain. The resident reported that she had been without a privacy curtain since admission and was unable to close the door herself when using a bed pan, resulting in concerns about her privacy for over two weeks. She stated that she had requested the installation of a privacy curtain, but it had not been addressed. Staff interviews revealed that both the Maintenance Manager and the Chief Nursing Officer were unaware of the missing privacy curtain and confirmed that a privacy curtain should have been installed for every resident prior to admission.
Failure to Provide Privacy Curtain for Resident
Penalty
Summary
The facility failed to maintain personal privacy for a resident by not having a privacy curtain installed in the resident's room. The resident, who was alert and oriented, reported that there had not been a privacy curtain since admission and that she was unable to close the door herself when using a bed pan, despite having requested the curtain be installed. Observations on multiple occasions confirmed the absence of a privacy curtain in the room. Both the Maintenance Manager and the Chief Nursing Officer were unaware of the missing curtain prior to being informed during the survey.
Failure to Conduct Thorough Post-Fall Investigation
Penalty
Summary
The facility failed to conduct a thorough investigation following an incident involving a resident who was found fallen in their room, face down and with their head positioned between the bedside table and bed. The resident was identified as being severely cognitively impaired, and fall risk precautions such as a low bed and floor mat were in place, with the call light within reach at the time of the incident. Documentation of the incident investigation did not include a root cause analysis or indicate whether additional interventions were necessary. The Chief Nursing Officer confirmed that the investigation should have addressed the root cause of the fall and ruled out abuse or neglect, but this was not completed as required.
Failure to Update Care Plan to Reflect Current Bed Placement and Side Rail Use
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised to accurately reflect current care needs. The resident, who was moderately cognitively impaired, had a care plan indicating the bed should be placed against the wall for increased living space and that a full side rail should be used for ease of mobility and transfers. However, multiple observations over several days showed that the resident's bed was not against the wall and only a quarter rail was present on the middle right side of the bed. The care plan did not document the use of a quarter rail, nor did it reflect the actual bed placement. Staff interviews confirmed that the care plan was outdated and did not match the resident's current environment or equipment in use. The Resident Care Manager and LPN acknowledged that the care plan was not updated to reflect the use of a quarter rail or the change in bed placement, and the Chief Nursing Officer stated that it was her expectation that care plans should be updated to reflect current care needs. This discrepancy was identified through observation, interview, and record review.
Failure to Follow Physician Orders for Weights and IV Labeling
Penalty
Summary
The facility failed to follow physician orders and care plans for two residents regarding weight monitoring and intravenous (IV) medication administration. For one resident with severe cognitive impairment, the care plan required weekly weights every Wednesday as ordered by the physician. However, electronic health records showed inconsistent documentation, including missed weights, incorrect entries, and a lack of follow-up when weights were recorded as incorrect. Staff interviews confirmed that weights were typically done monthly unless otherwise directed, and that incorrect weights should have been rechecked by the next day, which was not consistently done. For another resident with moderate cognitive impairment receiving IV antibiotics via a PICC line, physician orders and the care plan required that IV bags and tubing be labeled with the date, time, and nurse's initials, and that administration sets be changed every 24 hours. Observations on multiple occasions found empty IV bags and tubing hanging without the required labeling. Staff confirmed that labeling was expected per orders, but the required information was not present on the used IV sets and bags.
Bed and Linens Placed Against Baseboard Heater Creates Fire Hazard
Penalty
Summary
A deficiency was identified when a resident's bed was observed positioned against a wall with a baseboard heater, with bed linens hanging down and touching the heater. A plastic tub was also found under the bed near the heater. The area around the heater was marked with red tape indicating a 12-inch clearance zone, and a warning sign was posted stating that no items should be within 12 inches of the baseboard heater due to fire risk. The heater was off at the time of observation. The resident, who was moderately cognitively impaired, stated that the bed was not supposed to be against the wall and acknowledged the fire hazard, but noted the heater had not been on while the bed was in that position. Staff interviews revealed a lack of awareness and adherence to safety protocols regarding the required clearance around baseboard heaters. A housekeeper indicated that the bed blocked access to the heater's temperature control, and a LPN confirmed that regulations required beds to be a certain distance from heaters. Upon inspection, the LPN moved the bed away from the heater, acknowledging it should not have been placed there. The Chief Nursing Officer also confirmed that nothing should be within a 12-inch radius of the heater and that the bed placement was inappropriate.
Failure to Document and Manage Supplemental Oxygen Therapy
Penalty
Summary
The facility failed to ensure accurate documentation and proper management of supplemental oxygen therapy for a resident with chronic obstructive pulmonary disease and acute respiratory failure with hypoxia. Observations revealed that the resident was receiving oxygen via nasal cannula at varying flow rates, but the oxygen tubing was undated on multiple occasions, both in the resident's room and on a portable tank attached to the resident's wheelchair. Additionally, there was no documentation in the electronic medication or treatment administration records of the resident's supplemental oxygen use on the observed dates. The resident's electronic health record also lacked documentation of oxygen saturation (SPO2) measurements without oxygen and did not indicate that the oxygen tubing had been changed as required. Interviews with facility staff confirmed that the physician's order required supplemental oxygen to be administered if the resident's SPO2 was below 90, and that oxygen tubing should be changed weekly with corresponding documentation. Staff were unable to locate documentation of the resident's oxygen use, SPO2 assessments without oxygen, or evidence that the tubing had been changed according to protocol. The Chief Nursing Officer acknowledged that documentation of SPO2 assessment and effectiveness of oxygen therapy was not completed, and that the standard for changing oxygen tubing was not met.
