Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cascades Of St Anne during CMS and state inspections, most recent first.
The facility failed to designate a qualified dietary manager or food services director. A Cook stated there was no dietary manager and that they reported directly to the Administrator, who later confirmed the facility had not had a dietary manager or food services director and was essentially filling that role despite having only a state food safety certificate and no degree in food or nutrition.
Food safety and sanitation practices were not maintained in the kitchen and during meal service. A cook left food items in the refrigerator unlabeled, undated, and uncovered, and 54 cups of prune juice past the best-by date remained on a steel rack. Dishmachine and 3-compartment sink logs had multiple missing entries, a sanitizing bucket tested at 0 ppm, and a cook wiped a food thermometer with a towel from the sanitizing bucket instead of a probe wipe. Milk was served at 49-51 degrees F, and two staff delivered lunch trays with uncovered dessert bowls.
A facility failed to keep several resident rooms and the therapy gym in good repair and clean condition. Observations found a dusty, discolored air vent, baseboard heater covers that did not fully cover heater fins in two resident rooms and the therapy gym, and scrapes and scratches on lower door frame walls and floor molding in another resident room. The Maintenance Director and DON acknowledged the conditions during observation.
Inaccurate MDS coding affected multiple residents, including errors in GDR documentation, influenza and pneumococcal immunization status, and anticoagulant use. Records reviewed did not support the coded MDS entries for a resident with antipsychotic GDR documentation, residents coded for influenza vaccine receipt or refusal, a resident coded as up to date on pneumococcal vaccination, and residents coded for anticoagulant use despite MARs showing no such medication during the look-back period.
Incomplete Daily Nurse Staffing Posting: Surveyors observed that the Daily Posting of Nursing Staff did not include the facility name or the actual hours worked by RN and LPN staff directly responsible for resident care. The DON stated the actual hours were entered the following day, and the Administrator stated the form was posted with estimated hours and that they would not expect the facility name to appear on the posting.
Surveyors found the facility’s medication error rate exceeded the allowed threshold, with 3 errors in 28 observed medications. An RN crushed an ER metoprolol tablet for a resident, gave an enteric-coated aspirin instead of the ordered chewable form to another resident, an LPN prepared Tussin DM instead of ordered guaifenesin syrup for a third resident, and a resident’s ordered fluticasone nasal spray was not included in the medication pass because it did not appear on the EMAR.
The facility did not document annual review of IPCP policies, with several infection control policies last revised years earlier. In addition, a Restorative Aide, a CNA, and Laundry Staff were observed not following droplet precautions: one did not change a face mask after leaving a droplet room, one entered without eye protection and did not change a mask after care, and one entered multiple rooms without eye protection, mask changes, or hand hygiene. Staff interviews confirmed the expected PPE and hand hygiene practices were not followed.
Surveyors found that the facility did not follow its pneumococcal vaccination policy or CDC guidelines for two residents. One resident’s EHR contained no pneumococcal immunization record and no documentation that the vaccine was offered within the required timeframe after admission. Another resident’s record showed prior PPSV23 and PCV13 doses but no evidence that the recommended follow-up PCV20 or PCV21 dose was offered or administered at least five years after the last pneumococcal vaccine. During interview and record review, leadership staff confirmed that these pneumococcal immunizations were not up to date and that the relevant documentation was absent from the EHR.
Surveyors found that the facility did not maintain required documentation of COVID-19 vaccination status for a CNA, despite a policy stating that staff must provide vaccination records and that the infection preventionist and HR would track and maintain this information. The CNA reported being vaccinated in another state and stated they had given proof of vaccination to the facility. The DON and a regional operations leader indicated that staff vaccination records were kept by HR, but when surveyors requested the CNA’s documentation, no record of the CNA’s COVID-19 vaccination status was produced, resulting in a deficiency related to staff immunization documentation requirements.
A resident had prescription Lidocaine cream and Ammonium Lactate lotion at the bedside, and the resident stated they applied the lotion themselves while nurses applied the Lidocaine. However, the chart lacked documentation of an assessment, physician order, or care plan for self-administration of meds, even though staff and the DON said those records were expected before a resident self-administers.
Failure to Document Advance Directive Discussion: The facility did not provide documented information about advance directives for a resident admitted to the facility. The resident said they knew what an advance directive is but did not remember it being discussed, and the EHR lacked documentation that the SW or other staff discussed or offered advance directive information. The SW later confirmed there was no documentation to support that the discussion occurred, and the Admin also stated it should have been discussed.
Failure to investigate a resident incident: A cognitively intact resident reported that a wheelchair rolled back during medical transport and they hit the ground, with neck pain and hospital evaluation afterward. PT documented the event and multiple staff were told, including the DON, but the incident was not entered on the incident log and no thorough investigation was completed, despite staff acknowledging they were expected to investigate accidents and incidents.
Two residents were transferred to the hospital without receiving the required written bed-hold and/or transfer notices. Records showed one resident had only verbal communication about the transfer and no documented bed-hold notice, while the other resident’s chart lacked written transfer/discharge notice and contained an incomplete eINTERACT Transfer Form. Staff confirmed the notices were not provided as required.
The facility failed to develop comprehensive care plans for a resident with a pressure ulcer who was receiving anticoagulant and diuretic meds, another resident receiving Torsemide for CHF, and a resident with dementia. Staff confirmed the missing care plans, and the records showed no specific plans for the wound, anticoagulant use, diuretic use, or dementia-related care needs.
Care conference not documented for a resident. The record showed a care conference was scheduled, but there was no documentation that the meeting occurred or that the resident participated or refused to participate in the care planning process. Staff stated residents and/or representatives were expected to be involved, but the EHR did not show proof of a completed care conference or care plan meeting.
A resident who was dependent on staff for bathing and showering did not receive scheduled hygiene care as documented in the record. The resident reported inconsistent bed baths, and multiple shower/bath entries were marked as not occurring without any refusal documentation, despite the care plan calling for dependent assistance and scheduled bathing twice weekly.
Unsecured Oxygen Storage Room Door: The facility failed to keep the oxygen storage room door electronic keypad lock functioning and locked. Multiple observations showed the door was unlocked and accessible without entering the code. A CNA and the Maintenance Director both stated the door should have been locked for safety, and the Administrator confirmed the lock should have been functioning and locked.
Feeding tube formula was not administered as ordered for a resident who was severely cognitively impaired and dependent on staff for all care. Observations showed the TF running at 75 mL/hr instead of the ordered 85 mL/hr, and the formula bottle and water flush bag were not labeled or dated. MAR/TAR review did not show daily documentation of the total formula or water flush given, and an RN stated the amounts were not being documented at the end of the shift.
A resident with OSA had a CPAP assist order, but the active MAR/order summary did not show a physician order for CPAP settings. Surveyors observed the CPAP machine on the nightstand and the nasal mask uncovered in a drawer with personal items and later on the bed. The resident said they did not know the CPAP settings, and the DON stated the mask should be stored in a bag and labeled when not in use.
Improper storage of vaccines and resident medications. The facility kept pneumonia vaccines in a med room refrigerator but only checked temperatures once daily even though the log directed twice-daily checks when vaccines were present. The facility also left a resident’s lidocaine cream and ammonium lactate lotion on a bedside table despite no documented self-administration assessment, order, or care plan, and staff stated the meds should have been locked up.
Inadequate Dietary Staff Training and Sanitization Practices: Two dietary staff members were observed performing sanitizer bucket checks and food thermometer cleaning incorrectly. One staff member relied on strip color without using the color chart, and another used a towel from the sanitizing bucket to wipe the thermometer between food temperature checks. Record review showed blank, unsigned competency forms, and the Administrator stated there was no dietary manager or food service director.
A resident with paraplegia and Multiple Sclerosis, who was care-planned for two-person assistance during incontinence care and repositioning, experienced a fall when a CNA provided care alone instead of following the required two-person assist protocol. The DON confirmed that the care plan was not followed, and the CNA stated they acted alone due to staffing shortages.
A resident with a lower back fracture received as-needed pain medications, including Methocarbamol and Oxycodone, without documented attempts at non-pharmacological interventions as required by physician orders. Nursing staff and the DON confirmed that such interventions should have been tried and documented prior to medication administration, but records showed no evidence of this. Additionally, there was inadequate monitoring for adverse side effects of the pain medications.
A resident receiving antipsychotic medication was not adequately monitored for side effects, as staff documented check marks instead of indicating 'Y' for observed or 'N' for not observed side effects on the MAR. Nursing staff and the DON confirmed that the documentation did not clearly show whether side effects were present, resulting in a failure to meet required monitoring standards.
