Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Colonial Vista Post-acute & Rehab Center during CMS and state inspections, most recent first.
PASARR Level II referrals were not completed for several residents who had positive Level I findings and exempted hospital discharge status. Residents admitted with anxiety, depression, PTSD, dementia, and fracture-related diagnoses had PASARRs showing Level II was required or should have been triggered after the exempted stay, but no Level II evaluations were found. One resident’s Level I also did not accurately reflect depression, and a later corrected Level I still did not indicate the needed Level II review.
Lack of Meaningful Activities and Outings: The facility failed to provide an ongoing program of meaningful activities for 6 cognitively intact residents with significant ADL needs. In Resident Council, residents said outings had stopped, they were bored, and they missed prior trips such as shopping drives, local festivals, and other community events. The Activities Director said outings were limited because many residents used wheelchairs and it was difficult to load and unload them, and the Administrator and Regional Nurse acknowledged residents were requesting more outings.
A resident with cerebral palsy and dysphagia, requiring a modified diet and supervision during meals to prevent choking, was repeatedly left unsupervised while eating. Staff were unaware of the resident's swallowing precautions, and the resident reported relying on another resident for support during meals due to lack of staff monitoring.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
A resident with severe cognitive impairment was observed unclothed from the waist down, soiled with BM and urine, with a urine-soaked brief on the floor while multiple staff passed by without assisting. Another cognitively intact resident with CP and dysphagia was left waiting for meals in the dining room while a peer was already eating, and staff said the resident's tray was often sent to the room instead of the dining room, causing repeated late meal service.
Failure to assess residents for safe self-administration of meds. Two residents with intact cognition and significant medical histories, including MS, fibromyalgia, endocarditis, HTN, and DM, had no IDT evaluation or care plan documentation for self-medication. An LPN left unidentified meds at one resident’s bedside, and another resident kept multiple creams, eyedrops, a cough suppressant, and a sleep supplement in the room and took them as desired. Staff and the DON confirmed residents were not approved to self-administer meds and meds were not to be left at the bedside without the required process.
Two cognitively intact residents were denied use of their personal refrigerators in their rooms without explanation. Both residents said their refrigerators were taken away about a year earlier and they were told only that they could no longer have them, while other residents still had personal refrigerators. The DON and Regional Nurse stated they had no knowledge of why the items were removed and acknowledged residents have a right to personal items if properly maintained.
A resident with dementia, depression, PTSD, and insomnia was ordered an antipsychotic for insomnia, which was not an approved indication for use. The record showed no side effect monitoring for the psychotropic medication, and the DON stated the required review process for indication and monitoring was not followed.
A resident who was continent of bowel and bladder when toileted in time was left in briefs and reported that staff often did not answer the call light quickly enough to provide a bedpan or bedside commode. The resident said they had not been assessed for bowel/bladder function or placed on a scheduled toileting program, while charting showed frequent incontinence episodes and staff confirmed the resident often remained in bed and had not been evaluated for the cause of the decline.
A resident in a LTC facility was forced to move rooms due to a change in their payor source, despite their right to refuse the transfer. The resident, who was cognitively intact and undergoing skilled therapy, expressed a desire to appeal the insurance decision and reluctance to move due to past negative experiences. The facility moved the resident's belongings without consent, violating their rights.
The facility failed to maintain safe food holding temperatures during a lunch meal preparation, with food items stored in a steam table at temperatures below the safe holding level of 135 F. Staff Z, the cook, did not recheck food temperatures before serving, and Staff AA, the Food Service Manager, confirmed the oversight, placing residents at risk for foodborne illness.
The facility failed to discard expired food items in the kitchen, posing a risk of foodborne illness to residents. Expired items were found in both dry storage and the walk-in refrigerator, including orange juice concentrate, cranberry cocktail, tortillas, Worcestershire sauce, baking soda, and oranges. Interviews with dietary staff revealed a lack of adherence to protocols for monitoring and discarding expired foods.
