Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Buena Vista Healthcare during CMS and state inspections, most recent first.
Ice Machine 1 was observed with thick dust debris covering the vents on both sides during repeated kitchen observations. The Dietary Manager stated the machine had been cleaned recently and acknowledged that dust could enter the machine and cause contamination, while the Maintenance Director stated the ice machine was cleaned monthly and should be kept clean and working properly.
A resident with depression and PTSD received risperidone without informed consent being obtained before the first dose. The MAR showed the medication was started before consent was documented, and the care plan directed nursing staff to obtain informed consent for psychotropic use. An RN was unsure when consent was required, while the DON stated consent should be obtained the day the medication is started and before administration.
Two residents had edema documented on admission, but their care plans did not include goals or interventions for monitoring or managing the swelling. One resident had lower-extremity edema with hyponatremia and HTN, while the other had generalized and bilateral pitting edema with CKD and HTN. Observations and staff interviews showed ongoing swelling, taut skin, and sock indentations, yet the MAR/TAR and care plans did not reflect edema monitoring.
Failure to Follow Bowel Protocol: A resident with diabetes and depression, who was dependent on staff for toileting, had repeated periods of no BM for three to four days. The care plan did not address constipation, and although the facility had a stepwise bowel protocol and provider bowel orders, the MAR and bowel record showed the protocol was not followed as ordered.
Failure to implement resident-specific pressure injury prevention interventions for a resident at risk for skin breakdown. The resident had a Braden score indicating risk, with dx including incontinence, foot drop, polyneuropathy, diabetes, and depression, but the care plan lacked prevention measures. The resident later developed a suspected SDTI to the left heel, and surveyors observed the heels resting on the bed despite a pillow being placed under the legs; the DON acknowledged no specific heel protection interventions were in place.
A resident with obstructive uropathy, urinary retention, and a suprapubic catheter had the urinary collection bag placed in a canvas dignity bag under the wheelchair seat, but the tubing repeatedly dragged on the floor and the bag was visibly dirty with lint and debris. Staff said the bag was heavy fabric and there was no schedule to change it, while the DON and RCM stated the tubing and dignity bag should not be on the floor.
Incomplete Legionella Water Management Plan: The facility failed to develop a comprehensive Water Management Plan to prevent Legionella growth and spread. The plan identified the facility as at risk and included a water system diagram and a corporate policy on Legionnaires’ disease, but it did not document facility-specific risks, mitigation measures, monitoring methods, or the Water Management Team’s membership, activities, or communication process. The Legionella water temp log showed monitoring in resident rooms and other areas, and the Administrator acknowledged the plan needed further development.
The facility failed to maintain resident privacy by displaying clinical information on signage visible in the rooms of five residents. These signs, containing care instructions, were visible to visitors and roommates. Residents were either unaware of the signage or confused about its relevance. The DON acknowledged the issue and confirmed no resident consent or alternative privacy measures were documented.
The facility failed to document and convey necessary information during the transfer of two residents to the hospital, which is required for a safe transition of care. One resident was transferred due to a change in condition, but the medical record lacked documentation of communication to the hospital regarding essential information such as provider contact, family contact, code status, advanced directives, plan of care, current medications, and the reason for transfer. This deficiency was acknowledged by the DON.
The facility failed to develop comprehensive care plans for two residents, leading to potential risks for inadequate care. One resident's care plan lacked documentation for the use of an abductor wedge and active diagnoses, while another resident's care plan did not address specific sleep disturbances or non-pharmacological interventions. Staff acknowledged these omissions, indicating a lack of resident-centered care planning.
A resident requiring assistance with ADLs was observed in the same clothes for several days, with long facial hair and fingernails, indicating a lack of grooming and personal hygiene care. Staff interviews revealed inconsistencies in care and documentation, with only one refusal to change clothes documented. The DON expected residents to be offered night clothes and OT staff to handle grooming during showers.
A facility failed to coordinate hearing services for a resident identified as hard of hearing. Despite having a Caption Telephone device, the resident's care plan did not acknowledge their hearing difficulties or the use of the device. Staff used various communication methods, but there was no reassessment or revision of the care plan. A hearing aid trial was undocumented, and an audiology referral was not coordinated. The Speech Therapist was not involved, and the facility did not assist in locating resources to address the resident's hearing needs.