A registered nurse entered the room of a resident with a confirmed COVID-19 infection without wearing the required PPE, despite clear signage and established protocols. Facility leadership confirmed that full PPE, including an N95 mask, eye protection, gown, and gloves, was expected for all staff entering rooms of COVID-19 positive residents.
A resident with dementia and a history of elopement attempts managed to leave the facility unsupervised, despite wearing a device meant to alert staff when approaching exit doors. The resident was found by police at a shopping center over a mile away. Staff confirmed that door alarms were functional, but the Director of Nursing was unsure how the resident eloped.
The facility did not ensure survey results were accessible to residents and their legal representatives. Observations showed no survey binder in the lobby, and a resident confirmed they had to request access from the business office. The administrator admitted the binder was in their office for survey preparation.
The facility failed to accurately assess five residents using the MDS tool, leading to discrepancies in recording antibiotic, insulin, anticoagulant, intrathecal pump, diuretic use, and tube feeding. Staff acknowledged these errors during joint record reviews, highlighting inaccuracies in the residents' MDS assessments.
The facility failed to properly maintain, label, date, and store oxygen equipment for several residents, leading to a deficiency in respiratory care. A resident with heart failure used an undated nasal cannula, while another with respiratory failure had improperly stored and undated equipment. Staff were unaware of the last changes, and a resident with no documented oxygen orders had equipment on the floor. The facility's policy requiring weekly changes and proper storage was not followed.
The facility did not post the daily nurse staffing form in a prominent location accessible to residents, their representatives, and visitors. Observations showed the form was placed in an area not visible to residents and visitors, and interviews with residents and staff confirmed a lack of awareness and visibility of the postings. The facility's policy requires these postings to be clear and readable within two hours of each shift's start.
The facility failed to label and store medications properly, with undated multi-dose vials and medications found in the medication room and on a medication cart. Additionally, expired medical supplies and tube feeding formulas were not discarded, contrary to facility policy. Staff acknowledged these oversights during observations and interviews.
The facility failed to test sanitizing solutions in the kitchen, monitor refrigerator temperatures, and properly label nutritional supplements. The sanitizing solution levels were often below the recommended 200 ppm, and the snack refrigerator lacked temperature documentation. An undated Ensure container was found in the medication storage room, indicating lapses in labeling and discarding practices.
The facility failed to implement a comprehensive water management program to monitor Legionella risks and did not adhere to Enhanced Barrier Precautions for a resident with a gastrostomy. Staff inconsistently used gowns during high-contact care activities, and transfer lift equipment was not properly sanitized between uses, with staff using inappropriate wipes instead of disinfectant wipes.
The facility failed to maintain an effective pest control program, leading to a persistent fly infestation in resident rooms, the dining room, and the kitchen. Observations showed flies on residents, their meals, and personal items, with staff and residents consistently reporting the issue over several days. Despite pest control treatment, flies continued to be observed, indicating a significant deficiency in pest management.
A resident's dignity was compromised when a nurse administered oral medications in the dining room during breakfast, discussing the medications in front of other residents. This action violated the facility's policy, which requires medication administration to be based on resident need and not staff convenience. The DON confirmed that such actions should not occur unless specified in the resident's care plan.
The facility failed to thoroughly investigate allegations of abuse and neglect for two residents, leading to incomplete documentation and risk of repeated incidents. Investigations lacked witness statements, care documentation, and evidence of abuse or neglect being ruled out.
A facility failed to provide a written transfer/discharge notice to a resident and their representative during a hospitalization. The policy required notice as soon as practicable for emergency transfers, but no documentation was found in the resident's records. Staff interviews confirmed the oversight, with the Social Services Director noting the absence of documentation and the DON stating that notices should be provided at discharge.
A resident was not provided a bed hold notice during their transfer to a hospital, as required by the facility's policy. The policy mandates that residents or their representatives receive written information about bed-hold policies at least twice, but a review of the resident's records showed no documentation of such notice. Staff interviews confirmed the oversight.
A facility failed to complete the PASARR Level I for a resident with Serious Mental Illness (SMI) and mood disorders, as required by policy. The resident's PASARR was marked 'yes' for SMI, but Section IV was incomplete, and no Level II evaluation was recorded. The Social Services Director was unsure why the Level II evaluation was not sent, despite sending multiple requests. The administrator expected the PASARR Level I to be completed before admission, but this oversight risked the resident not receiving appropriate care.
The facility failed to develop and implement care plans for two residents prescribed diuretic medications. One resident, admitted with essential hypertension and end-stage renal disease, did not have a care plan for diuretics until over two months after admission. Another resident had a physician's order for diuretics but lacked a corresponding care plan. These deficiencies were confirmed by staff and indicate non-compliance with the facility's policy on comprehensive care plans.
The facility failed to provide consistent ADL assistance for two residents, particularly in showering and bathing. One resident, requiring partial assistance, received fewer showers than their care plan specified, while another, needing total assistance, reported infrequent showers. Staff interviews revealed lapses in following the shower schedule and documenting care provided.
A facility failed to provide diabetic nail care for a resident as per their care plan and did not monitor two residents on diuretic and anticoagulant medications for adverse side effects. The diabetic nail care was not documented or ordered, and monitoring for medication side effects was absent in the MARs, contrary to facility policy.
A facility failed to monitor antibiotic side effects and ensure appropriate use for a resident. The Antibiotic Stewardship policy requires monitoring and complete orders for antibiotics, but a review showed an order for Levofloxacin without an indication or side effect monitoring. The DON acknowledged these omissions, risking unnecessary medication and diminished quality of life.
A facility failed to maintain its Antibiotic Stewardship Program for a resident with hidradenitis suppurativa, leading to a deficiency. The resident was prescribed antibiotics, but was not included in the Antibiotic Infection Control Log, and there was no monitoring for adverse side effects. The DON admitted the resident should have been included, but the condition was not considered a real infection, resulting in the omission.
A facility failed to document a resident's refusal of pneumococcal and COVID-19 vaccines and did not provide information on the risks and benefits as required by their policy. The resident's EHR lacked consent forms, and the DON confirmed the absence of documentation, noting the resident's refusal of vaccines for two years.
The facility failed to ensure the safety of bed rails for three residents, leading to potential accident hazards. Observations showed that the bed rails were loose and had gaps between the mattress and rails, posing a risk of entrapment. Staff confirmed the looseness and lack of maintenance records, while interviews revealed uncertainty about inspection frequency and no documentation of routine checks.
A resident with impaired thinking reported being physically abused by a staff member, but the allegation was not reported to the State Agency or investigated until two days later. The delay occurred because the Business Office Manager did not immediately act on the report, believing it was a concern and comment issue. This failure placed residents at risk for abuse and unmet care needs.
A facility failed to ensure staff followed PPE protocols for a resident with COVID-19. A staff member entered the resident's room with only a surgical mask, contrary to guidelines requiring an N95 mask, gown, gloves, and eye protection. Other staff confirmed the PPE requirements, and the Director of Nursing emphasized the expectation for proper PPE use.
A resident with hemiplegia and at risk for pressure ulcers experienced a delay in treatment for non-blanchable deep tissue injuries on both great toes. The treatment orders were not implemented until five days after being written due to accessibility issues with the computer system, leading to a delay in care.
The facility failed to ensure a safe discharge process for three residents who left AMA. There was no documentation that risks and benefits were discussed, attending physicians were notified, or residents' safety was checked. One resident left due to concerns about care, another left crying without signing the AMA form, and the third left due to being unhappy with the care and facility temperature.
No Qualified Dietary Director Designated
Penalty
Summary
The facility failed to designate a person to serve as the director of food and nutrition services with the proper qualifications. Review of the key personnel list provided by the facility showed no staff names listed under the dietary manager. During an interview, a Cook stated that there was no dietary manager and that they reported directly to the Administrator, and they did not know when the facility last had a dietary manager. The Administrator later stated that the facility had not had a dietary manager or food services director since 12/05/2025 and that they had been in contact with the corporate resource person while essentially taking on the role of a dietary manager. The Administrator also stated that they had a state food safety certificate but no degree in food or nutrition.