Failure to Don PPE for Resident on Contact Precautions
Penalty
Summary
Staff failed to properly don personal protective equipment (PPE) when entering the room of a resident who was on contact precautions for conjunctivitis. The resident, who was severely cognitively impaired, had physician orders for contact isolation and was being treated with Ofloxacin Ophthalmic Solution for a bacterial eye infection. A sign was posted on the resident's door instructing staff to gown and glove at the door before entry. Despite these instructions, two staff members, a CNA and a Staffing Coordinator/CNA, entered the resident's room and assisted the resident in bed without wearing gloves or gowns. Upon interview, both staff members indicated they believed PPE was only required when performing personal care or handling urine, not for all room entry. Another staff member, an LPN, echoed this misunderstanding, stating PPE was only necessary when treating the specific problem. However, the Chief Nursing Officer clarified that staff were expected to don gloves and gowns at the door prior to entering the room for any resident on contact precautions. This discrepancy in understanding and practice led to the failure to implement proper infection prevention and control measures.
Failure to Administer Pneumococcal Vaccine After Consent and Order
Penalty
Summary
The facility failed to ensure that a pneumococcal vaccine was administered to one of five sampled residents reviewed for immunizations. The resident was admitted to the facility and was found to be alert and oriented, with documentation indicating that the pneumococcal vaccination was not up to date. The resident signed an acknowledgement form indicating receipt of the vaccine information sheet and consented to receive any needed vaccines. A physician's order was present, authorizing the administration of the pneumococcal vaccine if indicated. The electronic health record showed the vaccine status as pending, with consent confirmed by the infection preventionist. Despite the presence of consent and a physician's order, there was no documentation in the resident's record that the pneumococcal vaccine was administered. The infection preventionist confirmed that the vaccine had not been given and that it was not entered on the Medication Administration Record as required. The Chief Nursing Officer stated that the expectation was for vaccinations to be administered after obtaining orders and consents, but this process was not followed in this instance.
Failure to Ensure Residents Are Free from Significant Medication Errors
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the administration of medications at incorrect times and the omission of prescribed medications and treatments for all five sampled residents. For example, one resident with multiple sclerosis, sepsis, and osteomyelitis did not receive several medications, such as Tramadol, Vancomycin, and Ciprofloxacin, at the times ordered by the provider. Additionally, this resident missed multiple wound care treatments, skin inspections, hygiene care, weight monitoring, and other essential interventions as documented in the Medication Administration Record (MAR) and Treatment Administration Record (TAR). Another resident with an intracranial injury and paraplegia experienced omissions in the administration of catheter care, wound care, and education regarding anticoagulant therapy. Similarly, a resident with Parkinson's disease and a catatonic disorder did not receive several prescribed treatments, including hand splint application, edema monitoring, pain assessments, and specialty mattress checks. These omissions were consistently documented as blank spaces on the MAR and TAR, indicating that the tasks were incomplete or not performed. Further review revealed that residents with complex medical needs, such as those with multiple sclerosis, respiratory failure, hemiplegia, sepsis, and cellulitis, also experienced missed medication doses and treatments. These included failures to administer pain medications, perform wound care, monitor vital signs, and provide behavioral and psychotropic medication monitoring. Staff interviews confirmed that blank spaces on the MAR and TAR signified missed tasks or medications, and that the facility's policy allowed for a specific window of time for medication administration, which was not adhered to in these cases.
Failure to Provide Adequate Bed Mobility Assistance
Penalty
Summary
The facility failed to ensure that residents were free from avoidable accidents during bed mobility assistance, resulting in harm to a resident. The resident, who had a history of asthma, diabetes mellitus type 2, hypertension, and chronic heart failure, required maximum assistance for bed mobility as per their care plan. The care plan specifically indicated the need for two-person assistance for repositioning. However, on the night of the incident, only one staff member provided assistance, leading to the resident falling from the bed and sustaining a fractured femur. The incident occurred during personal care at approximately 2:00 AM, and the resulting injury required medical intervention. A hospital orthopedic surgery consult confirmed the femur fracture and discussed the limited options for treatment, focusing on comfort care due to the significant risks associated with surgery. The staff member involved in the incident was no longer employed at the facility following the failure to adhere to the care plan, which resulted in the resident's injury.
Failure to Notify Resident's Family of Significant Change
Penalty
Summary
The facility failed to ensure timely notification of a resident's representative following a significant change in the resident's condition. Specifically, a resident with a history of asthma, diabetes mellitus type 2, hypertension, and chronic heart failure was involved in an incident where they fell from their bed and were subsequently transported to the emergency room. Despite the facility's policy requiring immediate notification of a resident's representative in such cases, the family was not informed until over five hours after the incident occurred. The incident took place at approximately 2:30 AM, and the family was not notified until 7:45 AM. The delay in communication was attributed to Staff C, an LPN, who was responsible for the resident's care at the time of the incident. The Director of Nursing Services confirmed that neither the administrator nor the family was informed in a timely manner, which was a breach of the facility's policy on resident change of condition.