Staff at the facility failed to maintain proper hand hygiene during meal service, as observed during dining times. Nursing Assistants and the Administrator were seen serving food and beverages, handling dirty dishes, and touching their face and clothing without washing their hands, contrary to the facility's hand hygiene policy. This increased the risk of foodborne illness among residents.
The facility did not implement specific interventions to prevent pressure ulcers for a resident with limited mobility and contractures. Despite being identified as high risk and having existing pressure ulcers, the care plan lacked targeted measures for treatment and prevention. Progress notes showed continuous pressure leading to new and worsening ulcers between the toes. Interventions were only initiated after the resident complained and a shower aide reported the breakdown. The DON acknowledged the absence of proactive measures, highlighting a gap in the facility's skin integrity policy implementation.
Instances of falls leading to significant injuries were reported among residents with high fall risk. One resident with dementia and recent thoracic spine fusion sustained a hip fracture due to an unwitnessed fall shortly after admission, with no documentation of falls or risk on the baseline care plan. Another resident with a history of stroke and hemiplegia experienced multiple falls, including one resulting in a femur fracture, despite being identified as high risk and having interventions in place. The facility's failure to reassess and update care plan interventions after each fall contributed to the ongoing pattern of falls and injuries.
The facility did not provide sufficient cueing and meal assistance for a resident with cognitive impairments and a history of stroke, anemia, and ataxia. Despite being identified as a nutritional risk, the resident experienced a significant weight loss of 9.0% within a month, leading to the development of pressure ulcers. The care plan included interventions for skin integrity risks, but the resident's weight continued to decline, with no additional nutritional interventions until a 13.2% weight loss over three months. Observations showed the resident struggled to eat independently and did not receive necessary assistance. Staff interviews confirmed the need for supervision during meals and highlighted delays in implementing nutritional interventions.
The facility failed to implement bowel management protocols for two residents, leading to prolonged periods without bowel movements, and did not monitor or implement interventions for edema management for another resident. Staff interviews confirmed that necessary medications and interventions were not administered or documented as required.
The facility failed to ensure staff followed enhanced barrier precautions, cleaned mechanical lifts after usage, and performed hand hygiene when indicated during meal service and wound care, placing residents at risk of infection.
The facility failed to assess and care plan for safe self-medication administration for a resident who was observed with a bottle of TUMS on their nightstand. Despite having a provider order for TUMS 500mg, the resident had Ultra Strength 1000mg tablets and was self-administering without staff knowledge. Staff interviews revealed a lack of awareness and adherence to the facility's policy on self-medication administration, placing residents at risk of medication errors and adverse side effects.
A facility failed to provide assistive cups as care planned for a resident with moderate cognitive impairment and swallowing difficulties. Despite the care plan's requirement for a sippy cup, the resident was inconsistently provided with regular juice glasses, and staff were unsure about the specific assistive devices needed. The speech therapist confirmed the need for a sippy cup, but staff did not consistently follow the care plan, potentially putting the resident at risk.
A resident with dementia and cervical spinal stenosis experienced an unwitnessed fall resulting in a hip fracture. The facility failed to report the incident to the State Agency and did not conduct a thorough investigation, lacking necessary documentation and interviews to rule out abuse or neglect.
The facility failed to ensure proper nail care for two residents, leading to unsanitary conditions. Both residents were observed with unclean fingernails containing dark matter and were not assisted with hand hygiene after meals, despite requiring assistance with eating and personal hygiene.
The facility failed to maintain clean oxygen delivery equipment for a resident with pericardial effusion and sleep apnea, leading to observations of a dirty filter and nasal cannula lying on the floor. Staff interviews confirmed that improper storage and maintenance could increase the risk of respiratory infection.
The facility failed to ensure the Dietary Manager had the proper certification, as the manager's license had expired and they were in the process of getting certified. This was confirmed by the Administrator, placing all residents at risk for nutritional deficits and unmet nutritional needs.
The facility failed to maintain appropriate dishwasher temperatures, date and dispose of expired foods, and prepare food in a sanitary manner. The dishwasher was operating below the required temperature, and expired and undated food items were found in storage areas. Additionally, staff did not follow proper sanitary practices while handling food.