Food Safety and Sanitation Lapses in Kitchen and Tray Service
Penalty
Summary
Food items in the kitchen refrigerator were found unlabeled, undated, and in some cases uncovered during observation with a cook. A transparent pitcher containing a cream-colored pancake mixture was in the refrigerator without a label or date and was covered only with plastic cling wrap. In the same refrigerator, 11 glasses containing liquids such as orange juice, cranberry juice, milk, peach juice, and apple juice were observed uncovered, unlabeled, and undated. The cook stated the pancake mixture was leftover from breakfast and was being kept in case residents wanted it later, and stated there was no explanation for why the other liquids were not covered, labeled, or dated. The kitchen steel rack contained 54 cups of prune juice with a best-by date of 06/29/25. The cook stated they did not know why the prune juice cups were still there and expected them to have been thrown away. Record review also showed missing entries on the dishmachine temperature log for multiple breakfast, lunch, and dinner periods, and missing entries on the three-compartment sink log for multiple morning and afternoon/evening periods. Staff stated they checked and documented these items every mealtime, but the logs reviewed did not contain the expected entries. A sanitizing bucket near the stove was observed with 0 ppm on two test strip checks, and the cloth bucket ppm record showed missing initials and entries, including no entries under the noon column for multiple dates. A cook used a towel from the sanitizing bucket to wipe a food thermometer after checking hamburger steak patties and then used the same towel to wipe the thermometer before checking mashed potatoes. The administrator later instructed the cook to use disposable probe wipes instead. During tray line observation, milk served on meal trays was checked at 49 degrees Fahrenheit and 51 degrees Fahrenheit, both above the expected 41 degrees Fahrenheit stated by staff. In addition, two staff members delivered lunch trays with dessert bowls that were not covered while walking down the hallway to residents' rooms.
Environmental Maintenance Deficiencies in Resident Rooms and Therapy Gym
Penalty
Summary
The facility failed to maintain resident rooms and the therapy gym in a safe, clean, comfortable, and homelike condition for 4 of 15 resident rooms reviewed and 1 of 1 therapy gym reviewed. Observations showed an air vent in one resident room with dust toward the back of the vent louvers and dark grey discoloration on the top four louvers. In two resident rooms, baseboard heater covers were not fully covering the heater fins, and in the therapy gym the baseboard heater had no cover over the heater fins. In another resident room, repeated observations showed scrapes and scratches on the lower door frame walls on each side of the bathroom door frame and on the floor molding. During a joint observation, the Maintenance Director stated the air vent should have been cleaned, the baseboard heaters should have been fully covered, and the damaged lower door frame walls and molding would require a contractor. The Administrator stated that the air vent was expected to have been cleaned, the heater covers fully covering the fins, and the scrapes and scratches patched and painted.
Inaccurate MDS Coding for Immunizations, Anticoagulant Use, and GDR Documentation
Penalty
Summary
The facility failed to accurately complete MDS assessments for 6 of 16 residents reviewed, involving documentation of gradual dose reduction (GDR), immunization status, and anticoagulant use. The report states that inaccurate coding on the MDS placed residents at risk for unidentified and/or unmet care needs and diminished quality of life. The deficiencies were identified through interview and record review and were tied to the facility’s failure to ensure the MDS reflected the residents’ actual status during the applicable look-back periods. For Resident 7, the annual MDS listed the date for antipsychotic medication review and physician documentation of GDR as clinically contraindicated as 09/04/2024, but the medical record also contained a physician mental evaluation and documentation on 09/25/2025 stating GDR was not clinically indicated at that time. Staff acknowledged that the later documentation should have been used in the MDS. For Resident 38, the quarterly MDS coded the influenza vaccine as received outside the facility, but the EHR did not support that coding and the immunization record showed the resident refused the 2025/2026 trivalent influenza vaccine. For Resident 36, the annual MDS coded pneumococcal vaccination as up to date, but the immunization record showed PPSV23 in 2004 and PCV13 in 2019, with no documentation of PCV20 or PCV21 to support up-to-date status. The report also identified inaccurate coding related to influenza vaccine refusal and anticoagulant use. Resident 2’s admission MDS coded influenza vaccine as offered and declined, but the EHR did not show documentation that the vaccine had been offered and declined on or before the assessment date. Resident 3’s admission MDS and Resident 19’s quarterly MDS both coded anticoagulant use during the assessment period, but the MARs reviewed did not show anticoagulant administration during the applicable look-back periods. Staff interviewed stated that these MDS entries were inaccurate and would be modified.
Incomplete Daily Nurse Staffing Posting
Penalty
Summary
The facility failed to ensure that the posted daily nurse staffing information included the facility name and the actual hours worked by registered and licensed nursing staff directly responsible for resident care per shift for 6 of 6 days reviewed. Surveyors observed the facility's Daily Posting of Nursing Staff on 01/13/2026, 01/14/2026, 01/15/2026, 01/16/2026, 01/20/2026, and 01/21/2026, and found that the posting did not include the facility name or the actual hours nursing staff worked for the shift. The facility policy titled, Posting Direct Care Daily Staffing Numbers, revised in August 2022, stated that the Daily Posting of Nursing Staff form shall include the name of the facility and the actual time worked during that shift. In interviews on 01/21/2026, the DON stated the form was completed daily and the actual hours were entered the following day, and the Administrator stated the form was posted daily with total staff and estimated hours for each shift, with actual hours added the following day; the Administrator also stated they would not expect the facility name to appear on the form.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5%, with surveyors identifying 3 medication administration errors out of 28 observed medications for 4 of 5 residents, resulting in a 10.7% error rate. During observation, Staff Q, RN, crushed Resident 35’s ordered Metoprolol Succinate 25 mg ER and mixed it with applesauce even though the manufacturer instructions stated the extended-release tablet should be taken whole and not crushed. Staff Q also administered an Aspirin enteric-coated 81 mg tablet to Resident 10 even though the MAR ordered an 81 mg chewable tablet, and stated the chewable form was not available in the medication cart. Surveyors also observed Staff R, LPN, prepare 10 mL of Tussin DM containing dextromethorphan and guaifenesin for Resident 12 instead of the ordered guaiFENesin oral syrup; the medication was stopped before administration. For Resident 31, whose quarterly MDS dated 12/19/2025 showed intact cognition, the MAR ordered Fluticasone Propionate Nasal Suspension 50 mcg/actuation, 1 spray in both nostrils twice daily for allergies as unsupervised self-administration, but Staff S did not include the nasal spray in the morning medication pass. Staff S later stated the medication did not appear on the EMAR and Resident 31 reported being out of the nasal spray for three days.
IPCP annual review not documented and droplet precautions not followed
Penalty
Summary
The facility failed to ensure its Infection Prevention and Control Program (IPCP) policies and procedures were reviewed annually. Review of the IPCP policies showed several were not updated at least yearly, including Antibiotic Stewardship last revised in December 2016, Infection Surveillance last revised in September 2017, Legionella Surveillance and Detection last revised in September 2022, Influenza Vaccine and Pneumococcal Vaccine last revised in March 2022, and Coronavirus Disease (COVID-19) Vaccination last revised in May 2023. During a telephone interview and record review, the DON/Infection Preventionist and the Regional President for Operations stated they reviewed IPCP policies annually and discussed them in QAPI meetings, but no documentation of the annual review was provided by the facility. The facility also failed to ensure Transmission Based Precautions (TBP) were followed by three staff members. Staff J, a Restorative Aide, entered a droplet precaution room wearing a face mask, gown, goggles, and gloves, but later exited the room and stated they did not change their face mask after leaving the room, even though they were expected to do so. Staff O, a CNA, delivered a breakfast tray to a resident on droplet precautions while wearing a face mask but without a face shield or goggles, leaned over the resident who was coughing, and then exited the room without removing or changing the face mask. Staff O stated they should have worn a face shield and changed the mask for residents on droplet precautions. Staff V, a Laundry Staff member, was observed delivering care supplies to multiple resident rooms while wearing a mask but no face shield or goggles, entering a droplet precaution room without changing the mask on exit, and then entering several other rooms without performing hand hygiene before entering or after exiting the rooms. Droplet precaution signage outside the room instructed staff to clean their hands before entering and when leaving the room, cover eyes, nose, and mouth before room entry, and remove face protection before room exit. Staff V stated they should have worn a face shield, removed their mask before leaving the room, worn a new one before entering the next rooms, and performed hand hygiene before and after each room entry.
Failure to Maintain and Offer Up-to-Date Pneumococcal Vaccinations
Penalty
Summary
The deficiency involves the facility’s failure to ensure pneumococcal vaccinations were current and properly offered in accordance with its own policy and CDC recommendations. The facility’s pneumococcal vaccine policy, revised in March 2022, states that all residents are to be offered pneumococcal vaccines to prevent pneumonia and pneumococcal infections, that residents are to be assessed for eligibility prior to or upon admission, and that indicated vaccines are to be offered within 30 days of admission. The policy also states that administration is to follow current CDC recommendations. CDC guidance cited in the report specifies that an adult who previously received both PCV13 and PPSV23, but did not receive PPSV23 at age 65 or older, should receive one dose of PCV20 or PCV21 at least five years after the last pneumococcal vaccine dose. For one resident, admitted on an unspecified date, review of the EHR showed no pneumococcal immunization record and no documentation that the pneumococcal vaccine was offered, contrary to the facility’s policy requiring assessment and offering within 30 days of admission. For another resident born in 1950, the immunization record showed receipt of PPSV23 in 2004 and PCV13 in 2019, but no documentation that the recommended follow-up dose of PCV20 or PCV21 was offered or administered at least five years after the 2019 dose, as required by the cited CDC schedule. During a joint phone interview and record review, the DON stated that pneumococcal vaccines were offered annually and that CDC guidelines were followed, but acknowledged that one resident’s pneumococcal immunization was not up to date, and the regional operations staff confirmed that neither the missing pneumococcal record for the first resident nor the PCV20/PCV21 record for the second resident could be found in the EHR.