The facility failed to provide a written notice of bed hold to two residents or their representatives during hospital transfers, as required by policy. One resident with a history of stroke and heart attack was transferred due to chest pain, and another with digestive surgery aftercare and diabetes was transferred for abdominal pain. Staff interviews indicated inconsistent adherence to the bed hold notice procedure.
The facility failed to provide adequate care and monitoring for residents, including improper wound care, lack of skin assessments, and insufficient bowel management. Residents with conditions such as peripheral vascular disease, diabetes, and lymphedema experienced missed dressing changes, undocumented skin issues, and inadequate bowel movement tracking. Staff interviews revealed lapses in following care protocols and documentation practices.
The facility failed to ensure the safety of residents who smoked by not properly assessing their ability to smoke safely and not securing their smoking paraphernalia. A resident with intact cognition had smoking materials unsecured due to a missing lock box, while another with moderately impaired cognition stored smoking materials in an unlocked drawer. Additionally, a resident with asthma was observed smoking unattended without a care plan or assessment. The facility also failed to store a portable oxygen tank safely, as it was found unsecured in a room repurposed for PPE storage.
The facility failed to document and address Advanced Directives (AD) for two residents, risking their end-of-life care preferences. One resident, capable of making decisions, believed their POLST was their AD, but lacked a documented Living Will. Another resident, with impaired cognition, had no evidence of AD discussion or formulation, despite expectations for ADs to be addressed and documented.
A resident with diabetes and functional quadriplegia was not properly monitored for pressure injuries, leading to the development of new skin impairments. Despite a care plan requiring weekly skin checks and documentation, the facility failed to consistently follow these protocols. Observations showed untreated open areas on the resident's buttocks, and staff interviews revealed lapses in communication and documentation, exacerbated by a transition to a new medical record system.
A resident with a gastrostomy and severe malnutrition did not receive the prescribed enteral feeding formula due to improper labeling and substitution without physician approval. The facility failed to follow its policy and professional standards, risking expired or inaccurate nutrition delivery.
The facility failed to implement proper infection control measures during medication administration and in a contact precautions room. A nurse handled medications without performing hand hygiene, and staff entered a contact precautions room without PPE, contrary to posted instructions. Interviews confirmed expectations for hand hygiene and PPE use were not met.
A malfunctioning handicap push plate at the main entrance of the facility has been out of service since July 2023, affecting residents' ability to enter and exit independently. A resident reported delays in receiving assistance, while staff confirmed that repair bids were denied by the corporation due to cost concerns.
A facility failed to provide trauma-informed care for a resident with PTSD by not identifying or documenting their triggers in the care plan. The resident, with a history of PTSD, anxiety, and depression, reported triggers like news, loud noises, and interactions with men, which were not addressed in their care plan. Staff interviews revealed the absence of a trauma assessment and the need for a better system to manage such residents.
PASARR Level II referrals not completed for residents with positive Level I findings
Penalty
Summary
The facility failed to ensure PASARR Level II referrals were completed for residents who had positive Level I PASARR findings and were admitted as exempted hospital discharges. Resident 35 was admitted with a left leg fracture and anxiety, had intact cognition, and the PASARR dated 06/20/2025 identified SMI for anxiety disorders and noted that a Level II was required if the scheduled discharge did not occur, but no Level II evaluation was found in the record. Resident 64 was admitted with major depressive disorder, PTSD, and anxiety, had intact cognition, and the PASARR dated 07/18/2025 identified anxiety disorders and depression with the same Level II requirement if discharge did not occur, but no Level II evaluation was completed. Resident 44 was admitted with a right femur fracture, dementia, and depression, and was severely cognitively impaired. The PASARR Level I completed by hospital staff on 07/14/2025 identified anxiety disorder but did not accurately reflect depression, and it indicated the resident was exempt from further screening because discharge was expected in 30 days or less; by 08/22/2025 the resident was already five days past the 30-day exempted stay and required a Level II screening, but none was found. Resident 8 was admitted with cardiac disease and PTSD, had intact cognition, and a PASARR Level I dated 05/28/2025 initially showed no mental health diagnoses; a second Level I completed by facility staff on 06/23/2025 corrected the record to depressive mood disorder and PTSD, but still stated that no Level II was indicated, and no Level II evaluation was found. The Social Services Director stated the facility reviewed PASARRs for accuracy and for 30-day hospital exempted discharges upon admission, but the process was not followed.