Ice Machine Not Kept Sanitary
Penalty
Summary
The facility failed to maintain Ice Machine 1 in a sanitary manner. During an initial kitchen observation, the ice machine was found with thick dust debris covering the vents on both sides, and the Dietary Manager stated the machine had been cleaned three days earlier. During a second kitchen observation, the same ice machine was still covered with thick dust debris on both side vents. In interview, the Dietary Manager stated it was important to keep the ice machine free of dust debris because dust could enter the machine and cause contamination. The Maintenance Director later stated the ice machine was cleaned monthly and observed that it was important to keep the machine clean and working properly.
Delayed Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain consent for a psychotropic medication before the first dose was administered to one resident. A provider order was entered on 02/09/2026 for daily risperidone, and the resident’s March 2026 MAR showed the first dose was given on 03/26/2026. The resident’s 04/01/2026 admission assessment documented diagnoses of depression and PTSD, noted the resident was cognitively intact, and indicated the resident received medication for PTSD. The resident’s 04/06/2026 psychotropic medication use care plan documented that psychotropic medications were being given and instructed nursing staff to administer them as prescribed and obtain informed consent for use. The medical record showed informed consent for risperidone was not obtained until 06/04/2026, after the medication had already been administered. During interviews, an RN stated they were unsure when psychotropic medication consents needed to be obtained, while the DON stated informed psychotropic consent needed to be obtained the day the medication was started and prior to administration.
Failure to Care-Plan and Monitor Resident Edema
Penalty
Summary
The facility failed to develop care-planned goals and interventions related to peripheral edema for 2 of 2 sampled residents, Residents 5 and 44. The report states that this failure placed the residents at risk for possible worsening health conditions and decreased quality of life. The deficiency was identified during observation, interview, and record review, and the cited regulation was WAC 388-97-1020(1)(2)(a)(b). Resident 5’s baseline care plan dated 05/20/2026 had no goals or interventions related to lower extremity edema, and no orders were obtained to monitor the edema that was present on admission. The admission assessment documented diagnoses including hypo-osmolality, hyponatremia, and high blood pressure, and the resident needed partial assistance with most ADLs and was cognitively impaired. The admission nursing assessment documented 2+ non-pitting edema of both lower extremities. During multiple observations, Resident 5’s lower legs, ankles, and feet were puffy, the heels were resting on the mattress while the legs were elevated on a pillow, and the elastic from non-skid socks left clear indentations above the ankles. The resident stated the swelling was uncomfortable, and a family member stated the legs had become noticeably puffier since admission and that the fluid pill had been stopped in the hospital because of sodium levels. Resident 44’s admission skin assessment documented generalized edema, but the baseline care plan did not include a care area, goals, or interventions related to CKD, high blood pressure, or edema. A physician progress note documented 1+ edema to both lower extremities and instructed nursing staff to monitor blood pressure, renal function, and symptoms of fluid overload. The MAR/TAR showed no edema monitoring, and progress notes contained only one note stating the resident had minimal edema. Observations showed Resident 44 sitting in a recliner with legs that were edematous, shiny, and taut. During interview, Staff D assessed the legs and stated the resident had 2-3+ pitting edema to the mid-calf, and the resident’s family member stated the edema had worsened.
Failure to Follow Bowel Protocol
Penalty
Summary
The facility failed to implement the bowel protocol for one resident who was admitted with diagnoses including diabetes and depression, was cognitively intact, and was dependent on staff for toileting. The resident’s care plan did not address constipation, goals, or interventions. The facility policy required staff to check the bowel record every shift and follow a stepwise bowel protocol when there was no bowel movement, including prune juice, laxatives, Milk of Magnesia, suppository, enema, and physician notification if needed. Review of the resident’s bowel record showed multiple periods with no bowel movement for three to four days, including one period of four days without a bowel movement. The MAR showed prune juice was given on one occasion, but the facility did not follow the bowel movement protocol as ordered. Staff interviews confirmed bowel movements were monitored every shift, that the resident experienced constipation, and that bowel medications were expected to be administered as ordered to prevent bowel obstruction and pain.
Failure to Implement Heel Pressure Injury Prevention
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not implemented for one resident who was identified as at risk for skin breakdown. The resident had a Braden score of 17, and the skin integrity care plan documented risk related to incontinence, left foot drop, and polyneuropathy, but the care plan did not include documentation of prevention measures for skin issues or pressure ulcers. The resident’s annual assessment also identified diagnoses of diabetes, polyneuropathy, and depression, and documented that the resident was at risk for developing pressure ulcers. The resident later complained of left heel pain, and staff found a light purple non-blanchable area on the back of the left heel. The facility’s incident investigation identified a suspected deep tissue injury to the left heel. At the time of the survey observation, the resident was lying in bed with a pillow under the legs, but the weight of the legs pushed the pillow down so the heels were resting on the bed. The resident stated they had a blister on the heel and believed it was acquired at the facility, possibly related to the bed being too small. Staff interviews showed the RN and DON knew residents at risk for skin breakdown should have heel-floating and other interventions based on assessment, but the DON acknowledged the resident did not have specific interventions in place to prevent skin breakdown to the heel.