Failure to Maintain Documentation of Staff COVID-19 Vaccination Status
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to maintain documentation of COVID-19 vaccination status for a staff member. The facility’s policy, revised in May 2023 and titled “Coronavirus Disease (COVID-19)-Vaccination of Staff,” stated that staff would provide documentation of their vaccination, that the infection preventionist would maintain a tracking worksheet of staff and their vaccination status, and that the facility would maintain documentation related to staff COVID-19 vaccination status. Review of the staff list showed that a CNA, hired on 11/03/2025, was among the staff for whom COVID-19 immunization status was to be documented. During an interview, the CNA stated they had received their COVID-19 vaccination in another state and had provided a copy of their vaccination status to the facility. In a subsequent phone interview, the DON stated that the facility kept COVID-19 vaccination records for staff and indicated that Human Resources (HR) had this CNA’s vaccination record. A regional operations leader also stated that HR staff were not in the building and that they would look in the HR office for the CNA’s vaccination record. By the end of the surveyor’s follow-up on the same day, no information or documentation regarding the CNA’s COVID-19 vaccination status was provided, demonstrating the facility’s failure to produce required documentation in accordance with its policy and WAC 388-97-1620(2)(b)(i)(ii).
Failure to Assess and Document Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that Resident 23 was evaluated, assessed, and care planned for self-administration of medications. The facility policy stated that residents may self-administer medications only if the interdisciplinary team determines it is clinically appropriate and safe, and that this decision must be documented in the medical record and care plan. However, review of Resident 23’s EHR, physician orders, and care plan printed on 01/15/2026 did not show any documentation for assessment, evaluation, physician order, or care plan related to self-administration of medications. Observations on 01/13/2026 and 01/15/2026 showed two prescription tubes of Lidocaine 2% cream and one prescription bottle of Ammonium Lactate 12% lotion on Resident 23’s bedside table. During interview, Resident 23 stated they did not apply the Lidocaine cream and that nurses at the facility and dialysis center applied it, but that they did apply the Ammonium Lactate lotion themselves to their arms, feet, and legs and kept both medications on the bedside table. Staff stated that if a resident wants to self-administer medications, they would assess cognition and monitor the resident, but the record review showed no documentation supporting self-administration. The DON and Regional President of Operations also stated they expected residents who self-administer medications to have an assessment, physician order, and care plan, and the record review did not show these documents.
Failure to Document Advance Directive Discussion
Penalty
Summary
The facility failed to provide information regarding advance directives for Resident 3, who was admitted to the facility on [DATE]. Review of the facility policy titled, Advance Directives, showed that upon admission the facility would inquire about the existence of any written advance directive and provide written information about formulation of an advance directive. However, review of Resident 3's EHR did not show documentation that an advance directive had been discussed or that Resident 3 had been provided information about advance directives. During an interview on 01/14/2026, Resident 3 stated that they knew what an advance directive is but did not remember it being discussed. Staff E, Social Worker, stated that advance directives were discussed upon admission, during care conferences, and as needed, and said the information had been provided to Resident 3, mostly by phone. A joint record review did not show documentation that advance directives were discussed with Resident 3, and Staff E later stated there was no documentation to support that the advance directive was discussed. The Administrator also stated there was no documentation that an advance directive was discussed or offered to Resident 3 and that it should have been discussed.
Failure to Investigate Resident Fall Incident
Penalty
Summary
The facility failed to thoroughly investigate a reported incident involving Resident 8, who had intact cognition on the admission MDS dated 11/28/2025. Resident 8 stated that on 01/08/2026, while returning from an appointment via medical transport, the driver pushed the wheelchair up a ramp, the wheelchair rolled back, and the resident hit the ground. Resident 8 said they informed a therapist about the incident when they returned to the facility and were later sent to the hospital for further evaluation. A therapy progress note documented by Staff U on 01/08/2026 recorded that Resident 8 had a fall when they went out for an appointment, but no other documentation related to the fall was found in the EHR, and the incident did not appear on the facility's January 2026 incident log. Staff interviews showed that Resident 8 told Staff U about neck pain and the fall, Staff Y was present during that conversation, and Staff Y said they spoke with nursing and told Staff D that the wheelchair tipped over. Staff D stated that Resident 8 reported the incident to them, that they informed Staff B verbally right away, and that Resident 8 was sent to an acute care hospital for evaluation. Staff D said they were not aware of any investigation. Staff B stated they did not do an investigation because Resident 8 said the wheelchair tipped rather than that they had a fall, but also acknowledged they were expected to investigate accidents and incidents and said they should have done more of an investigation.
Failure to Provide Written Transfer and Bed-Hold Notices
Penalty
Summary
The facility failed to provide written bed-hold and/or transfer notices for two residents who were transferred to the hospital. For Resident 25, the record showed an unplanned discharge to a short-term general hospital, and a nursing progress note documented that the resident was discharged for further evaluation. Review of the record did not show that a bed-hold notice or written transfer notice was provided to the resident or the representative. During interview and record review, the Social Services Director stated the facility’s process was to provide the bed-hold notice after the resident transferred to the hospital, but acknowledged that no bed-hold notice had been provided to Resident 25 or the representative and that the communication about the transfer was only verbal, with no written notice given. For Resident 32, the record showed the resident was transferred to the hospital, but the electronic record did not contain written notification of transfer or discharge for the resident or the representative. Joint record review also showed an eINTERACT Transfer Form that was incomplete and blank. Staff stated that the transfer/discharge process included provider notification, provider order, completion of the eINTERACT Transfer Form, family notification, and progress note documentation, but confirmed that the transfer form was not completed for Resident 32 and that no written notice had been provided.
Failure to Develop Care Plans for Wound, Medication, and Dementia Needs
Penalty
Summary
The facility failed to develop and/or implement comprehensive care plans for 3 residents reviewed for care planning. Resident 2 was admitted with severe cognitive impairment and was receiving anticoagulant and diuretic medications during the assessment period; the resident also developed a facility-acquired pressure ulcer on the left heel, which was being treated by nursing staff. Review of the resident’s comprehensive care plan showed no care plans for the pressure ulcer, anticoagulant medication, or diuretic medication, and staff confirmed these care plans had not been initiated. Resident 15 was prescribed and receiving Torsemide for congestive heart failure, but the comprehensive care plan contained no care plan for diuretic medication. Resident 36 was readmitted with a diagnosis that included dementia, but the comprehensive care plan contained no care plan for dementia. Staff stated that Resident 36 had an impaired cognitive function care plan, but no separate dementia care plan, and staff confirmed there was no dementia care plan specifically in place.
Care Conference Not Documented for Resident
Penalty
Summary
The facility failed to ensure that a care conference or care plan meeting was conducted for Resident 3, and the record did not show that the resident participated in or refused participation in the care planning process. Resident 3 was admitted to the facility, and a social services progress note dated 10/15/2025 showed that a care conference was scheduled for 10/17/2025. During interview, Resident 3 stated they did not remember participating in a care conference or care plan meeting. Review of the electronic health record did not show documentation that the scheduled care conference took place or that Resident 3 had been involved in the care planning process. The Social Services Director stated that care conferences were scheduled and invites were sent to the interdisciplinary team, the resident, and/or the resident's representative, and that documentation could be from anyone attending the conference. The Admission/MDS Nurse stated that care plans were developed during the MDS process and upon admission, and that the resident and/or representative were involved through a care plan meeting with the interdisciplinary team, but also stated there was no proof in the record that a care conference had occurred. The DON and Regional President for Operations likewise stated that residents were expected to be involved in care planning, but the record still did not show that a care conference was held or that Resident 3 participated or refused.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
The facility failed to provide necessary bathing services to maintain personal hygiene for one resident who was dependent on staff for showering and bathing. The resident had a diagnosis that included generalized muscle weakness and, according to the quarterly MDS dated 12/23/2025, had intact cognition and required dependent assistance with shower/bathing. The resident stated in interview that bed baths were not being provided consistently and reported going without a bed bath for up to two and a half weeks. The resident’s Kardex directed dependent assistance with showering, with bed baths to be offered if the resident chose not to shower, and the shower schedule listed bathing on Tuesdays and Saturdays. Record review showed multiple scheduled bathing entries in November and December 2025 and January 2026 were blank or documented as “Activity itself did not occur.” Progress notes from 11/01/2025 through 01/21/2025 contained no documentation that the resident refused showers or bathing. Staff interviews confirmed the resident was dependent with bathing and that refusals should have been documented as refusals and reported, rather than recorded as activity not occurring.