Lack of Meaningful Activities and Outings
Penalty
Summary
The facility failed to provide an ongoing program of meaningful activities for 6 of 6 residents reviewed for activities: Resident 74, Resident 14, Resident 66, Resident 57, Resident 15, and Resident 69. The residents’ records showed they were cognitively intact and required varying levels of assistance with ADLs, including total assistance for some residents and extensive assistance for others. Their diagnoses included poliomyelitis, diabetes, obesity, kidney disease, heart disease, stroke, and cerebral palsy. During a Resident Council meeting, Resident 74 stated they were unhappy with the activities provided and said that since the new Activities Director started, they had not gone outside the facility on outings. Resident 74 said they used to ride the facility bus for shopping or drives, but that had stopped, and they were told there was no one available to drive the bus or enough help to take residents out. Resident 14 stated they missed outings and had been told there were not enough staff or volunteers to safely take residents out, while Resident 69 said the former "Tour of Washington" drives had stopped and that not being able to go outside was depressing. Resident 15 stated they had not been able to go on outings for over a year because their wheelchair was too large for the facility bus and they had been told the bus was broken, leaving the community bus as the only option. Resident 57 stated they missed going to local events such as the apple festival and the annual [NAME], and Resident 66 stated they were frequently bored and wanted more interesting activities both inside and outside the facility. The Activities Director stated residents had requested outings but that it was difficult to load and unload wheelchair users by herself, and the Administrator and Regional Nurse stated they were aware residents wanted more outings and were working on arranging more now that the bus was repaired.
Failure to Provide Required Meal Supervision for Resident with Dysphagia
Penalty
Summary
The facility failed to provide adequate supervision during meals for a resident with cerebral palsy and dysphagia, who was at risk for choking. The resident's medical record indicated a need for a regular texture diet with soft, bite-sized pieces and thin liquids with straws, as well as monitoring and supervision during meals to observe for choking, coughing, or holding food in the mouth. Despite these documented needs and care plan interventions, multiple observations showed the resident eating meals in the activity room without any staff supervision present. Interviews confirmed that nursing staff were unaware of the resident's swallowing precautions and did not provide the required supervision during meals. The resident reported relying on another resident for support during meals due to fear of choking and stated that staff did not monitor them while eating. Staff interviews further revealed a lack of awareness regarding the resident's dietary and supervision needs, resulting in the resident being left unsupervised during multiple meal times.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Provide Dignified Care and Timely Meals
Penalty
Summary
The facility failed to ensure care and services were provided in a respectful and dignified manner for 2 of 5 residents reviewed for dignity. Resident 6 had diagnoses including stroke and Alzheimer's disease, and the 04/10/2025 comprehensive assessment showed severely impaired cognition and a need for two staff for ADLs including toileting hygiene and lower body dressing. During multiple observations on 08/19/2025, Resident 6 was visible from the hallway unclothed from the waist down, lying in bed without an incontinent brief in place, with a urine-soaked brief on the floor, and the resident's bottom and bed linens were soiled with BM and urine. A strong odor of BM was noted in the hallway, four staff members walked past the doorway without assisting, and one NA looked into the room, saw the resident partially unclothed, and continued down the hallway without providing care. The resident remained soiled and uncovered during continued observations, and Staff J stated they did not enter the room or provide the needed care at that time. Resident 15 had diagnoses including cerebral palsy, depression, and dysphagia, and the comprehensive assessment showed the resident was cognitively intact and able to independently feed self after meal setup. During observations in the dining room, Resident 15 was seated while another resident had already been served and was eating, and the resident stated they were hungry and asked someone to find their lunch, saying this happened quite a bit. The resident did not receive a tray until 30 minutes after the other resident had been served on one occasion, and on another observation the resident was served 10 minutes after the other resident. Staff L stated the resident's tray was usually sent on the hall cart and placed in the resident's room instead of the dining room, which was why the meal was late every day. Staff K stated residents were expected to be served meals at the same time to ensure dignity was maintained.