Catheter tubing and dignity bag were allowed to drag on the floor
Penalty
Summary
A resident with diagnoses including obstructive uropathy and urinary retention had an indwelling suprapubic catheter and used a wheelchair for mobility. The resident’s bowel and bladder care plan directed staff to clean the catheter every shift, keep the urinary collection bag hung below the bladder, ensure there were no kinks in the tubing, maintain dignity with a dignity bag, and secure the tubing to prevent the catheter from being pulled out. During multiple observations, the urinary collection bag was placed in a canvas dignity bag hung under the wheelchair seat, but the tubing dragged on the floor next to the wheelchair’s front wheels and extended under the resident’s pant leg to the catheter insertion site. The dignity bag had greyish dirt smears and lint on the outside and, when later inspected, had a large wad of lint and dirt and debris on the bottom and was no longer pliable. Staff stated the bag was heavy fabric, there was no schedule to change it, and it could be sent to laundry, while the DON and Resident Care Manager stated it was not recommended for the dignity bag and tubing to drag on the floor and that the floor was not sanitary.
Incomplete Legionella Water Management Plan
Penalty
Summary
The facility failed to develop a comprehensive Water Management Plan to prevent the growth of water-borne viruses and bacteria such as Legionella. During record review, the plan included a document identifying the facility as at risk for Legionella because of the population served and included a diagram of the facility water systems, along with a corporate policy describing Legionnaires’ disease, symptoms, and general outbreak response. However, the plan did not document facility-specific risks for Legionella growth, where those risks were located in the facility, what mitigation measures were in place, or how the plan was monitored. The plan also lacked documentation identifying the Water Management Team, the activities the team would perform, and how those activities would be documented and communicated. The Legionella Water Temperature Log 2026 showed resident rooms and other areas where water temperatures were monitored, and it noted that Legionella grows best in the range of 77-113 degrees Fahrenheit and that adjustments were needed if temperatures were within that range. No temperatures were recorded that required adjustment for each month of 2026. During interview, the Administrator acknowledged areas of the Water Management Plan that needed further development.
Failure to Maintain Resident Privacy with Visible Clinical Signage
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of residents' personal and medical information by displaying clinical information in visible areas within the rooms of five residents. Observations and interviews revealed that signage containing clinical directives was posted on overhead lights in the rooms of Residents 16, 24, 21, 3, and 18. These signs were visible not only to staff but also to visitors, roommates, and outside vendors. The signage included care instructions such as mobility assistance requirements and specific medical precautions. Resident 16, who had intact cognition, was unaware of the signage's content and stated an inability to read them. Similarly, Resident 24, who was alert and oriented, had signage visible in their room. Resident 21, with intact cognition, expressed confusion about the signage's relevance to them. Resident 3, who was alert and oriented but sometimes minimally confused, noted that the signage was for a previous occupant. Resident 18, with impaired cognition and a designated Power of Attorney, also had visible signage. The Director of Nursing acknowledged the issue and confirmed that there was no documentation showing that residents or their representatives had consented to the use of such signage, nor were alternative privacy measures discussed.
Failure to Document and Convey Information During Resident Transfers
Penalty
Summary
The facility failed to document and convey necessary information during the transfer of two residents to the hospital, which is a requirement for ensuring a safe transition of care. Resident 16 experienced a change in condition on January 17, 2025, necessitating a hospital transfer. However, the medical record lacked documentation of communication to the hospital regarding essential information such as the resident's provider contact, family or representative contact, code status, advanced directives, plan of care, current medications, and the reason for transfer. Similarly, Resident 24 was transferred to the hospital on June 10, 2024, due to a change in condition, but there was no documentation of adequate communication at the time of transfer. This deficiency was acknowledged by the Director of Nursing, who confirmed the absence of documentation in the medical records.