Unsecured Oxygen Storage Room Door
Penalty
Summary
The facility failed to ensure the oxygen storage room door electronic keypad lock was functioning and locked. Observations on 01/13/2026 at 2:58 PM, 01/14/2026 at 8:29 AM, 01/16/2026 at 3:51 PM, and 01/20/2026 at 8:43 AM showed the oxygen storage room door was unlocked and accessible without entering the keypad code. During a joint observation on 01/20/2026 at 9:42 AM, a CNA stated the keypad-locked doors were supposed to be locked so residents would not have access and get hurt, and the oxygen storage room door was again observed unlocked and accessible. During another joint observation on 01/20/2026 at 11:07 AM, the Maintenance Director stated the keypad-locked doors were for safety, and the oxygen storage room door was again observed unlocked and accessible; he stated it should have been locked and not accessible to residents or unauthorized people because of the safety of oxygen tanks, oxygen liquid refill, and explosion risks. In a phone interview on 01/21/2026 at 3:03 PM, the Administrator stated the oxygen storage room electronic keypad lock should have been functioning and should have been locked.
Feeding Tube Formula and Flushes Not Administered or Documented as Ordered
Penalty
Summary
Enteral nutrition was not administered in accordance with the physician’s order for Resident 2, who was severely cognitively impaired, dependent on staff for all aspects of care, and received all nutrition and water through a feeding tube. The physician ordered Osmolite 1.2 CAL via pump at 85 mL per hour with 60 mL water flushes every hour, but observations on 01/13/2026, 01/14/2026, and 01/21/2026 showed the formula running at 75 mL per hour instead of the ordered rate. During these observations, the TF formula bottle and water flush bag were also not labeled or dated. Record review showed the care plan directed staff to provide enteral feeding as ordered and record intake on the MAR, but the MAR and TAR for November 2025, December 2025, and January 2026 did not show documentation of the total amount of formula or water flush provided daily. During interview, an RN stated they were following the TF physician order, but also stated they were not documenting the total amount of formula or water flush administered at the end of the shift. The DON stated staff were expected to label the TF formula and water flush bag with date and time, follow the TF physician order, and document the amount of formula and water flush infused during the shift.
CPAP Mask Improperly Stored and CPAP Settings Order Missing
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met for Resident 19, who was admitted with a diagnosis that included obstructive sleep apnea and had intact cognition on the quarterly MDS. The January 2026 TAR showed an order for CPAP assist to set up and take off daily two times a day with a start date of 09/05/2024, and the care plan included altered respiratory status/difficulty breathing related to sleep apnea with an intervention for CPAP settings per orders as tolerated. Record review showed the active order summary did not include a physician order for the resident’s CPAP settings. During multiple observations, the CPAP machine was on the nightstand and the nasal mask was left uncovered in the nightstand drawer with the resident’s personal items, and later was observed uncovered on the bed. The resident stated they did not know their CPAP settings and said the nasal mask was always stored in the nightstand drawer when not in use. Staff D and Staff B stated the mask should be stored in a bag and labeled when not in use, and Staff B stated the CPAP setting order should have been entered in the resident’s medical record.
Improper storage of vaccines and resident medications
Penalty
Summary
Drugs and biologicals were not stored in accordance with accepted professional principles when the facility kept two vials of pneumonia vaccine in the medication room refrigerator but did not check the refrigerator temperature twice daily as directed when vaccines were present. The facility’s January 2026 temperature log showed the refrigerator was checked once each morning from 01/01/2026 through 01/19/2026, except on 01/13/2026, despite the written instruction on the log stating that temperatures needed to be taken twice daily when vaccines were present. Staff B, the DON, stated that the medication refrigerator temperature should have been checked twice a day. The facility also failed to properly store medications for Resident 23. Review of the resident’s record showed no assessment, provider order, or care plan for self-administration of medications. During observations, Resident 23 had two prescription tubes of lidocaine 2% cream and one prescription bottle of ammonium lactate 12% on the bedside table, and a later observation again found one tube of lidocaine cream and one bottle of ammonium lactate on the bedside table. Staff S stated the resident’s records did not show that the resident could self-administer medications and said the lidocaine cream and ammonium lactate lotion should not have been on the bedside table. Staff B stated the medications should have been stored in a locked box with a key or in a place where they could be locked up.
Inadequate Dietary Staff Training and Sanitization Practices
Penalty
Summary
The facility failed to employ sufficient staff that were adequately trained to properly perform kitchen sanitization practices and safely carry out meal preparation functions for two dietary staff members reviewed for food safety. The deficiency was identified during observation, interview, and record review and involved sanitizing bucket procedures and the use of a food thermometer in the kitchen. The report cited WAC 388-97-1160 and noted that the failures placed residents at risk for food-borne illnesses and a diminished quality of life. Staff L, a dietary aide hired on 11/16/2020, stated during a joint observation that sanitizing buckets were tested three times a day and logged in the kitchen form. When asked to demonstrate, Staff L dipped a test strip into the sanitizing bucket and stated it was 200 ppm based on the strip being green, without comparing it to a color chart. Staff L stated they had not used a color chart to show the result of the test. Staff M, a cook hired on 12/23/2025, was observed preparing the sanitizing bucket and later using a food thermometer on hamburger steak patties and mashed potatoes. Staff M wiped the thermometer with a towel from the sanitizing bucket between temperature checks and stated this was the process they had been using. Staff M also stated they did not know about the color chart for sanitizer testing. The Administrator later instructed Staff M to use disposable probe wipes for the thermometer. Record review showed blank, undated, and unsigned skills performance checklists, and the Administrator stated there was no dietary manager or food service director and that staff training had been limited to discussion rather than demonstration.
Failure to Follow Two-Person Assist Care Plan During Incontinence Care
Penalty
Summary
A deficiency occurred when staff failed to follow the care plan for a resident with paraplegia and Multiple Sclerosis, who required two-person assistance for incontinence care and repositioning. The resident, who had intact cognition, was care-planned for two-person assistance as documented in the Care Plan Kardex. Despite this, a Certified Nursing Assistant (CNA) provided incontinence care alone, without the required second staff member present. During the incident, the resident fell out of bed while being changed by the CNA, who admitted to performing the care alone due to insufficient staffing. The Director of Nursing Services confirmed that the care plan required two-person assistance and that the CNA did not follow this directive. The facility's policy and the resident's care plan both specified the need for two-person assistance, which was not adhered to at the time of the fall.
Failure to Implement Non-Pharmacological Pain Interventions and Monitor Side Effects
Penalty
Summary
The facility failed to initiate non-pharmacological interventions for pain management prior to administering as-needed pain medications for a resident with a lower back fracture and associated pain. Review of the resident's Medication Administration Records (MAR) for February and March 2025 showed multiple administrations of Methocarbamol and Oxycodone, both as-needed, without documentation that non-pharmacological interventions were attempted beforehand, despite physician orders listing several such interventions. Interviews with nursing staff and the Director of Nursing confirmed that the expectation was to try non-pharmacological methods before administering as-needed pain medications, but there was no evidence these were offered or documented prior to medication administration. Additionally, the facility did not adequately monitor for adverse side effects of the pain medications given to the resident. The lack of documentation and implementation of non-pharmacological interventions, as well as insufficient monitoring for medication side effects, were identified through record review and staff interviews. These failures were found during the review of the resident's care and medication records, as well as through direct questioning of facility staff and leadership.
Failure to Adequately Monitor and Document Antipsychotic Medication Side Effects
Penalty
Summary
The facility failed to ensure adequate monitoring of antipsychotic medication for a resident admitted with a diagnosis that included delirium. The resident had physician orders for Quetiapine, an antipsychotic, with instructions to monitor for specific side effects every shift and to document 'Y' if side effects were observed and 'N' if not. However, review of the Medication Administration Records (MAR) for February and March showed that staff used check marks instead of the required 'Y' or 'N', making it unclear whether side effects were observed or not. Interviews with nursing staff and the Director of Nursing Services confirmed that the documentation system was not followed as intended, and the check marks did not indicate if the resident experienced any side effects from the antipsychotic medication. This lack of clear documentation failed to meet the requirement for monitoring and documenting potential adverse effects of unnecessary drugs, as specified by facility policy and regulatory standards.
