Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Cashmere Post Acute during CMS and state inspections, most recent first.
The facility failed to keep a current CLIA certificate for lab testing. The Administrator stated the certificate had expired months earlier, acknowledged awareness of the lapse, and said the QA team was responsible for tracking fees and certification payments.
Psychotropic medications were not reviewed for GDRs for three residents. One resident with PTSD, depression, and anxiety was receiving aripiprazole, bupropion, and trazodone without documented GDR attempts or a clinical contraindication. A second resident with dementia, depression, PTSD, and anxiety was receiving Seroquel and venlafaxine with no GDR review documented in monthly psychotropic meetings. A third resident with dementia and depression had an outdated GDR review record, and the SSD and DON acknowledged the facility was behind on psychotropic GDRs.
A resident with dementia and behavioral disturbances was involved in two resident-to-resident altercations after wandering unsupervised in the halls, despite a care plan that included behavior interventions but no supervision interventions. Staff described the resident as frequently pacing, paranoid, and known for verbal and physical aggression. In a separate issue, another resident who used a transfer pole had the bed and pole positioned without floor markings or a care plan process to keep the equipment in the correct place, and staff confirmed the bed placement was not marked.
Surveyors found unsafe, unsanitary conditions in the kitchen dishwasher room and multiple utility rooms, including peeling and eroded floor surfaces, greasy debris and splash-back residue, damaged walls with exposed metal, missing and chipped floor tiles, deteriorated caulking, and exposed subfloor in several areas. The DON/maintenance leadership acknowledged the poor condition of the areas, stated some damage had been present for about a year, and said the repairs were low priority because the areas were not resident areas.
Failure to honor a resident’s preference for female caregivers during personal care. A resident with dementia and DM required assistance with toileting, bathing, and dressing, but reported that male NAs were sometimes assigned when female staff were unavailable, which the resident found embarrassing. The preference was not documented on the care plan or Kardex, and the RN/RCM and DON were not aware the preference was being missed.
A resident with diabetes, lymphoma, kidney stone, and acute kidney failure had a retention catheter in place, but the resident and RR stated they were not told where the catheter had been placed, whether it would remain in place, or when discharge would occur. The resident had moderately impaired cognition, and RN staff could not find documentation that the care review had been completed; the DON stated the care review was missed.
Failure to prevent resident-to-resident abuse occurred when a resident with dementia and behavioral disturbances threatened and struck another resident, then later assaulted a second resident. The first incident involved yelling, threats to kill, and kicking a wheelchair; the second involved verbal abuse and a fist strike to the face. The DON stated both events were abuse and that increased supervision should have followed the first altercation.
Failure to Report and Investigate Resident-to-Resident Abuse: Staff did not follow the abuse prevention policy after two resident-to-resident altercations involving a resident with dementia and behavioral disturbances. In one event, a resident threatened another resident and kicked the back of the resident’s wheelchair, but the incident was only reported to an RN and not escalated for required reporting or investigation. In another event, the same resident struck another resident in the face during a confrontation, and staff again failed to consistently identify, report, and investigate the abuse as required.
Failure to Report Resident-to-Resident Abuse Incident: Staff witnessed a verbal and physical altercation between two residents, including a threat to kill and kicking a wheelchair, but the incident was not reported to the State Agency as required. One resident had vascular dementia, Alzheimer's disease, and delirium with severe cognitive impairment and needed substantial to maximal ADL assistance, while the other had dementia with behavioral disturbance, diabetes, and kidney disease with severe cognitive impairment. Staff did not escalate the event because they believed another nurse would report it, and the RN did not consider it abuse.
Failure to thoroughly investigate a resident-to-resident abuse incident: a resident with vascular dementia, Alzheimer's disease, and delirium was involved in an altercation with another resident with dementia with behavioral disturbance, diabetes, and kidney disease, but the RN did not identify the event as abuse and no thorough investigation was completed. The DON and Administrator stated the incident should have been immediately investigated with resident, staff, and witness statements and complete documentation.
A resident with ESRD, DM, muscle weakness, and severely impaired cognition was transferred to the hospital after an unwitnessed fall with hip pain and forehead bruising. The resident’s representative was present, but the record had no documentation that the required bed hold notice was provided at the time of transfer, and the Administrator and DON stated the notice could not be located and should have been discussed and signed by the resident or representative.
PASARR screening was not accurately completed before admission for one resident and was not updated when another resident later developed a new SMI diagnosis. One resident was admitted with PTSD, dementia, MDD, anxiety, and OCD, but the PASARR did not identify PTSD or OCD as SMI; another resident later had delusional disorder added, but no updated Level I or Level II referral was completed. Staff stated PASARRs should be reviewed before admission and reassessed when new qualifying mental health diagnoses are identified.
Failure to Provide Fluids and Monitor Bruising: A resident with stroke-related deficits, dysphagia, severe cognitive impairment, and high dehydration risk was repeatedly observed with a dry mouth, thick saliva, and no fluids or toothettes available, while staff had no process to track fluid intake and did not respond when the resident called out for a snack. Another resident with dementia, diabetes, and anticoagulant use had multiple abdominal bruises from insulin injections, including 17 bruised areas in various stages of healing, but weekly skin checks, the MAR, and the care plan did not document or monitor the bruising or the resident’s pain.
A resident with PTSD and a history of sexual assault did not have trauma-informed triggers identified in the care plan. The resident rep reported the resident became anxious around men and should only have female caregivers, but the trauma-informed care assessment and care plan did not include resident-specific triggers, behaviors, or interventions. The SSD stated the resident rep was not consulted, and the RN stated the assessment should have been completed with the resident rep and included trauma-based interventions.
Expired medications and supplies were found in the med room, including port access kits, nicotine lozenges, dietary supplement tablets, and blood collection tubes past their manufacturer expiration dates. The med refrigerator temperature log also showed 14 days without the required twice-daily documentation, and an RN stated nurses were responsible for checking expiration dates, destroying expired items, and documenting refrigerator temperatures twice per day.
The facility failed to ensure a designated Infection Preventionist (IP) worked at least part-time, with Staff J only dedicating 15% of their time to infection control duties. The Facility Assessment did not specify required IP hours, and Staff B, the DON, confirmed the insufficiency of time allocated for IP duties, placing residents at risk for infectious disease transmission.
The facility failed to develop baseline care plans within 48 hours for three residents, including one with vertebral fractures and another with heart failure. The plans lacked necessary PASARR recommendations and social services goals, and a readmitted resident's previous care plan was not updated promptly. Staff interviews indicated lapses in the timely creation and delivery of these care plans.