Deficient Care Planning for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, leading to potential risks for inadequate care. For Resident 16, observations revealed the use of an abductor wedge, which was not documented in the care plan or the February 2025 Treatment Administration Record. Additionally, the care plan lacked documentation of the resident's active diagnoses of atrial fibrillation and congestive heart failure, as well as the necessary nursing interventions related to these conditions. The care plan also failed to address the resident's depression, despite the administration of Trazodone since January 2025. Staff acknowledged these omissions, indicating a lack of resident-centered care planning. For Resident 24, the care plan identified a mood problem related to insomnia but did not document specific disturbances to the resident's sleep or non-pharmacological interventions to improve sleep patterns. The care plan only included general interventions such as administering medications and monitoring sleep via a sleep monitor. Staff acknowledged the absence of resident-centered interventions, highlighting a deficiency in addressing the resident's specific needs for improved sleep hygiene.
Failure to Provide Adequate Grooming and Hygiene Assistance
Penalty
Summary
The facility failed to provide adequate grooming and personal hygiene assistance to Resident 35, who required staff assistance for activities of daily living (ADLs) such as personal hygiene, dressing, and grooming. Observations over several days revealed that Resident 35 was in the same clothes, had long facial hair, and long, jagged fingernails. The resident reported wearing the same clothes for three or four days since their last shower and stated that no one had offered to change them into clean clothes brought by their daughter. Additionally, the resident mentioned not being asked about trimming their fingernails or shaving their facial hair. Interviews with staff revealed inconsistencies in the care provided to Resident 35. Staff O, a Nursing Assistant, stated that residents were typically shaved and had their nails trimmed weekly during baths, but was unfamiliar with Resident 35 due to their preference for female caregivers. Staff M and Staff N, both Nursing Assistants, mentioned that Resident 35 frequently refused baths and ADL care, but documentation of these refusals was lacking. Only one refusal to change clothes was documented after a conversation with staff. The Director of Nursing stated that it was expected for residents to be offered to change into night clothes and that Occupational Therapy staff should handle shaving and nail trimming if they provided the shower.
Failure to Coordinate Hearing Services for a Resident
Penalty
Summary
The facility failed to coordinate hearing services for Resident 24, who was identified as hard of hearing upon admission. Despite the presence of a Caption Telephone (CapTel) device in the resident's room, which transcribes spoken words into written text, there was no documentation in the resident's care plan acknowledging the resident's specific hearing difficulties or the use of the CapTel device. Staff members reported using various methods to communicate with the resident, such as speaking loudly, making eye contact, and using hand gestures, but there was no evidence of a reassessment or revision of the care plan to include these methods or the effectiveness of the CapTel device. Interviews with staff and a resident representative revealed that the facility had offered a hearing aid to the resident, which was refused, but there was no documentation of this trial or any follow-up actions. The Social Services Director was unaware of the hearing aid trial and confirmed that an audiology referral, as instructed by the care plan, had not been coordinated. Additionally, the Speech Therapist had not been involved in evaluating the resident's communication deficits, and there was no evidence that the facility assisted the resident or their representative in locating and utilizing available resources to address the resident's hearing needs.
Failure to Maintain Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to adhere to professional standards for food service safety during dining observations, as staff members were observed not performing appropriate hand hygiene. Specifically, staff members were seen serving food and beverages without washing their hands or using an alcohol-based hand rub, as required by the facility's hand hygiene policy. Staff J, a Nursing Assistant, was observed moving between the dining room and kitchen, serving beverages, and handling dirty dishes without performing hand hygiene. Additionally, Staff J touched their face and clothing, and handled residents and their wheelchairs without washing their hands. Similarly, Staff L, another Nursing Assistant, was observed serving drinks with bare hand contact on the rims of cups and touching their face, facial hair, and clothing without performing hand hygiene. Staff I was also seen serving a resident cocoa and handling dirty dishes without washing their hands. Furthermore, the facility's Administrator, Staff A, was observed serving meals and moving in and out of the dining room without performing hand hygiene. These actions increased the risk of foodborne illness among residents due to the lack of adherence to hand hygiene protocols.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to implement interventions to prevent pressure ulcers for Resident 8, who had a history of limited mobility and contractures to the knees and ankle. Despite being identified as high risk for pressure ulcers and having existing pressure ulcers on their toes, the care plan did not include specific interventions for treatment and prevention. Progress notes indicated a lack of action to prevent further skin breakdown, with observations of continuous pressure leading to open wounds between the toes. The resident's condition deteriorated over time, with new pressure areas developing and worsening, ultimately resulting in multiple pressure ulcers between the toes. Staff interviews revealed that interventions were only initiated after the resident complained and breakdown was reported by a shower aide. The Director of Nursing acknowledged the lack of specific interventions for Resident 8's toes and expressed the need for proactive measures to prevent skin breakdown. Despite having a policy in place for skin integrity, the facility failed to effectively implement preventive measures tailored to the resident's individual needs, leading to the development of avoidable pressure ulcers. The resident's worsening condition and the delayed response to their complaints highlight the facility's oversight in providing adequate pressure ulcer care and prevention.