Failure to Follow PPE Protocols for COVID-19 Positive Resident
Penalty
Summary
Staff failed to follow proper Personal Protective Equipment (PPE) protocols when caring for a resident who had tested positive for COVID-19. Specifically, a registered nurse entered the room of a resident on aerosol and contact precautions without donning the required PPE, which included a respirator/N95 mask, eye protection, gown, and gloves. Signage was posted at the resident's door indicating the need for these precautions, and the resident's positive COVID-19 status was documented in the medical record. Interviews with facility staff, including the interim administrator and the Director of Nursing Services/Infection Preventionist, confirmed that the expectation was for all staff to use full PPE when entering rooms of residents with COVID-19. The registered nurse acknowledged awareness of the resident's COVID-19 status and the PPE requirements but did not comply with the protocol at the time of observation.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide necessary supervision for a resident at risk of elopement, resulting in the resident leaving the facility unsupervised. The resident, who had dementia and required assistance for all care, was admitted with a history of attempts to leave the facility unattended. Despite having a device to alert staff when the resident approached monitored exit doors, the resident managed to elope. On the day of the incident, the resident was found missing at approximately 5:15 PM, prompting a search by facility staff both inside and outside the premises. The police were notified, and the resident was eventually found at a shopping center one and a half miles away from the facility at 6:35 PM. Interviews with staff revealed that the facility had alarms on all exit doors, which were supposed to sound when the resident approached. Staff members, including the Maintenance Supervisor, Certified Nursing Assistant, and Registered Nurse, confirmed that the alarms were functional and could be heard throughout the facility. However, the Director of Nursing Services admitted uncertainty about how the resident managed to leave the facility undetected. The care plan for the resident indicated that the device on the resident's wrist was to be checked every shift, but the report does not specify if this was done on the day of the incident.
Survey Results Not Readily Accessible
Penalty
Summary
The facility failed to ensure that survey results were posted in a location that was readily accessible to residents and their legal representatives. Observations on three separate occasions revealed that the facility lobby did not have a survey binder available for residents and their representatives. During an interview, a resident mentioned that they would need to ask the business office to view the survey results, as they had not seen a survey binder in the lobby. Additionally, the facility's administrator stated that the survey binder was kept by the business office window in the lobby but was not currently out because it was in their office for survey preparation.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to accurately assess five residents using the Minimum Data Set (MDS), an essential assessment tool. Resident 9's quarterly MDS did not mark the use of antibiotics, despite the Medication Administration Record (MAR) indicating the administration of Rifaximin during the look-back period. Staff G, the Admission/MDS Coordinator, acknowledged the oversight during a joint record review. Similarly, Resident 17's admission MDS inaccurately recorded the number of insulin injections and failed to mark the use of anticoagulants, contrary to the MAR records. Staff G confirmed these discrepancies, noting that the insulin injections should have been coded as six instead of seven, and the anticoagulant use should have been marked. Resident 3's admission MDS failed to mark the use of an intrathecal pain medication pump as IV medication in Section O, despite physician orders indicating its presence since admission. Staff G confirmed the inaccuracy during a joint record review. Resident 31's admission MDS also did not mark the use of diuretic medication, despite physician orders and Staff B's acknowledgment of the resident's diuretic use. These inaccuracies in the MDS assessments were confirmed by the staff involved, who admitted to the errors during interviews and joint record reviews. Resident 4's quarterly MDS inaccurately marked the resident's eating ability as dependent, despite the resident receiving 100% of sustenance through tube feeding. Staff G admitted the error, stating that the MDS should have been marked as not applicable or not attempted due to medical conditions. Staff B, the Director of Nursing, expressed an expectation for accurate MDS coding and acknowledged the inaccuracies in the assessments of all the residents involved.
Deficiency in Respiratory Care Due to Improper Oxygen Equipment Management
Penalty
Summary
The facility failed to maintain, label, date, and properly store oxygen tubing and nasal cannulas for four residents, leading to a deficiency in respiratory care. Resident 9, who was admitted with heart failure, was observed using a nasal cannula that was not labeled or dated. Both the resident and the staff were unaware of when the oxygen tubing was last changed, which is contrary to the facility's policy that requires nasal cannulas to be changed weekly and dated. Resident 22, diagnosed with respiratory failure with hypoxia, was found using an undated nasal cannula. Additionally, another nasal cannula was improperly stored on the resident's wheelchair seat without a bag. Staff confirmed the lack of labeling and improper storage, acknowledging that nasal cannulas should be dated and stored in a bag when not in use. Resident 32, also with respiratory failure, was observed using a new but undated oxygen tubing, and staff admitted to not labeling it despite the facility's expectations. Resident 28, with respiratory failure and congestive heart failure, was using oxygen without any physician orders documented. The resident's oxygen cannula was found on the floor, undated, and improperly stored. Staff interviews revealed a lack of awareness regarding the resident's oxygen orders and the need for regular changes of the oxygen tubing. The facility's policy was not followed, as the oxygen cannulas were not dated, and there were no documented orders for oxygen use or tubing changes.
Failure to Post Daily Nurse Staffing Information Prominently
Penalty
Summary
The facility failed to ensure that the daily nurse staffing form was posted in a prominent location accessible to residents, their representatives, and visitors. According to the facility's policy, the staffing numbers, including the number of licensed nurses and unlicensed nursing personnel, should be posted within two hours of the beginning of each shift in a clear and readable format. However, observations on two separate days revealed that the staffing form was posted in the south area of the facility along with other notices, making it not visible to residents and visitors. Further observations confirmed that there were no other postings of the daily nurse staffing form in other areas of the facility. Interviews with residents and staff highlighted the lack of awareness and visibility of the staffing postings. One resident, who had been in the facility for eight years, stated they were unaware of the staffing postings and had never seen them, relying instead on counting the nurses and aides themselves. Another resident, who had been in the facility for three months, also reported not seeing the postings and not being informed about them. Staff F, responsible for completing and posting the forms, confirmed that the postings were only placed in the south area. The facility administrator acknowledged that the postings should be in a prominent place accessible to all.
Deficiencies in Medication Labeling and Storage
Penalty
Summary
The facility failed to properly label and store drugs and biologicals, as well as manage expired medical supplies and tube feeding formulas. During an observation and interview, an undated multi-dose vial of Tuberculin PPD was found in the medication room refrigerator. Additionally, several medications on the South Medication Cart, including eye drops and nasal spray, were opened and undated, with one eye drop bottle lacking a resident's name. These actions were contrary to the facility's policy, which requires medications to be dated when opened and labeled with the resident's name. Furthermore, the facility did not ensure the removal of expired medical supplies and tube feeding formulas from the medication storage room. Expired foam dressings and disposable syringes were found, along with tube feeding formulas past their expiration dates. Staff members acknowledged that these items should have been discarded, indicating a lapse in adherence to the facility's policies regarding the management of medical supplies and medications.
Deficiencies in Sanitization and Food Storage Practices
Penalty
Summary
The facility failed to periodically test the sanitizing solution used in the kitchen to ensure proper sanitation of food preparation surfaces. Observations and interviews revealed that the Three-Compartment Sink Sanitizing Solution PPM Log was not consistently filled out, with missing documentation for certain dates. The sanitizing solution levels were found to be below the recommended 200 ppm on multiple occasions, and the sanitizing bucket was not replaced or changed as required. Staff acknowledged that the readings were guesstimates and should have been corrected according to the manufacturer's recommendations. Additionally, the facility did not consistently monitor and document refrigerator temperatures for the snack refrigerator located in the nurse station. Observations showed that the refrigerator contained various food items but lacked a thermometer and documentation of temperature checks. Staff interviews confirmed that there were no temperature logs available for the snack refrigerator for the current or previous months, indicating a lapse in monitoring practices. Furthermore, the facility failed to properly label, date, and discard nutritional supplements in the food refrigerator within the medication storage room. An open container of Ensure was found undated, contrary to the label instructions that required it to be used within 48 hours of opening. Staff admitted to not knowing when the container was opened and acknowledged that it should have been dated. This oversight in labeling and discarding practices placed residents at risk for foodborne illness.