The facility failed to properly store and label potentially hazardous food in the kitchen, with numerous items found without use-by dates. Additionally, the concentration of disinfectant solution used for cleaning food preparation areas was below the required range, increasing the risk of cross-contamination. Staff E, the Dietary Department Director, acknowledged these lapses in procedure.
The facility failed to honor the rights of two residents regarding shower frequency and meal preferences. A resident with bipolar disorder was limited to one shower per week despite requesting more, and another resident with diabetes faced meal restrictions contrary to facility policy. The DON confirmed that the correct processes were not followed.
A facility breached a resident's privacy by posting a sign in their room that disclosed their schizophrenia diagnosis and personal preferences. The sign, observed by surveyors, included sensitive health information, which a registered nurse later confirmed should not be displayed in resident rooms.
The facility failed to maintain a sanitary and homelike environment in the shower room, which contained personal items and clutter, including a staff desk with electronic devices and personal drink containers. The resident bathtub area had damaged tiles and a crusty film on the faucet, compromising the comfort and safety of residents during showers. Staff acknowledged the inappropriate presence of food and drink in the shower room.
The facility failed to provide written bed-hold notices to two residents during hospital transfers, as required by policy. One resident experienced multiple hospital transfers without receiving complete or any bed-hold notices, while another resident's representative confirmed not receiving a notice. The DON acknowledged issues with the transition to electronic forms, affecting clarity and acknowledgment of bed-hold agreements.
The facility failed to ensure accurate PASARR assessments for residents with mental health conditions, leading to deficiencies in care. A resident was readmitted with mental health diagnoses, but the PASARR Level I form was incorrect, and no Level II screening was conducted. Two residents with mood disorders were not referred for Level II evaluations, and another resident was admitted without a completed PASARR Level I form. Staff acknowledged these procedural failures.
A facility failed to develop and implement a comprehensive care plan for a resident with a heart condition, as required by a physician's order. The resident refused to wear a pulmonary vest and take medication multiple times, but these refusals were not documented, nor was the physician notified. Staff interviews confirmed the resident's autonomy in decision-making, but the care plan was not updated to reflect these refusals, leaving the resident at risk for unmet care needs.
A facility failed to monitor fluid intake for a resident with a fluid restriction order, leading to consistent overages in fluid consumption. Additionally, another resident with mobility and positioning needs was not provided with necessary care, resulting in unsafe eating and mobility conditions. Staff interviews revealed a lack of awareness and procedures for both issues, placing residents at risk for health complications.
A resident with chronic pain conditions experienced inadequate pain management due to the facility's failure to implement an effective program. Despite receiving medications like oxycodone and Tylenol, the resident consistently reported high pain levels. Observations and interviews revealed a lack of clear dosing parameters and follow-up on specialist recommendations, contributing to unmanaged pain. The resident's care plan was outdated and lacked non-pharmacological interventions.
The facility had a medication error rate of 7.69% due to improper insulin administration for two residents. An LPN administered insulin without holding the needle in place for the recommended duration, as per facility policy and FDA guidelines. Both the LPN and the DON demonstrated a misunderstanding of the correct procedure, leading to potential incomplete dosage delivery.
The facility failed to remove expired medications from use and secure medication carts when unsupervised. Expired medications were found in multiple medication carts, and carts were left unlocked and unattended. Additionally, the facility did not follow CDC guidance for vaccine temperature monitoring, recording temperatures only once daily. These issues risked residents receiving expired or compromised medications and vaccines.
The facility failed to implement an effective Infection Control and Prevention Program, with staff not adhering to hand hygiene, equipment sanitation, and PPE protocols. Observations included improper handling of food, unsanitized use of mechanical lifts, and non-compliance with Enhanced Barrier Precautions and Transmission-Based Precautions, increasing the risk of infection transmission.
The facility failed to update the daily nursing staff posting, with observations showing outdated information for four out of five days. Interviews revealed confusion over responsibility for weekend updates, with the Staffing Coordinator and DON acknowledging the need for a better system. The Administrator was informed of the inconsistency and planned to assign the task to a dedicated staff member.
A resident with intact cognition and independent mobility left the facility unsupervised, and the investigation was incomplete, lacking witness statements and documentation of notifications. No interventions were formulated to prevent further elopement, and the care plan was not updated. The resident went missing again the next day and discharged against medical advice.
The facility failed to assess and implement interventions for residents with substance use disorder (SUD) and elopement risks. A resident with a PICC line and high elopement risk was allowed unsupervised access outside the facility, leading to multiple elopements. Two other residents with SUD were also at risk for elopement, but their care plans lacked necessary interventions. Staff interviews revealed a lack of training in managing SUD, contributing to inadequate care planning and delayed responses to elopement incidents.
A facility failed to inform a resident and their representative of an increase in monthly financial responsibility before charging the updated amount to the debit card on file. The Business Office Manager altered the Credit Card Authorization Form without agreement, and attempts to notify the representative were unsuccessful. Both the former and current administrators acknowledged the facility's responsibility to notify residents and representatives of billing changes.
Expired CLIA Certificate
Penalty
Summary
The facility failed to maintain a current Clinical Laboratory Improvement Amendment (CLIA) certificate required to perform laboratory tests within the facility. During an observation and concurrent interview, the Administrator stated that the facility's CLIA certification had expired 9 months and 10 days earlier and that they had noticed the expiration. The Administrator stated they recalled paying the renewal fee for the previous year and later acknowledged awareness that the CLIA certificate was expired, stating they were ultimately responsible for the compliance of the facility's certifications. The Administrator also stated that the quality assurance team was responsible for tracking financial items to ensure such fees were paid.
Psychotropic Medications Not Reviewed for GDRs
Penalty
Summary
The facility failed to ensure that 3 of 5 residents reviewed for psychotropic medication use were assessed for gradual dose reduction (GDR) or had a documented clinical rationale showing why a GDR was contraindicated. The deficiency involved Residents 81, 2, and 77, all of whom were receiving psychotropic medications. The facility policy titled Use of Psychotropic Medications, revised 01/2025, stated that residents who use psychotropic drugs shall receive GDRs unless clinically contraindicated. Resident 81 was admitted with diagnoses including PTSD, major depressive disorder, and anxiety, and the comprehensive assessment showed moderately impaired cognition. The resident’s March 2026 physician orders included daily aripiprazole 10 mg, bupropion ER 150 mg, and trazodone 100 mg, with start dates in 2025. Review of the Psychotropic Drug Review Meeting minutes from 07/25/2025, 09/24/2025, 11/26/2025, and 02/24/2026 showed no documentation that Resident 81 was reviewed for GDRs or that a clinical contraindication was placed in the medical record. The DON stated the resident had not had any GDR attempts since admission and did not have any clinical contraindications documented. Resident 2 was admitted with diagnoses including dementia, depression, PTSD, and anxiety, and had moderate cognitive impairment with limited assistance needed for transfers and mobility. April 2026 physician orders showed daily Seroquel 50 mg three times daily and venlafaxine 150 mg daily. Review of the Psychotropic Drug Review Meeting minutes from January through March 2026 showed no documentation that Resident 2 had been reviewed for GDRs, and the SSD stated there had been no GDR review in the monthly psychotropic drug meetings. Resident 77 was admitted with diagnoses including dementia, depression, and diabetes, and the 03/06/2026 comprehensive assessment showed moderately impaired cognition and substantial assistance needs for daily activities. Psychotropic Drug Review Meeting minutes from January through March 2026 showed the last GDR review documented as completed on 02/11/2025, and the SSD stated the last GDR completed for the resident’s antidepressant was on 02/11/2026 and did not meet the annual review requirement. The DON stated the GDRs were not current and the facility had fallen behind.