Fall Risk Management and Documentation Deficiencies
Penalty
Summary
The report highlights multiple instances where residents in the nursing home facility experienced falls, leading to significant injuries such as hip fractures. In the case of Resident 51, who had dementia and recent thoracic spine fusion, the facility failed to document falls or risk for falls on the baseline care plan. Resident 51 sustained a right hip fracture two days after admission due to an unwitnessed fall, indicating a lack of appropriate supervision and fall prevention measures. The facility's policy required completion of a fall risk assessment using the Morse fall scale, but interventions were not implemented effectively, placing Resident 51 at high risk for falls. Similarly, Resident 36, who had a history of stroke with hemiplegia and hemiparesis, experienced multiple falls within a short period, including one resulting in a left femur fracture. Despite being identified as high risk for falls and having interventions in place, Resident 36 continued to overestimate their abilities and fell repeatedly. The facility's failure to reassess and update care plan interventions after each fall contributed to the ongoing pattern of falls and injuries for Resident 36.
Inadequate Cueing and Nutritional Support Leading to Weight Loss and Pressure Ulcers
Penalty
Summary
The facility failed to provide adequate cueing and meal assistance, monitor for significant weight loss, and address the risk of skin integrity for Resident 29, who had diagnoses including stroke, anemia, and ataxia. Despite documented cognitive impairments and the need for assistance with eating, Resident 29 experienced a severe weight loss of 9.0% within a month, leading to the development of pressure ulcers. The care plan indicated risks for skin breakdown related to incontinence and low body weight, with interventions such as an air mattress added to address these concerns. Nutritionally, Resident 29 was identified as a nutritional risk, with instructions for nursing staff to provide substitute meals or supplemental drinks if less than 50% of the meal was consumed. However, Resident 29's weight continued to decline significantly, with no additional nutritional interventions implemented until a liquid supplement was finally added after a 13.2% weight loss over three months. Observations during meal services revealed that Resident 29 struggled to eat independently, often unable to use utensils effectively and consuming only a portion of the provided food without receiving the necessary cueing or assistance. Staff interviews highlighted the need for supervision and cueing during meals due to Resident 29's confusion and distraction with utensils. The Director of Nursing acknowledged the progression of Resident 29's wound from MASD to a pressure ulcer, emphasizing the need for increased assistance post-stroke. The Registered Dietician noted the missed opportunity to add protein earlier to address weight loss and skin breakdown, indicating a delay in implementing necessary interventions.
Failure to Implement Bowel and Edema Management Protocols
Penalty
Summary
The facility failed to implement the bowel management protocol for two residents, leading to prolonged periods without bowel movements. Resident 26, who required maximal to total assistance for most activities of daily living and had severe cognitive impairments, had multiple instances from January 2024 through March 2024 where they went several days without a bowel movement. Despite having active orders for various bowel medications, these were not administered as needed, and there was no documentation of bowel interventions on the facility's paper bowel program flow sheet tool. Staff interviews confirmed that the bowel medications should have been administered to prevent constipation and impaction but were not. Similarly, Resident 31, who required moderate to maximal assistance and had moderate cognitive impairment, also experienced multiple instances of constipation from February 2024 through April 2024. The resident's bowel record showed several periods of three to eleven days without a bowel movement, and the bowel medications were not administered as ordered. Additionally, there was no documentation of bowel interventions on the facility's paper bowel program flow sheet tool. Staff acknowledged that the bowel protocol should have been implemented but was not. The facility also failed to monitor and implement interventions for edema management for Resident 31. The resident had 3+ pitting edema to bilateral lower extremities upon admission, which was documented in a single progress note. No further assessment, monitoring, or intervention documentation was found. Observations over several days showed the resident with significant edema, and no compression stockings were being worn. Staff interviews revealed that typical edema interventions such as leg elevation, diuretic medication, and compression stockings were not implemented for Resident 31, despite the increasing severity of the edema.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to ensure staff followed enhanced barrier precautions, cleaned mechanical lifts after usage, and performed hand hygiene when indicated during meal service and wound care. These failures placed residents at risk of transmission of communicable diseases and/or healthcare-associated diseases, and diminished quality of life. Resident 10, who was on enhanced precautions due to a urinary catheter, was transferred by staff without the required PPE. Additionally, the mechanical lift used for the transfer was not sanitized after use. Similar failures were observed with other residents on enhanced precautions, including Resident 8, who had wounds on their toes. Staff did not wear the required PPE during dressing changes and did not sanitize equipment after use. Resident 4, who had a urinary catheter, was observed with their catheter collection bag lying on the floor without a cover, increasing the risk of infection. During wound care for Resident 10 and Resident 28, staff failed to perform hand hygiene between glove changes and after handling soiled dressings. During meal service, staff did not perform hand hygiene between assisting different residents, further increasing the risk of cross-contamination.