Deficiencies in Infection Control and Water Management
Penalty
Summary
The facility failed to implement a comprehensive water management program to assess and monitor potential risks for exposure to Legionella and other waterborne pathogens. Despite having a policy in place, the Maintenance Supervisor and Director of Nursing/Infection Preventionist did not conduct any testing, citing the absence of standing water and reliance on city water. The facility had only recently completed a schematic flow diagram of the water system, and there was no evidence of ongoing checks to ensure the water system was free of Legionella. The facility also failed to adhere to Enhanced Barrier Precautions (EBP) for a resident with a gastrostomy. Observations revealed that staff did not wear gowns during high-contact care activities, such as tube feeding and changing incontinent briefs, despite EBP signage outside the resident's room. Staff interviews confirmed the lack of PPE carts and inconsistent use of gowns, indicating a failure to follow the facility's EBP policy. Additionally, the facility did not properly sanitize transfer lift equipment between uses. Observations showed that staff used inappropriate wipes intended for personal hygiene rather than disinfectant wipes to clean the Hoyer lifts. Interviews with staff revealed a misunderstanding of the correct sanitization procedures, and the expected use of disinfectant wipes was not consistently followed, as evidenced by the availability of proper disinfectant wipes at the nurse's station.
Pest Control Deficiency: Persistent Fly Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a significant presence of houseflies in resident rooms, the dining room, and the kitchen. Observations revealed flies on residents, their meals, and personal items, such as a fly on Resident 29's bedside table and another on Resident 5's forehead. Residents reported seeing flies in their rooms and the dining area, with one resident noting a fly attempting to enter their ear. Staff and residents consistently observed flies over several days, indicating a persistent issue. In the dining room, multiple observations during meal times showed flies landing on meal trays, tables, and residents, with counts reaching up to 32 flies at one point. Staff members, including a CNA and the Dietary Manager, confirmed the presence of flies and reported the issue to maintenance. Despite pest control treatment, flies continued to be observed in the dining room and kitchen, with flies seen on a sink hose handle and in the Dietary Manager's office. The facility's administrator acknowledged the issue, stating that they were unaware of fly problems until a resident reported a fly in their drink.
Violation of Resident Dignity During Medication Administration
Penalty
Summary
The facility failed to ensure a homelike dining experience for Resident 94, which compromised their dignity and quality of life. During an observation, a Registered Nurse, Staff N, administered oral medications to Resident 94 in the main dining room during breakfast, in the presence of seven other residents. Staff N informed Resident 94 about the medications and their purposes in front of these other residents. This action was contrary to the facility's policy, which states that medications should be administered in a safe and timely manner based on resident need and benefit, not staff convenience. The Director of Nursing, Staff B, confirmed that medications should not be given in the dining room unless specified in the resident's care plan, indicating that Staff N's actions were inappropriate.
Incomplete Investigations into Abuse and Fall Incidents
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse and neglect for two residents, which placed them at risk for repeated incidents and inappropriate corrective actions. For Resident 3, who was cognitively intact, the investigation into an incident where another resident patted their cheek and head was incomplete. The investigation lacked interviews with Resident 29 or other witnesses, documentation of care provided to Resident 3, skin assessments, and evidence that abuse or neglect was ruled out. For Resident 31, who had severe cognitive impairment, the facility did not conduct thorough investigations into two fall incidents. The investigations lacked witness statements, documentation of care provided, skin assessments, and evidence of neurological checks. Additionally, there was no documentation showing that care plan interventions were reviewed or updated. Staff members acknowledged the deficiencies in the investigation process, indicating a failure to adhere to established guidelines and expectations.
Failure to Provide Transfer/Discharge Notice
Penalty
Summary
The facility failed to provide a written transfer/discharge notice to a resident and/or their representative, specifically for Resident 28, who was hospitalized. This deficiency was identified during a review of the facility's policy and the resident's electronic health records. The policy, revised in October 2024, states that in cases of emergency transfers, notice should be provided as soon as practicable. However, there was no documentation in the electronic health record indicating that Resident 28 was offered or provided a transfer/discharge notice when they were discharged to the hospital on August 17, 2024. Interviews with facility staff revealed that the expected protocol was not followed. Staff D, the Social Services Director, confirmed the absence of documentation for the transfer/discharge notice in Resident 28's records and noted that it was a weekend when the transfer occurred. Staff O, a Registered Nurse, and Staff B, the Director of Nursing, both stated that residents should receive a transfer/discharge notice at the time of discharge to the hospital. The lack of documentation and adherence to the facility's policy placed Resident 28 and their representative at risk of not being informed about the transfer or discharge.
Failure to Provide Bed Hold Notice During Hospital Transfer
Penalty
Summary
The facility failed to provide a bed hold notice to a resident, identified as Resident 28, during their transfer to a hospital. According to the facility's policy titled 'Bed Holds and Returns,' residents or their representatives should receive written information about bed-hold policies at least twice: once in advance of any transfer and again at the time of transfer, or within 24 hours if the transfer was an emergency. However, a review of Resident 28's electronic health records for August 2024 showed no documentation that a bed hold notice was offered when the resident was discharged to the hospital on August 17, 2024. Interviews with facility staff confirmed the oversight. During a joint record review and interview, the Social Services Director, Staff D, acknowledged the absence of documentation for the bed hold notice in Resident 28's records. Additionally, the Director of Nursing, Staff B, stated that it was expected for bed hold notices to be provided to residents upon discharge to the hospital, indicating that Resident 28 should have received a written notice as per the facility's policy.
Failure to Complete PASARR Level I for Resident
Penalty
Summary
The facility failed to ensure the completion of the Preadmission Screening and Resident Reviews (PASARR) Level I for a resident, identified as Resident 17, who was reviewed for unnecessary medications. The PASARR process is crucial for determining if individuals with Serious Mental Illness (SMI) or Intellectual/Developmental Disabilities (ID/DD) are appropriately placed in nursing homes. The facility's policy requires that all new admissions and readmissions be screened for mental disorders, intellectual disabilities, or related disorders. If the Level I screen indicates potential criteria for these conditions, a referral for a Level II evaluation is necessary. However, Resident 17's PASARR, signed on 08/06/2024, was marked 'yes' for SMI and mood disorders, but the Section IV (Services Needs and Assessor Data) was not completed, and there was no record of a Level II evaluation in the resident's Electronic Health Record (EHR). During an interview, the Social Services Director, Staff D, acknowledged that they review PASARR forms upon receipt from the hospital and modify them as needed. Despite sending multiple Level II PASARRs, Staff D was unsure why Resident 17's Level II evaluation was not sent. The facility administrator, Staff A, stated that they expected the PASARR Level I form to be completed before a resident's admission. This oversight placed Resident 17 at risk of not receiving appropriate care and services tailored to their needs, as required by the Washington Administrative Code (WAC) 388-97-1915.
Failure to Implement Care Plans for Diuretic Medications
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents who were prescribed diuretic medications. Resident 31, who was admitted to the facility on an unspecified date, had a physician's order for diuretic medication dated June 16, 2024. However, a review of the care plan on October 30, 2024, revealed that there was no care plan in place for the use of diuretic medication. This oversight was confirmed during a joint record review and interview with a registered nurse, who acknowledged that a care plan should have been developed. Similarly, Resident 17, admitted with diagnoses including essential hypertension and end-stage renal disease, had physician orders for diuretic medication twice a day starting August 6, 2024. Despite this, a care plan for the use of diuretic medication was not added until October 30, 2024, over two months after admission. The Director of Nursing confirmed that the care plan should have been included at the time of admission. These deficiencies indicate a failure to adhere to the facility's policy requiring comprehensive, person-centered care plans to be developed and implemented within a specified timeframe.
Inconsistent ADL Assistance for Residents
Penalty
Summary
The facility failed to consistently provide assistance with Activities of Daily Living (ADL) for two residents, specifically in the area of showers and bathing. Resident 34 expressed a desire for more frequent showers than the once-a-week schedule allowed, and despite communicating this preference to the staff, the resident did not receive the additional showers as per their care plan. The care plan indicated that Resident 34 should receive showers two to three times a week, but records showed they only received showers on three occasions in October 2024. Staff interviews revealed a lack of adherence to the shower schedule and documentation of showers given or refused. Similarly, Resident 26 reported having only received three showers since admission, with the last one occurring a month prior. The resident's care plan required total assistance with bathing, yet documentation showed only one shower provided in October 2024. Staff interviews confirmed that showers were scheduled but not consistently documented or provided, with no records of refusals. Both residents were at risk for poor hygiene due to the facility's failure to adhere to their care plans and document the provision or refusal of showers.