Inadequate supervision and unsafe equipment placement
Penalty
Summary
The facility failed to provide adequate supervision and to implement care plan interventions to prevent resident-to-resident altercations involving three residents. Resident 3 had diagnoses including dementia with behavioral disturbances, diabetes, and metabolic encephalopathy, and a comprehensive assessment showed moderately impaired cognition. Resident 48 had diagnoses including dementia with agitation, Alzheimer’s disease, and anxiety, with severely impaired cognition and substantial/maximal assistance needs. Resident 38 had diagnoses including dementia with behavioral disturbance, diabetes, and weakness, with moderately impaired cognition and moderate to substantial assistance needs. Resident 3’s care plan included interventions for delusions, hallucinations, paranoia, physical/verbal aggression, and sexually inappropriate behaviors, including redirection, snacks, exercise, pain assessment, family contact, one-on-one supervision as needed, and communication in the resident’s native language. The care plan also stated staff should intervene before agitation escalated, guide the resident away from the source of distress, and engage calmly in conversation, but there were no interventions for supervision despite the resident’s history of behaviors. Facility investigations showed Resident 3 and Resident 48 had an altercation in the hallway outside Resident 3’s room when Resident 48 was self-propelling in a wheelchair past the room, Resident 3 exited the room, made verbal threats, and kicked the wheelchair from behind. Another investigation showed Resident 3 and Resident 38 had an altercation in the hallway near the kitchen area when Resident 38 was self-propelling in a wheelchair, Resident 3 struck Resident 38 on the face, and Resident 38 struck Resident 3’s arm. Observations showed Resident 3 wandering unsupervised through the halls, looking into resident rooms, stopping at the central nursing station, and continuing to pace the same path without staff monitoring. Staff stated Resident 3 constantly wandered the halls, claimed to be guarding and protecting the hall, had paranoia, and that staff tried to keep eyes on the resident’s location. Staff also stated they were aware of Resident 3’s history of verbal and physical aggression and tried to keep the resident separated from certain other residents, including Resident 38. Staff further stated Resident 3 had been placed back on one-on-one supervision indefinitely following the incidents. The facility also failed to ensure safe placement of equipment for Resident 77, who used a transfer pole. Resident 77 had diagnoses including dementia, depression, and diabetes, and required substantial assistance with ADLs including dressing, transfers, bed mobility, and toileting. During observation, the resident’s transfer pole was positioned between the resident’s legs while the resident stated it was in the way, though they used it to get in and out of bed. The resident also stated the bed had been moved, which caused the transfer pole to be improperly positioned. The bed was observed close to the window and heating/cooling system, with no floor markings to indicate proper bed placement. The care plan identified the transfer pole use but had no interventions to ensure appropriate bed placement in relation to the pole, and staff confirmed there was no tape on the floor to show where the bed should be placed.
Unsafe and Unsanitary Conditions in Kitchen and Utility Rooms
Penalty
Summary
The facility failed to maintain a safe, comfortable, and sanitary environment in the kitchen dishwasher room and in three utility rooms, including the West clean and soiled utility rooms and the South clean utility room. In the kitchen dishwasher room, surveyors observed significant peeling, chipping, and erosion of the floor sealant exposing uncleanable concrete, thick greasy brown debris and splash-back residue on the wall and at the floor-to-wall junctions, visible gaps at the wall and floor under the dishwasher, and cleaning supplies stored directly on the floor under the dishwasher, including a yellow scrub brush and an unlabeled chemical spray bottle. In the South Clean Utility Room, surveyors observed extensive wall damage with a deep horizontal gouge, missing plaster exposing metal, and tape applied over damaged wall areas, along with grey and black speckled staining and splash-back residue around the soap dispenser. In the Soiled Utility Room, the vinyl floor tiles were chipped and missing in sections, exposing subfloor and adhesive, with jagged tile edges, peeling hazard tape, visible gaps between tiles, and heavy debris buildup along the rubber baseboard. In the Clean Utility Room, a large section of floor tile was missing, exposing uneven concrete and adhesive, the baseboard was missing along part of the wall with eroded plaster and exposed gaps, and the caulking at the countertop-to-wall junction was deteriorated. The Director of Maintenance stated the kitchen looked bad but was believed to be structurally sound, and acknowledged the damaged utility room conditions had been present for about a year; the Administrator stated the environmental issues were known but were not a priority because the areas were not resident areas.
Failure to Honor Resident’s Preference for Female Caregivers
Penalty
Summary
The facility failed to ensure Resident 79 received dignified care and services by not honoring the resident’s preference for female caregivers for personal care. Resident 79 was admitted with diagnoses including dementia and diabetes, and the comprehensive assessment showed the resident required assistance with toileting, showering/bathing, and dressing while cognition was intact. During interview, Resident 79 stated a preference for female caregivers only and reported that nursing assistants sometimes told them only male caregivers were available on the evening and night shifts, which occurred about two times monthly. The resident stated this was embarrassing because it involved having pants down and a shirt off in front of a man. The resident’s care plan dated 01/09/2026 did not address the preference for female caregivers only. Staff P stated the preference was normally found on the Kardex, but Resident 79’s preference was not listed there and was only known through word of mouth. Staff P also stated they had provided personal care to Resident 79 when no female caregivers were available. Staff O stated Resident 79 preferred female caregivers for care involving undressing, would provide their own perineal care, and would allow certain male staff to assist if no female staff were on the floor. Staff G, the RN/RCM, stated they were not aware of the preference and expected it to be included in the care plan, and Staff B, the DON, stated the preference was not being honored and the correct process had not been followed.