Failure to Assess and Care Plan for Safe Self-Medication Administration
Penalty
Summary
The facility failed to assess and care plan for safe self-medication administration for Resident 28, who was observed with a bottle of TUMS on their nightstand. Despite having a provider order for TUMS 500mg every 4 hours as needed for indigestion, Resident 28 had a bottle of Ultra Strength 1000mg tablets and was self-administering without staff knowledge. The facility's policy required a self-medication evaluation and care plan, which were not completed for Resident 28. Additionally, there was no documentation in the medical record or care plan regarding self-administration or bedside storage of medications. Staff interviews revealed a lack of awareness and adherence to the facility's policy on self-medication administration. Staff C, an LPN, was unaware of why Resident 28 had the TUMS at their bedside and acknowledged the discrepancy in the medication strength. Staff B, the Director of Nursing, confirmed that an assessment and care plan were necessary for self-administration and that medications kept at the bedside needed to be locked for safety. The failure to follow these protocols placed residents at risk of medication errors and adverse side effects.
Failure to Provide Assistive Cups as Care Planned
Penalty
Summary
The facility failed to provide assistive cups as care planned for a resident with moderate cognitive impairment and swallowing difficulties. The resident's comprehensive admission assessment and care plan indicated the need for a sippy cup for all liquids to prevent spillage and aspiration. However, during multiple observations, the resident was provided with regular juice glasses without lids, handles, or straws, contrary to the care plan. The resident was seen using both types of drinkware inconsistently, and staff were unsure about the specific requirements for assistive devices, relying on meal tickets that did not contain the necessary information. Interviews with staff revealed a lack of awareness and understanding of the resident's care plan and the importance of using the prescribed assistive devices. The speech therapist confirmed the recommendation for a sippy cup due to the resident's difficulty in swallowing and tendency to spill fluids. Despite this, the resident was observed with a regular juice glass in their room, and staff did not consistently follow the care plan, potentially putting the resident at risk of aspiration or other complications. The Director of Nursing acknowledged the expectation for staff to follow care plans and the potential risks of not doing so.
Failure to Report and Investigate Unwitnessed Fall
Penalty
Summary
The facility failed to identify, report, and thoroughly investigate a potential incident of neglect involving Resident 33, who experienced an unwitnessed fall resulting in a serious bodily injury. The resident, who had diagnoses including cervical spinal stenosis and dementia, was found on the floor with a hip fracture that required surgery. The incident was not reported to the State Agency, and the facility's incident report lacked resident or staff interviews and did not indicate how abuse or neglect was ruled out. Resident 33 had a history of increased confusion and paranoid behaviors, which were documented in the progress notes. Despite these behaviors, no new interventions were added to the resident's care plan in November 2023. The resident's care plan indicated they required maximal assistance for bed mobility and had a history of falls, but no recent updates were made to address the increased risk. The Director of Nursing stated that abuse and neglect were ruled out by asking the resident, who was alert enough to communicate what happened. However, the facility's investigation did not include thorough documentation or interviews to support this conclusion. The facility's failure to report the incident and conduct a comprehensive investigation is a clear deficiency in their handling of the situation.