Failure to Provide Timely Medicare Coverage Notices
Penalty
Summary
The facility failed to provide timely and complete notifications regarding Medicare coverage and potential liability for services not covered, specifically the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) and the Notice of Medicare Non-Coverage (NOMNC). For three residents, the facility did not issue these notices at least two calendar days before the end of Medicare services, as required. Resident 33 received both the SNF ABN and NOMNC on the last covered day of services, and the SNF ABN was incomplete, lacking details on what Medicare may not pay for, the reason, estimated cost, and the resident's chosen option. Similarly, Resident 49's SNF ABN was undated and incomplete, and the NOMNC lacked a documented date. Resident 214 was not provided with a NOMNC at all. Staff G, the Social Service Director, acknowledged the errors, stating that the notices were not properly filled out or dated, and there was confusion about whether to keep original documents after scanning them into the Electronic Health Record. The Chief Executive Officer expected that SNF ABNs and NOMNCs be filled out completely, signed, and dated with at least two days' notice before non-coverage. The lack of proper documentation and timely notification placed residents at risk of not having adequate information to make informed financial decisions regarding their continued stay in the facility.
Failure to Provide Grooming Assistance for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide grooming assistance for a resident, identified as Resident 44, who was severely cognitively impaired. The resident was admitted to the facility and had an annual Minimum Data Set assessment indicating severe cognitive impairment. On multiple occasions, Resident 44 was observed with unkempt facial hair and a brown-colored substance on his face, despite being assisted out of the shower by a certified nursing assistant (CNA). The resident's son expressed concern about the resident's consistently dirty beard. Staff members, including a Resident Care Manager and a CNA, acknowledged that Resident 44 was supposed to be shaved on shower days and noted that the resident did not often refuse care. These observations and interviews indicate a failure to ensure proper grooming assistance, as required by the facility's care standards.
Discrepancies in Code Status Documentation and Communication
Penalty
Summary
The facility failed to ensure that policies and procedures were in place to accurately reflect residents' choices regarding their code status, leading to discrepancies in the documentation and communication of these preferences. For four residents, there were inconsistencies between the Physician Order for Life Sustaining Treatment (POLST) forms and the physician orders in the electronic health records (EHR). Specifically, Resident 10's POLST indicated a Do Not Resuscitate (DNR) status, while the physician order in the EHR showed a Full Code status. This discrepancy was not addressed by the staff, as evidenced by the heart sticker outside Resident 10's room, which incorrectly indicated a Full Code status. Similar issues were observed with Residents 8, 11, and 36, whose POLST forms indicated a DNR status, but the stickers outside their rooms suggested otherwise. Staff members, including the Chief Nursing Officer and other nursing staff, were unaware of these discrepancies and relied on the stickers to determine the residents' code status. This lack of accurate communication and documentation placed residents at risk for receiving care that was not aligned with their documented wishes.
Failure to Follow Physician Orders for IV/TF Labeling and Bowel Protocol
Penalty
Summary
The facility failed to adhere to physician's orders and care plans for labeling intravenous (IV) and tube feeding (TF) bags and tubing for a resident. The resident, who was moderately cognitively impaired, was receiving vancomycin IV and Jevity enteral nutrition. Despite physician orders requiring the labeling of IV and TF bags and tubing with date, time, and initials, observations on multiple occasions revealed that these items were not labeled. Staff members acknowledged the oversight, confirming that the labeling was necessary to ensure compliance with physician orders and care plans. Additionally, the facility did not follow the bowel protocol for two residents experiencing constipation. One resident did not have a bowel movement for five days, and the electronic medication administration record (EMAR) showed that PRN bowel medications were not administered as per physician orders. The orders included a sequence of administering Miralax, milk of magnesia (MOM), Dulcolax suppository, and Fleet enema if necessary, but this protocol was not initiated. Staff confirmed the protocol was not followed. For the second resident, the bowel management orders required MOM to be given if no bowel movement occurred for two days, followed by a Dulcolax suppository if there were no results within 24 hours. However, the Dulcolax suppository was administered four days after the MOM, not within the required 24-hour period. This failure to implement the bowel protocol as ordered by the physician was acknowledged by the staff, indicating a lapse in following the prescribed treatment plan.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 394 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Battle Ground
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Salmon Creek Post Acute & Rehabilitation | 6.5 mi | ★★★★★ | 27 | 0 |
| Bridge Crest Post Acute | 10.7 mi | ★★★★★ | 28 | 0 |
| Vancouver Specialty And Rehab Care | 11.1 mi | ★★★★★ | 29 | 0 |
| Hudson Bay Health And Rehabilitation | 11.2 mi | ★★★★★ | 14 | 0 |
| The Oaks At Timberline | 11.5 mi | ★★★★★ | 15 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.