Resident not fully informed about catheter care and discharge
Penalty
Summary
The facility failed to ensure that Resident 100 was fully informed of their health status, care, and treatments related to a urinary retention catheter. Resident 100 was admitted with diagnoses including diabetes, lymphoma, kidney stone, and acute kidney failure. The comprehensive care plan dated 03/27/2026 showed the resident had moderately impaired cognition and required assistance of one person for daily cares and transfers. During an observation and interview on 03/30/2026, Resident 100 was sitting in a wheelchair with a retention catheter hanging from the bottom of the chair and stated they were unaware of where the catheter had been placed or whether they would be going home with it. The resident also stated they wanted to go home but had not been told when they would be discharged. The resident representative stated the catheter had been placed in the hospital for a kidney stone that caused an infection and was unsure whether Resident 100 would go home with the catheter. The resident and representative both stated they had not been informed when the catheter would be removed or when discharge could be expected, and the representative said they had not yet talked with anyone from the facility about the resident’s care or discharge needs. Staff G, RN, stated they could not find documentation that Resident 100’s care had been reviewed with the resident and said the staff member responsible for ensuring the review was on vacation. Staff G stated there was no excuse for the resident not having had their care reviewed. Staff B, DON, stated the care review with Resident 100 was missed.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure residents were free from abuse in two resident-to-resident altercations involving a resident with dementia and behavioral disturbances. Resident 3 had diagnoses including dementia with behavioral disturbances, diabetes, and metabolic encephalopathy, and was independent with ADLs but had severely impaired cognition. On 03/02/2026, a medication assistant observed Resident 3 in the hall outside their room yelling at Resident 48, who had dementia with agitation, Alzheimer's disease, anxiety, substantial to maximal ADL dependence, and severely impaired cognition. Resident 3 used profanity, threatened to kill Resident 48 and feed them to the pigs, and kicked the back of Resident 48's wheelchair, moving it forward about 2 feet before Resident 48 stopped it with their feet. A RN was called to separate the residents, and Resident 3 continued making threats while being redirected to their room. A second altercation occurred on 03/31/2026 when Resident 3, while wandering in the hall, encountered Resident 38 outside the kitchen area. Resident 38 had dementia with behavioral disturbance, diabetes, weakness, moderate to substantial ADL assistance needs, and moderately impaired cognition. Resident 3 yelled at Resident 38, called them a dog and said they were in their workspace, then pulled their right hand into a fist and struck Resident 38 in the face. Resident 38 also made contact with Resident 3's right arm with a fist. A housekeeper witnessed the incident and separated the residents. The DON stated they were not aware of the first altercation and that both incidents were abuse; they also stated Resident 3 should have been placed on increased supervision after the first incident to prevent the second.
Failure to Report and Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to implement its abuse prevention policy for identification, investigation, protection, and reporting after two resident-to-resident altercations involving a resident with dementia and behavioral disturbances. The policy required staff education on identifying abuse and immediate reporting of alleged abuse, including resident-to-resident altercations, with protection of residents during and after investigation and reporting to the Administrator, State Agency, Adult Protective Services, and law enforcement within the required timeframes. One resident involved in the incidents had diagnoses including dementia with agitation, Alzheimer’s disease, and anxiety, and required substantial to maximal assistance with ADLs with severely impaired cognition. Another resident involved had dementia with behavioral disturbance, diabetes, and weakness, and required moderate to substantial assistance with ADLs with moderately impaired cognition. A third resident had dementia with behavioral disturbances, diabetes, and metabolic encephalopathy, and was independent with ADLs but had moderately impaired cognition. In one incident, the third resident threatened to kill one resident and kicked the back of that resident’s wheelchair, but the witnessing medication assistant separated the residents and reported the event only to an RN, believing the RN would report it. The RN stated the event was not reported because staff did not feel there was abuse since there was no physical contact, and the DON stated the incident was abuse and should have been reported. In a second incident, the third resident verbally confronted another resident, called the resident a dog, and made contact with the resident’s face with a closed hand while the other resident struck the third resident’s arm; a housekeeper separated them. The Administrator stated staff were trained on abuse reporting and that suspected or observed abuse should be reported immediately, but the first incident was not reported to the State Agency or administrative staff and was not handled through the facility’s incident investigation process.
Failure to Report Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to ensure an incident of abuse was reported to the State Agency for 1 of 3 residents reviewed for an altercation between two residents. A written policy titled Abuse, Neglect, and Exploitation required alleged violations to be reported to the administrator, State Agency, adult protective services, and other required agencies within specified timeframes, including immediately but no later than 2 hours when abuse or serious bodily injury was involved. The policy also required the administrator to follow up with government agencies and report the results of the investigation within five working days. Resident 48 had diagnoses including vascular dementia, Alzheimer's disease, and delirium, and required substantial to maximal assistance with ADLs with severely impaired cognition. Resident 3 had diagnoses including dementia with behavioral disturbance, diabetes, and kidney disease, and was independent with ADLs but also had severely impaired cognition. A nursing progress note documented that Resident 3 had a verbal and physical altercation with Resident 48 in the hall outside Resident 3's room, threatened to kill Resident 48, and kicked the back of Resident 48's wheelchair. Staff E, a Medication Assistant, stated they witnessed the incident and separated the residents, then reported it to Staff F, RN, but did not report it to administration or the State Agency because they thought Staff F would. Staff F stated they did not report the incident because they did not feel there was abuse in the situation. The DON and Administrator stated the incident should have been reported to administrative staff and the State Agency.
Failure to Thoroughly Investigate Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to thoroughly investigate a resident-to-resident incident involving Resident 48 and Resident 3. The report states that an immediate investigation was warranted when abuse, neglect, or exploitation was suspected or reported, and that the process included identifying staff responsible for the investigation, interviewing the alleged victim, alleged perpetrator, witnesses, and others with knowledge of the allegation, and documenting the investigation completely and thoroughly. Instead, the incident on 03/02/2026 was not investigated because Staff F, RN, did not identify it as abuse. Resident 48 had diagnoses including vascular dementia, Alzheimer's disease, and delirium, and the 01/05/2026 comprehensive assessment showed substantial/maximal assistance was needed for ADLs and cognition was severely impaired. Resident 3 had diagnoses including dementia with behavioral disturbance, diabetes, and kidney disease, and the 12/30/2025 comprehensive assessment showed independence with ADLs and severely impaired cognition. During interviews, the DON stated the incident was not investigated due to the RN not identifying it as abuse, and the Administrator stated suspected or actual abuse needed to be thoroughly investigated with witness, staff, and resident statements, initiated immediately after the incident, and completed within five working days of the initial report.