Failure to Assess Residents for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure residents were evaluated and assessed for safe self-administration of medications for 2 of 3 residents reviewed for self-medication administration. The facility policy titled, Self-Administration of Medications, stated residents could self-administer medications when the IDT determined it was safe and appropriate through evaluation of cognitive and physical abilities, and that this would be documented in the medical record and care plan. However, the medical records for Resident 35 and Resident 79 showed no IDT evaluation for self-administration and no documentation on their care plans. Resident 35 was admitted with diagnoses including a left leg fracture, multiple sclerosis, and fibromyalgia, and the comprehensive assessment showed the resident required one to two staff members for ADLs and had intact cognition. During observation, an LPN brought three unknown medications into Resident 35's room, placed them on the bedside table, and left without identifying the medications or ensuring they were taken. Resident 35 later stated the medications were given during the morning medication pass and were held until after therapy. Resident 79 was admitted with diagnoses including endocarditis, high blood pressure, and diabetes, and the comprehensive assessment showed the resident required substantial/set-up assistance of one to two staff for ADLs and had intact cognition. During observation, Resident 79 had pain relief creams, eyedrops, a topical cough suppressant, and a sleep supplement on the bedside table and stated family had brought them from home and the resident took them when desired. Staff interviews confirmed there were no residents on the unit approved to self-administer medications and that nurses were not to leave medications at the bedside unless the self-administration process was in place.
Residents Denied Use of Personal Refrigerators
Penalty
Summary
The facility failed to ensure that two cognitively intact residents were able to use personal possessions in their rooms, specifically personal refrigerators. Resident 74 was admitted with diagnoses including poliomyelitis, diabetes, and obesity, and the comprehensive assessment showed the resident required total assistance from one to two staff members with ADLs. Resident 69 was admitted with diagnoses including heart disease and kidney disease, and the comprehensive assessment showed the resident required extensive assistance from one staff member with ADLs. During a Resident Council meeting, both residents stated that approximately one year earlier their personal refrigerators were taken away from their rooms without explanation other than being told they were no longer allowed to have them. They reported they were told that if they wanted personal food and drink items requiring refrigeration, the activities department would keep the items for them. They also stated they knew of other residents who still had personal refrigerators and felt it was not right for some residents to have them and others not, with no explanation or facility policy given for the decision. During a concurrent interview, the DON and Regional Nurse stated they were looking into getting the refrigerators back to the residents because they had no knowledge of why they had been taken away, and the Regional Nurse stated they understood residents have a right to have personal items in their rooms if properly maintained.
Inadequate Monitoring and Indication for Antipsychotic Use
Penalty
Summary
The facility failed to ensure adequate monitoring and appropriate indications for use were in place for psychotropic medication management for one resident reviewed for unnecessary medications. The facility policy on antipsychotic medication stated nursing staff would observe and document the effectiveness of antipsychotic medications, review the indication for use, and monitor for and report side effects and adverse consequences to the attending physician. Resident 10 was admitted with diagnoses including dementia, depression, PTSD, and insomnia, and the comprehensive assessment showed impaired cognition and a need for assistance from one staff member with ADLs. The physician's order dated 07/19/2025 showed an antipsychotic medication ordered for insomnia, which was not an approved indication for use. The record also showed no monitoring for side effects related to the antipsychotic medication. Staff D stated they had not been notified that the resident had been placed on an antipsychotic medication, so the process for reviewing psychotropic medication use was not followed. Staff B stated residents prescribed psychotropic medications were expected to have side effect monitoring documented in the physician's orders and MAR, and stated insomnia was not the correct diagnosis for the medication prescribed.