Failure to Provide Proper Nail Care
Penalty
Summary
The facility failed to ensure proper nail care for two residents, leading to unsanitary conditions that could increase the risk of bacterial and diarrheal illnesses. Resident 17, who had diagnoses including spinal stenosis and an enlarged prostate requiring an indwelling urinary catheter, was observed multiple times with long fingernails containing dark matter. Despite requiring set-up/clean-up assistance for eating and personal hygiene, the resident used their fingers to help scoop food onto their utensils and pick up food from their plates. The care plan for Resident 17 included instructions to keep fingernails short, but the Individual Service Plan lacked specific instructions regarding hand hygiene or nail care. Observations over several days showed that the resident's nails remained unclean, and they were not assisted with hand hygiene after meals. Similarly, Resident 29, who had diagnoses including stroke, ataxia, and anemia, was also observed with unclean fingernails containing brown matter. This resident required partial to moderate assistance with eating and set-up/clean-up assistance with personal hygiene. Despite these needs, Resident 29 was seen using their fingers to eat without being assisted to wash their hands or clean under their nails after meals. Interviews with staff confirmed that nail care, including trimming, filing, and cleaning under the nails, was the responsibility of the aides unless the resident was diabetic. The Director of Nursing acknowledged that residents who used their fingers to eat should have their nails cleaned daily to prevent bacterial risks.
Failure to Maintain Clean Oxygen Delivery Equipment
Penalty
Summary
The facility failed to ensure that oxygen delivery equipment was maintained in a clean manner for Resident 26, who had diagnoses including pericardial effusion and sleep apnea, and required oxygen to maintain oxygen saturations greater than 90 percent. The physician orders specified that the filter should be changed monthly and the oxygen tubing should be changed if damaged or unable to be cleaned. However, the resident's care plan did not include instructions for respiratory care needs related to oxygen. Observations over several days revealed that the oxygen concentrator's filter was thick with dust and the nasal cannula was found lying on the floor, which was not in compliance with the facility's protocol for storing oxygen tubing in a bag on the side of the concentrator or on the wheelchair. Interviews with staff confirmed that the nasal cannula should be stored properly to prevent respiratory infections. Despite multiple observations of the dirty filter and improperly stored nasal cannula, the issues were not addressed promptly. The Director of Nursing acknowledged that dirty oxygen equipment could increase the risk of respiratory infection. These failures placed the resident at risk for respiratory complications and infection, as the facility did not adhere to the prescribed maintenance and storage protocols for oxygen delivery equipment.
Dietary Manager Certification Deficiency
Penalty
Summary
The facility failed to ensure that the dietary staff had the proper qualifications, specifically the Dietary Manager. During an interview, the Dietary Manager admitted that their license had expired and they were in the process of getting certified. This was confirmed by the Administrator, who acknowledged that the Dietary Manager was not currently certified. This deficiency placed all residents at risk for nutritional deficits, unmet nutritional needs, and diminished quality of life.
Failure to Maintain Dishwasher Temperatures, Date and Dispose of Expired Foods, and Ensure Sanitary Food Preparation
Penalty
Summary
The facility failed to maintain appropriate dishwasher temperatures, date and dispose of expired foods, and prepare food in a sanitary manner. During an observation, the dishwasher was found to be operating below the required temperature of 120 degrees, with trays reaching only 117 degrees. Staff Q, the Dietary Manager, and Staff R, the Dietary Aide, did not follow proper procedures to ensure the dishwasher was functioning correctly, and there was no documentation to show that the issue had been resolved. Additionally, expired and undated food items were found in the pantry, freezer, and refrigerator, including raisin bread, thickened orange juice, french fries, tater tots, smoked ham, apple pie, pastrami, brown wilted lettuce, and sliced cheese. Staff Q acknowledged that these items should have been dated and discarded if expired. Sanitary practices were also not followed, as observed with Staff S, Dietary Aide, and Staff T, Cook, who wore hairnets that only covered the hair bun on the top of their heads, leaving the rest of their hair uncovered while handling food. This was observed on multiple occasions, and Staff Q confirmed that all dietary workers should have worn hairnets that cover all hair or a hat to avoid contamination. These failures placed the residents at risk for foodborne illnesses and decreased their quality of life.
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What surveyors actually found near you
We read the 2 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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Colville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Colville Health And Rehabilitation Of Cascadia | 2 mi | ★★★★★ | 2 | 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 October 2026) and official state health department websites.