Missing Bed Hold Notice at Hospital Transfer
Penalty
Summary
The facility failed to provide a written bed hold notice at the time of transfer to the hospital for Resident 10. The facility’s policy titled, Bed Hold Notice, dated 2025, stated that written information regarding bed hold practices would be provided to the resident and/or representative well in advance and at the time of transfer for hospitalization or therapeutic leave. Resident 10 was admitted with diagnoses including end stage renal disease, diabetes, and muscle weakness. The 02/04/2026 comprehensive assessment showed the resident required substantial to maximum assistance from one staff member for activities of daily living and had severely impaired cognition. On 12/08/2025, Resident 10 had an unwitnessed fall from a chair in the room and was transferred to the local hospital for evaluation of right hip pain and bruising to the right forehead; the resident’s representative was present at the time of transfer. The medical record contained no documentation that a bed hold notice was provided to Resident 10 or the representative, and the Administrator and DON stated they were unable to locate the required notice and that the transfer nurse should have discussed bed hold and obtained a signed form.
PASARR Screening Not Completed or Updated for Two Residents
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not accurately completed before admission for one resident and was not updated when a new serious mental illness diagnosis was identified for another resident. Facility policy required all applicants to have a Level I PASARR prior to admission, with a Level II evaluation if the Level I indicated SMI/ID/DD, and required prompt referral for a Level II if a qualifying diagnosis was made after admission. The Social Service Director was responsible for tracking PASARR status and referrals. One resident was admitted with diagnoses including PTSD, dementia, major depressive disorder, anxiety, and OCD, and the record showed moderate cognitive impairment and use of antidepressant and antipsychotic medications. The 07/18/2025 PASARR did not mark PTSD or OCD as SMI on admission. In interviews, the SSD stated they reviewed PASARRs on admission and would complete a new one if they were not correct, and the DON stated PASARRs should be reviewed before admission and corrected before admitting the resident. Another resident had a prior Level I PASARR showing no need for Level II, but later had delusional disorder added to the diagnoses on 10/02/2025. There was no PASARR Level I update or Level II referral for the new diagnosis, and staff stated the new mental health diagnosis should have triggered reassessment and that they were not notified of the new diagnosis.
Failure to Provide Fluids and Monitor Bruising
Penalty
Summary
The facility failed to ensure fluids were readily available and provided to a resident with hemiplegia and hemiparesis following a stroke, adult failure to thrive, dysphagia, severely impaired cognition, and dependence on staff for ADLs. The resident scored 16 on a dehydration risk screener and was identified as at risk for malnutrition after recent significant weight loss. The care plan directed staff to monitor needs, offer fluids, and encourage fluids during the day, but observations showed the resident repeatedly in bed with a dry mouth, thick stringy saliva, dry and flaky lips, and no beverages or toothettes in the room. The bedside table was often across the room, and the resident called out for a snack on multiple occasions without staff responding. During one meal observation, the resident had thickened liquids in front of them, attempted to drink, and had difficulty swallowing, and the meal record showed the resident refused the meal despite asking for a snack. Staff interviews showed there was no process to monitor fluid intake and no way to track it. A NA stated residents received fluids at mealtimes and that if fluids were not enough, a toothette would be used to try to get the resident to suck on it, but fluid intake was not recorded for any resident. The RCM stated the resident received thickened liquids with meals and medications and had thickened liquids available at the bedside, but fluid intake was not monitored despite the high dehydration risk assessment. The DON stated the dehydration screener was used to identify residents at high risk for dehydration, but the facility did not do anything with the information collected and had no process for monitoring fluid intake. The facility also failed to identify and monitor skin bruising for a resident with dementia and diabetes who required assistance from one staff member with ADLs and was prescribed anticoagulant medication. The resident showed multiple bruised areas on the abdomen during observations, including a large multicolored bruise and later a total of 17 bruised areas in various sizes and stages of healing, with the resident stating the bruises hurt when another shot was given in the same spot. Weekly skin evaluations repeatedly documented no current or active skin issues, and the March and April treatment administration record contained no monitoring, assessment, or documentation of the abdominal bruises. The care plan did not identify the current skin impairments, did not include interventions for assessment, monitoring, or treatment of the bruised areas, and did not address the resident's reports of pain related to injection sites. Staff stated they only documented bruises if they were present on admission or were large, massive, and dark, while another nurse stated any bruising should be captured in the weekly skin assessment and formally documented.
Failure to Identify Trauma Triggers in Care Plan
Penalty
Summary
The facility failed to ensure that a resident with a history of PTSD received culturally competent, trauma-informed care by not identifying resident-specific triggers during the admissions and care planning process. The resident was admitted with diagnoses including PTSD, had moderately impaired cognition, and required assistance from one staff member for activities of daily living. The resident representative stated that the resident’s PTSD stemmed from a history of sexual assault, that the resident became nervous around men, became very quiet and anxious, and reported feeling as though men were following them, and that the resident should only have female caregivers. The resident’s care plan, dated 07/25/2025, did not include trauma-informed care, triggers, behaviors, or person-centered interventions. The trauma-informed care assessment, dated 08/08/2025, documented that the resident experienced sexual assault and severe human suffering, but it did not identify resident-specific behaviors or triggers that would cause fear, panic, agitation, or depression. The Social Service Director stated the assessment process should include asking about triggers and consulting the resident representative when the resident could not answer, but acknowledged that the resident representative was not consulted in this case and that the correct process was not followed. The Resource Nurse stated the trauma-informed care assessment should have been completed with the resident representative upon admission and that trauma-based triggers and interventions should have been included in the care plan.
Expired Medications and Incomplete Refrigerator Temperature Monitoring
Penalty
Summary
Expired medications and supplies were found in the medication room during observation. Three port access kits had a manufacturer expiration date of 8/31/2025, a box of nicotine lozenges contained both 2 mg and 4 mg lozenges with a manufacturer expiration date of 02/2026, one bottle of [NAME]-Vite tabs had a manufacturer expiration date of 01/2026, 25 orange-top blood collection tubes had a manufacturer expiration date of 01/31/2026, and 12 light-blue-top blood collection tubes had a manufacturer expiration date of 0/28/2026. The facility policy titled Medication Storage stated medications were to be stored according to manufacturer recommendations and with proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Review of the March 2026 medication refrigerator temperature log showed staff were instructed to document temperatures twice daily at the beginning and end of each workday, but there were 14 days without the required twice-daily documentation. During observation and interview, an RN stated the refrigerator temperatures had to be checked and documented twice daily, and that nurses were responsible for monitoring expiration dates and ensuring expired items were not used and were properly destroyed. The DON later stated the expired medications and medical supplies had been discussed with the RN and that the facility understood it needed a better system to monitor medication refrigerator temperatures.