Failure to Provide Diabetic Nail Care and Monitor Medication Side Effects
Penalty
Summary
The facility failed to provide diabetic nail care for a resident with diabetes, as outlined in their care plan. The resident was admitted with a diagnosis of diabetes and was supposed to receive nail care on bath/shower days, which were scheduled for Saturdays. However, the facility did not have an order for diabetic nail care in the resident's treatment administration records, and the care was not documented as provided. Staff acknowledged that the nail care should have been scheduled and documented, but it was not included in the physician's orders or the Medication Administration Record (MAR). Additionally, the facility did not monitor two residents who were on diuretic and anticoagulant medications for adverse side effects. One resident, with diagnoses including atrial fibrillation and end-stage renal disease, had orders for these medications but lacked monitoring orders for potential side effects. Similarly, another resident with a diagnosis of nontraumatic subarachnoid hemorrhage was on anticoagulant medication without orders to monitor for adverse effects. Staff confirmed the absence of monitoring orders in the MARs for both residents, which was expected to be in place according to the facility's policy.
Failure to Monitor Antibiotic Use and Side Effects
Penalty
Summary
The facility failed to ensure proper monitoring of antibiotic side effects and the appropriate use of antibiotics for a resident, which was identified during a survey. The facility's policy on Antibiotic Stewardship, revised in December 2016, mandates monitoring antibiotic use among residents, including training on the consequences of inappropriate antibiotic use. This includes the relationship between antibiotic use and gastrointestinal disorders, opportunistic infections, medication interactions, and the development of drug-resistant pathogens. The policy also requires prescribers to provide complete antibiotic orders, including drug name, dose, frequency, duration, route, and indication for use. In the case of Resident 22, a review of the October 2024 Medication Administration Record (MAR) revealed an order for Levofloxacin, an antibiotic, without a documented indication for its use. Additionally, there was no monitoring for adverse side effects related to the antibiotic on the MAR. During a joint record review and interview, the Director of Nursing acknowledged the absence of an indication for the antibiotic and the lack of monitoring for side effects, indicating a need for clarification from the physician. This oversight placed the resident at risk of receiving unnecessary medication and a diminished quality of life.
Failure to Maintain Antibiotic Stewardship Program
Penalty
Summary
The facility failed to consistently maintain an established Antibiotic Stewardship Program, which is designed to promote the appropriate use of antibiotics. This deficiency was identified for one resident who was prescribed antibiotics to treat hidradenitis suppurativa, a condition causing painful lumps under the skin. The facility's policy required the use of standardized tools and criteria, such as the Loeb Minimum Criteria, to determine the necessity of antibiotic treatment. However, the facility did not ensure these tools were utilized, placing residents at risk for potential adverse outcomes associated with inappropriate antibiotic use. The review of the facility's records revealed that the resident was not included in the Antibiotic Infection Control Log from April to October 2024, and there was no monitoring for adverse side effects of antibiotic use documented in the Medication Administration Record. The Director of Nursing acknowledged that the resident should have been included in the antibiotic line list and admitted that the condition was not considered a real infection, which led to the omission. The facility's failure to document and monitor antibiotic use as per their policy resulted in a deficiency under the Washington Administrative Code (WAC) 388-97-1320(1)(2) (a-c).
Failure to Document Vaccine Refusal and Provide Information
Penalty
Summary
The facility failed to ensure that a resident was provided with the pneumococcal and COVID-19 vaccines, as required by their policy. The policy, revised in May 2023, mandates that all residents be offered vaccines and that information regarding the benefits and potential side effects be provided to the resident or their legal representative. Additionally, any refusal of vaccines must be documented in the resident's medical record. However, for Resident 9, who was admitted to the facility on an unspecified date, there was no documentation in the Electronic Health Record (EHR) indicating that the risks and benefits of the vaccines were provided when the resident refused them. During a joint record review and interview with the Director of Nursing, it was confirmed that there were no consent forms related to the refusal of the vaccines in the EHR, and it was noted that Resident 9 had not wanted any vaccines for 2022 and 2023.
Failure to Maintain Bed Rail Safety
Penalty
Summary
The facility failed to conduct routine maintenance to ensure the safety of bed rails for three residents, leading to potential accident hazards. Observations revealed that the bed rails for Residents 32, 5, and 25 were loose, with gaps between the mattress and the rails that could pose a risk of entrapment. Staff M, a Registered Nurse, and Staff C, the Maintenance Supervisor, confirmed the looseness of the bed rails during joint observations. Staff C noted that the bed rails were attached with clips instead of screws, which contributed to their instability. Additionally, there was no record of maintenance for these bed rails, indicating a lack of routine checks. Interviews with facility staff, including the Director of Nursing and the Administrator, revealed uncertainty about the frequency of bed rail inspections. Staff B, the Director of Nursing, mentioned that the maintenance department was responsible for checking the bed rails, but was unsure of the inspection schedule. Staff A, the Administrator, acknowledged the expectation for bed rails to be checked for safety but admitted to having no documentation of such maintenance. This lack of routine maintenance and documentation placed the residents at risk for injury and/or entrapment.
Delayed Reporting and Investigation of Abuse Allegation
Penalty
Summary
The facility failed to timely report an allegation of abuse to the State Agency and did not initiate a timely investigation for a resident who reported being physically abused. The resident, who had impaired thinking and required assistance with care and mobility, reported to the Business Office Manager (BOM) that a staff member had punched them in the shower room and did not provide a shower. This allegation was documented on a concern and comment form but was not reported to the State Agency or investigated until two days later. Staff interviews revealed that the BOM did not take immediate action to report the incident or initiate an investigation, believing it should be handled as a concern and comment. The Director of Nursing Services and the Administrator were not informed of the allegation until two days later, at which point the incident was reported to the State Agency and reclassified as an abuse investigation. The delay in reporting and investigating the allegation placed residents at risk for abuse and unmet care needs.
Failure to Adhere to PPE Protocols for COVID-19 Isolation
Penalty
Summary
The facility failed to ensure that staff adhered to the proper use of Personal Protective Equipment (PPE) in accordance with the Centers for Disease Control guidelines when caring for residents with known COVID-19 infection. This deficiency was observed in the case of a resident who presented with COVID-19 symptoms and was placed on isolation precautions. Despite the facility's policy requiring the use of an N95 respirator, gown, gloves, and eye protection, a staff member, identified as a dietician, entered the resident's room wearing only a surgical mask and did not don the appropriate PPE. The incident was further compounded when the staff member exited the room with the surgical mask pulled down under their nose, acknowledging the failure to perform hand hygiene and use the correct PPE. Interviews with other staff members, including a Certified Nursing Assistant and a Registered Nurse, confirmed the requirement for PPE use when entering the resident's room. The Director of Nursing Services also stated the expectation for staff to wear the necessary PPE before entering a COVID-19 isolation room.
Delay in Pressure Ulcer Treatment
Penalty
Summary
The facility failed to provide timely treatment for pressure ulcers for a resident who was admitted with hemiplegia after a stroke and was at risk for pressure ulcers. Upon admission, redness was observed on the resident's toes, which was later identified as non-blanchable deep tissue injuries on both great toes. The wound care team provided treatment orders to cleanse and dress the wounds every other day, but these orders were not implemented until five days after they were written. The delay in treatment was due to the treatment order being sent to a computer that was not accessible to other staff members, as the staff member responsible was not at work. This resulted in a delay in care, as confirmed by the Director of Nursing Services and the Administrator. The failure to start the treatment promptly placed the resident at risk of further skin integrity issues, wound infection, and related complications.
Failure to Ensure Safe Discharge Process for Residents Leaving AMA
Penalty
Summary
The facility failed to ensure a safe discharge process for three residents who left against medical advice (AMA). Resident 1, who had fractures in the right humerus and ulna and required substantial assistance for mobility, left the facility with a friend without medical advice. There was no documentation that risks and benefits were discussed with Resident 1, that the attending physician was notified, or that the resident's safety was checked after leaving. Additionally, Resident 1's representative was unaware of the discharge and mentioned that the resident had multiple concerns about the care at the facility, including long wait times for assistance in the bathroom. Resident 2, who required extensive assistance for dressing, left the facility crying and wanting to go home without signing the AMA form. There was no documentation that risks and benefits were discussed with Resident 2 or their representatives, nor that the attending physician was notified. Similarly, Resident 3 left the facility AMA due to being unhappy with the care and the facility's temperature. There was no documentation that the facility inquired about Resident 3's concerns, discussed risks and benefits, or notified the attending physician. Staff B confirmed that the facility's process was not followed, and the interdisciplinary team did not discuss the residents' safety or document physician notifications in the progress notes.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Seattle
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Shoreline Health And Rehabilitation | 1.8 mi | ★★★★★ | 55 | 0 |
| Avamere Rehabilitation Of Shoreline | 2 mi | ★★★★★ | 12 | 0 |
| Hearthstone, The | 2.8 mi | — | 0 | 0 |
| The Broadview Center | 3.4 mi | ★★★★★ | 16 | 1 |
| Life Care Center Of Kirkland | 3.7 mi | ★★★★★ | 30 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.