Inadequate Infection Preventionist Time Allocation
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist (IP) who worked at least part-time and was responsible for the Infection Control and Prevention Program (IPCP). This deficiency was identified through interviews and record reviews, which revealed that the current IP, Staff J, only devoted approximately 15% of their working hours to infection control duties. The remaining time was spent on responsibilities as a Resident Care Manager. The facility's policy required the IP to be employed on-site at least part-time, with enough time allocated to assess, develop, implement, monitor, and manage the IPCP, as well as address training requirements and participate in required committees such as Quality Improvement and Performance Improvement (QAPI). The Facility Assessment (FA) dated 09/20/2024, indicated the need for an IP to develop and regularly update infection control protocols, ensure personal protective equipment availability, and manage vaccination availability. However, the FA did not specify the number of IP hours per week required to meet the needs of residents and staff. During an interview, Staff B, the Director of Nursing, confirmed that they did not perform any IP duties and acknowledged that the 15% of time Staff J devoted to IP duties was insufficient to cover the facility's needs. This lack of adequate time and resources for infection prevention placed residents at risk for the transmission of infectious diseases and unmet care needs.
Failure to Develop Timely Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for three residents, which is a requirement to ensure continuity and resident-centered care. Resident 48 was admitted with conditions such as vertebral fractures, kidney and respiratory failure, and muscle weakness, requiring maximum assistance for ADLs. However, the baseline care plan was not documented until five days after admission, missing PASARR recommendations and behavioral health goals. Similarly, Resident 196, admitted with heart failure and adult failure to thrive, did not have a baseline care plan with PASARR recommendations or social services goals until four days post-admission. Resident 9, who was a readmission, had their previous care plan automatically pulled into their new admission record, which was not updated until five days after their current admission. This oversight was due to the previous care plan not being closed out in the electronic medical record upon their prior discharge. Staff interviews revealed that the responsibility for creating and delivering the baseline care plans was assigned to specific staff members, but the process was not completed within the required timeframe, leading to the deficiency.
Improper Food Storage and Disinfectant Use in Kitchen
Penalty
Summary
The facility failed to properly store and label potentially hazardous food (PHF) and dry goods in the kitchen, as observed during a survey. Items in the refrigerator, such as green beans, peas, chicken noodle soup, shredded American cheese, carrots, thickened cranberry juice, health shake, and whipped topping bags, were found without use-by dates. Similarly, items in Freezer #1, Freezer #2, and Freezer #3, including ground beef, diced ham, battered fish, biscuits, garlic bread, various soups, chicken breast, pork sausage patties, beef hot dogs, chili, beef steaks, ham, and cinnamon rolls, were also unlabeled and lacked open or use-by dates. Staff E, the Dietary Department Director, acknowledged that the process for labeling and dating food items was not being followed, which is contrary to the facility's policy and the Washington State Retail Food Code. Additionally, the facility failed to maintain the proper concentration of disinfectant solution used for cleaning food preparation areas, which is crucial to prevent cross-contamination. During an observation, Staff E tested a bucket of Disinfect Multi-Quat 146 solution and found it had a concentration of 100 parts per million (PPM), which is below the required range of 150 to 400 PPM. Staff E admitted there was no process for testing the solution in the disinfectant buckets, and they were changed approximately every four hours. This failure to maintain the correct concentration of disinfectant solution further increased the risk of cross-contamination in the kitchen.
Failure to Honor Resident Choices in Showers and Meals
Penalty
Summary
The facility failed to honor the residents' rights to self-determination and choice, specifically regarding the frequency of showers and meal preferences. Resident 87, who has diagnoses including bipolar disorder and personality disorder, was only scheduled for one shower per week despite expressing a desire for at least two showers weekly. The resident had communicated this preference to the staff, but the request was not accommodated. The Director of Nursing acknowledged that the process for accommodating such requests was not followed. Resident 22, who has diabetes mellitus, heart failure, and liver disease, reported limitations on the amount of food they could have at meals, which was contrary to the facility's stated process. The resident expressed dissatisfaction with the meal restrictions, noting that if they were still hungry after a meal, they could not receive additional food. The Director of Nursing confirmed that it was not the facility's process to limit food and that residents should be allowed additional meals if requested.
Violation of Resident Privacy Due to Posted Medical Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical condition by posting a sign in the resident's room that disclosed private health information. The sign, observed on January 6, 2025, was laminated and displayed in bold black lettering above the bed of a resident diagnosed with schizophrenia. It included details about the resident's mental health condition, stating, 'I have schizophrenia, I come in and out of reality (not from drugs),' along with other personal preferences and needs. This action violated the resident's right to privacy regarding their medical condition. A registered nurse confirmed during an interview on January 9, 2025, that such signs should not be displayed in resident rooms as they contain private personal health history information.
Unsanitary and Cluttered Shower Room Environment
Penalty
Summary
The facility failed to ensure a sanitary and homelike environment in the shower room, which was observed to contain various personal items and clutter. During an observation and interview, it was noted that the shower room had a staff desk with a laptop, computer tablet, and a clipboard of resident names, along with personal items such as a large pink jug, a black shaker cup, and a pink cell phone. The shower area also contained a large pink drink tumbler and a Dutch Bro's cup with a brown and white liquid. Additionally, the resident bathtub area had a chair with torn fabric, bulging tiles, and broken tiles with sharp edges, as well as a white, crusty film on the faucet handles and spout. Staff G, a Nursing Assistant, was observed using the personal items in the shower room, and Staff B, the Director of Nursing, acknowledged that food and drink should not be present in the shower room. Staff B also stated that the desk was intended for nursing assistants to document, but they could use the nursing station instead. The presence of these items and the condition of the shower room did not provide a comfortable and homelike experience for residents during showers, as required by the facility's policy on resident rights.
Failure to Provide Bed-Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to issue a written notice of bed hold to residents or their representatives at the time of hospital transfer, as required by their policy. This deficiency was identified for two residents, Resident 27 and Resident 58, who were transferred to the hospital for evaluation due to various health issues. The facility's policy mandates providing written information about the duration of the bed hold, reserve bed payment, and policies regarding bed-hold periods before transferring a resident to the hospital. However, the records for Resident 27 showed that during multiple hospital transfers, either the bed-hold notice was incomplete or not provided at all. Similarly, for Resident 58, there was no documentation of a bed-hold notice being issued during their hospital transfer. Interviews conducted with Resident 58's representative and the Director of Nursing (DON) revealed further insights into the deficiency. Resident 58's representative confirmed that they were not provided with a bed-hold notice during the resident's hospital stay. The DON acknowledged that while bed holds were offered upon admission, the transition from paper to electronic forms had led to issues with clarity and acknowledgment of the bed-hold agreement by residents or their representatives. This oversight placed residents at risk of not being informed about their rights and potential charges associated with bed holds during hospital stays.
Deficiencies in PASARR Assessments for Residents with Mental Health Conditions
Penalty
Summary
The facility failed to ensure accurate Preadmission Screening and Resident Review (PASARR) assessments for residents with mental health conditions, leading to deficiencies in the care provided. Resident 51 was readmitted with multiple mental health diagnoses, including bipolar disorder and adjustment disorder, but the PASARR Level I form incorrectly indicated no serious mental illness, and no Level II screening was conducted. Staff D acknowledged the oversight, noting that a new PASARR Level I was not completed upon the resident's return from the hospital. Resident 55, admitted with major depressive disorder and experiencing delusions, was identified in the PASARR Level I assessment as having a mood disorder. However, a Level II evaluation was not conducted, contrary to the requirements. Similarly, Resident 84, with diagnoses of schizophrenia and major depressive disorder, was also not referred for a Level II evaluation despite being identified with a schizophrenic and mood disorder in the PASARR Level I assessment. Staff D admitted to not following the correct process for these residents. Additionally, Resident 9 was admitted without a completed PASARR Level I form, as required. Staff E and Staff F were unable to locate the form in the medical record, indicating a lapse in the admission process. The facility's administrator, Staff A, confirmed the necessity for timely and accurate PASARR screenings upon admission, highlighting the procedural failures in the facility's handling of PASARR assessments.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for Resident 27, who had complex medical diagnoses including a heart condition that could lead to fluid in the lungs. Despite a physician's order from November 2024 directing staff to assist the resident with wearing a pulmonary vest and documenting any refusals, the facility did not create a care plan addressing the use of the pulmonary vest or the resident's refusal of care. The resident's medical record showed numerous refusals of the pulmonary vest and medication, yet there was no documentation of these refusals, no risk and benefits assessment, and no notification to the physician. Interviews with staff revealed that Resident 27 had worn the pulmonary vest initially but had since stopped, and staff did not document the refusals or update the care plan accordingly. The Director of Nursing acknowledged that refusals should be part of the care plan to meet the resident's needs. The lack of a comprehensive care plan and failure to document refusals left the resident at risk for unmet care needs and other negative health outcomes.
Deficiencies in Fluid Monitoring and Positioning Care
Penalty
Summary
The facility failed to develop and implement a process for monitoring daily fluid intake for a resident with a physician's order for fluid restriction. Resident 196, who was admitted with diagnoses including biventricular heart failure and generalized edema, had a physician's order for a 2000 mL fluid restriction per day. However, observations and interviews revealed that the nursing staff did not accurately monitor or record the resident's fluid intake. The medication administration record showed consistent overages in fluid intake, with daily totals significantly exceeding the prescribed limits. Staff interviews indicated a lack of awareness and proper procedures for tracking fluid intake, leading to the resident receiving more fluids than allowed. Additionally, the facility failed to provide necessary care and services for Resident 4, who required assistance with positioning during meals and wheelchair use. Resident 4, diagnosed with conditions such as osteoporosis and spastic hemiplegia, was observed in a hunched position in their wheelchair, which affected their ability to eat and move safely. The care plan lacked interventions for proper positioning, and staff interviews confirmed that no assessments or instructions were provided for Resident 4's positioning needs. Observations showed that Resident 4 struggled with eating and mobility due to their positioning, leading to concerns about their safety and well-being. The deficiencies in monitoring fluid intake and providing appropriate positioning care placed both residents at risk for health complications and poor clinical outcomes. The facility's failure to implement effective processes and provide necessary care highlights significant gaps in the quality of care provided to these residents.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to develop and implement an effective pain management program for a resident, identified as Resident 51, who was reviewed for pain management. The resident was admitted with multiple diagnoses, including neck pain, chronic pain syndrome, lumbar stenosis with neurogenic claudication, and osteoarthritis of the knee. Despite receiving scheduled pain medication, PRN medications, and non-medication interventions, the resident consistently reported high pain levels, indicating that their pain was not adequately managed. Observations and interviews revealed that Resident 51 experienced significant pain in their knees, hip, and back, and expressed feelings of not being believed about their pain. The resident was receiving oxycodone and Tylenol for pain management, but continued to rate their pain at a high level on the pain scale. The facility's pain assessments indicated that the resident's pain appeared to be fairly well controlled, despite the resident's verbal and non-verbal expressions of pain. Additionally, the resident had not been evaluated by relevant specialists for over two years, and there was a lack of follow-up on recommended treatments such as steroid injections. Interviews with facility staff highlighted inconsistencies in the administration of pain medication, with no clear parameters for dosing based on pain levels. Staff members acknowledged the need for a process to ensure appropriate medication administration and conversion of PRN medications to scheduled medications. The resident's care plan had not been updated for over two years and did not include non-pharmacological interventions for pain management. The lack of clear guidelines and follow-up on specialist recommendations contributed to the deficiency in providing effective pain management for the resident.
Medication Administration Errors in Insulin Delivery
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a rate of 7.69% during a survey. This was identified through observations of medication administration for two residents, Resident 8 and Resident 345, out of 26 opportunities. Resident 8, who had diabetes and a history of stroke, was observed receiving 12 units of insulin, but the needle was only held in place for two seconds instead of the recommended six to ten seconds. This improper technique could lead to incomplete dosage delivery. Similarly, Resident 345, who also had diabetes, was administered seven units of insulin with the needle held for only three seconds, contrary to the facility's policy and FDA guidelines. The observations revealed that Staff C, an LPN, did not adhere to the correct procedure for insulin administration, as confirmed by their statement that holding the needle for a second or two was sufficient. This was further corroborated by the Director of Nursing, who also indicated a misunderstanding of the correct procedure. The facility's failure to ensure proper insulin administration practices contributed to the medication errors, potentially affecting the therapeutic outcomes for the residents involved.
Expired Medications and Unsecured Carts Found in Facility
Penalty
Summary
The facility failed to ensure expired medications were removed from use and that medication carts were secured when unsupervised. During observations, expired medications were found in the South and North Hall medication carts, including Nystatin powder and cream, Ketoconazole cream, Ciclopirox cream, GI Cocktail, Nitroglycerin, Flonase Spray, Albuterol inhalers, wound gel, Ondansetron, and Chlorhexidine Gluconate. Additionally, the East Hall medication cart was left unlocked and unattended by a registered nurse on two occasions, and the wound treatment cart, which contained vaccines and other medications, was also left unsecured. The wound treatment cart lacked a locking mechanism, and staff were observed walking away from it while it contained medications. The facility also failed to adhere to CDC guidance for temperature monitoring of vaccines stored in the medication refrigerator. The refrigerator, which contained RSV and influenza vaccines, had its temperature recorded only once a day, contrary to CDC recommendations of using a digital data logger or recording temperatures at least twice daily. The Director of Nursing was unaware of the requirement for more frequent temperature monitoring. These deficiencies placed residents at risk of receiving expired or compromised medications and vaccines, as well as unauthorized access to potentially harmful medications.
Inadequate Infection Control and Prevention Program
Penalty
Summary
The facility failed to implement an effective Infection Control and Prevention Program (IPCP), as evidenced by multiple observations of staff not adhering to established infection prevention measures. Staff Q was observed during dining service handling food and soiled items without performing hand hygiene, which is a critical step in preventing the spread of infection. This lack of hand hygiene was contrary to CDC guidelines, which emphasize the importance of cleaning hands before and after patient contact and after contact with potentially contaminated surfaces. Additionally, the facility did not ensure proper cleaning of equipment, as observed with the use of mechanical lifts by multiple staff members (Staff W, Y, S, V, T, U, AA, and BB). These lifts were used for resident transfers without being sanitized between uses, increasing the risk of cross-contamination. The mechanical lifts were stored in a soiled utility room, which was not an appropriate storage area for clean equipment, as it contained soiled items and standing water, further compromising infection control practices. The facility also failed to adhere to Enhanced Barrier Precautions (EBP) and Transmission-Based Precautions (TBP). Staff members were observed not wearing the required personal protective equipment (PPE) such as gowns and gloves during high-contact resident care and while in isolation rooms. This non-compliance with PPE protocols was observed during wound care, catheter management, and other resident interactions, which are critical moments for preventing the spread of multidrug-resistant organisms and other infections. Furthermore, food service practices were inadequate, with meal carts containing uncovered food items being left unattended, increasing the risk of foodborne illnesses.
Failure to Update Daily Nursing Staff Posting
Penalty
Summary
The facility failed to ensure that the nursing staff posting was updated daily to reflect the actual nursing staff hours worked during four out of five days of the survey period. Observations on multiple days showed that the nursing staff posting, located across from the nurses' station, was outdated and did not display the current day's staffing information. Specifically, on January 6th, 7th, 8th, and 9th, the posting was dated January 3rd, and on January 10th, it was dated January 9th, failing to show the actual nursing staff hours for those days. Interviews with facility staff revealed a lack of clarity and communication regarding the responsibility for updating the nursing staff postings, particularly over the weekends. Staff H, the Staffing Coordinator, mentioned that the postings were prepared in advance and left for the nursing staff to display over the weekend, but acknowledged the need to revisit this process. Staff B, the Director of Nursing, admitted the necessity for a better system, and Staff A, the Administrator, was made aware of the inconsistency and planned to assign the task to a dedicated staff member. This deficiency prevented residents, family members, and visitors from knowing the facility's actual number of available nursing staff.
Failure to Investigate Resident Elopement
Penalty
Summary
The facility failed to thoroughly investigate an incident involving a missing resident, identified as Resident 1, who was reviewed for elopement. Resident 1, who had an intact cognition and was independent in transfers and walking, left the facility unsupervised and without staff knowledge. The investigation into the incident was incomplete, lacking witness statements, a timeline of events, and documentation of notifications to the provider, local law enforcement, or the resident's representative. Additionally, there were no interventions formulated to prevent further elopement, and the resident's care plan was not updated to reflect the risk or actual elopement. Staff interviews revealed that key personnel were out of town during the incident, and those present did not conduct interviews with staff or other residents to determine how Resident 1 left unnoticed. Notifications to the resident's representative and law enforcement were made but not documented. A verbal agreement was made with Resident 1 not to leave the facility again without notifying staff, but this was not documented in the care plan. The following day, Resident 1 went missing again and was later found at a bus stop, after which they discharged from the facility against medical advice. The second elopement was not treated as such, and no investigation was conducted.
Failure to Address Elopement Risks and SUD in Residents
Penalty
Summary
The facility failed to ensure that residents with substance use disorder (SUD) received appropriate assessments and interventions, particularly concerning the risk of elopement. Three residents were identified as having SUD and were at risk for elopement, yet their care plans did not reflect necessary interventions or increased supervision. Resident 1, who had a history of drug use and was previously homeless, was assessed as high risk for elopement but was allowed to leave the facility unsupervised, even with a PICC line in place. The care plan for Resident 1 lacked coping strategies and did not address the elopement risk or the potential misuse of the PICC line. Resident 2, who was assessed as a moderate risk for elopement, was observed attempting to leave the facility without proper supervision or intervention. Their care plan also failed to include coping strategies or specific interventions for their alcohol/drug dependency and elopement risk. Similarly, Resident 3, also assessed as a moderate risk for elopement, had no care plan addressing their SUD or elopement risk. The facility's policies on elopement and SUD were not effectively implemented, as evidenced by the lack of staff training and the absence of appropriate care planning. Interviews with staff revealed a lack of training and awareness regarding the management of residents with SUD. Staff E, responsible for formulating care plans, admitted to not assessing residents for SUD due to a lack of training. The facility's response to Resident 1's elopement incidents was delayed, with notifications to law enforcement and the resident's representative occurring hours after the resident was last seen. The facility's failure to implement timely and effective interventions for residents with SUD and elopement risks placed these residents at risk for preventable accidents.
Failure to Notify Resident of Increased Financial Responsibility
Penalty
Summary
The facility failed to inform a resident and their representative of an increase in their monthly financial responsibility before charging the updated amount to the debit card on file. The resident, who was admitted with diagnoses including a left hip fracture, osteoporosis, and severe obesity, had intact cognition and required assistance for mobility and personal care. The admission agreement stipulated that residents would be notified of any rate changes at least 30 days in advance. However, the facility received notification from a State Agency about the change in the resident's care cost participation amount, but did not inform the resident or their representative before charging the increased amount. The Business Office Manager admitted to altering the Credit Card Authorization Form using correcting tape to reflect the new amount without obtaining agreement from the resident or their representative. Attempts to notify the representative via phone were unsuccessful, and no written notification was provided. The former and current administrators acknowledged the facility's responsibility to notify residents and representatives of billing changes and stated that a new authorization form should have been obtained. The failure to properly notify and obtain agreement for the increased charge was identified as a deficiency.
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We read the 41 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Cashmere
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Regency Wenatchee Rehabiliation & Nursing Center | 10.3 mi | ★★★★★ | 3 | 0 |
| Colonial Vista Post-acute & Rehab Center | 10.6 mi | ★★★★★ | 38 | 0 |
| Mountain View Post Acute | 36.9 mi | ★★★★★ | 37 | 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.