Failure to Assess and Support Continence Needs
Penalty
Summary
The facility failed to ensure a resident who was continent of bowel and bladder received services and assistance to maintain that status. Resident 19 was admitted with diagnoses including respiratory disease, diabetes, obesity, kidney disease, and depression. The resident’s comprehensive assessment showed they required total assistance of two staff members for bed mobility and transfers with a mechanical lift and were cognitively intact. During observation, the resident was in bed wearing only a gown and an incontinent brief, and stated they preferred a bedpan or bedside commode when they needed to toilet and were continent of both bowel and bladder if toileted in time. Resident 19 stated they repeatedly used the call light several times a day to request toileting, but staff rarely responded in time, resulting in accidents in the brief and embarrassment when being cleaned up. The resident also stated they had not been assessed for bowel and bladder function or placed on a scheduled toileting program since admission. The care plan documented bladder and bowel incontinence with interventions such as wearing briefs, peri-care after incontinence, and providing a bedpan or bedside commode, but nursing assistant documentation showed frequent incontinence episodes and some missed bowel documentation. Staff interviews confirmed the resident often used the call light for toileting, rarely got out of bed, and had not been evaluated for the cause of the incontinence or trialed on a scheduled toileting program.
Failure to Honor Resident's Right to Refuse Room Transfer
Penalty
Summary
The facility failed to honor a resident's right to refuse a room transfer when their payor source changed. Resident 1, who was cognitively intact and required assistance for daily activities, was admitted with diagnoses including respiratory failure, diabetes, and chronic kidney disease. The resident was participating in skilled therapy services with the goal of regaining strength to discharge home. When the resident's insurance no longer covered their stay, the facility informed them of the need to move to a semiprivate room due to financial constraints. Despite the resident's expressed desire to appeal the insurance decision and their reluctance to move due to a previous negative experience, the facility proceeded with the room transfer. The facility's policy allowed residents to refuse room transfers if the purpose was to relocate them from a Skilled Nursing unit to a Long-Term Care unit. However, the facility moved Resident 1's belongings to the new room while they were out at an appointment, effectively forcing the transfer without their consent. Staff interviews confirmed that the resident was upset about the move and felt their rights were violated. The facility's administrator acknowledged that the resident had the right to refuse the transfer, but this right was not honored, leading to the deficiency.
Failure to Maintain Safe Food Holding Temperatures
Penalty
Summary
The facility failed to maintain safe food holding temperatures during a lunch meal preparation, which was observed on September 26, 2024. The food items, including baked chicken, ground chicken, brown gravy, carrots, green beans, rice, and chicken, were stored in a steam table with temperatures ranging from 119 F to 134 F, all below the safe holding temperature of 135 F. Staff Z, the cook, admitted to placing the food in the warmer for about 20 minutes, with pureed and bite-sized food placed about 45 minutes prior to temperature testing. Staff Z only checked the food temperatures upon removing them from the oven and did not recheck them before serving, leading to the deficiency. During an interview, Staff AA, the Food Service Manager, confirmed that food temperatures should have been checked prior to serving to ensure they were at safe levels. Staff AA also stated that the prepared food should not be placed in the steam tables until 20-30 minutes before serving. The failure to follow the correct process for holding and rechecking food temperatures placed all residents at risk for foodborne illness due to the potential growth of harmful pathogens in food held at unsafe temperatures.
Expired Food Items Found in Kitchen
Penalty
Summary
The facility failed to maintain safe and sanitary conditions in its kitchen by not discarding expired foods, which placed all residents at risk for foodborne illness. During a general tour of the kitchen, surveyors observed expired items in both the dry storage and the walk-in refrigerator. Specifically, the dry storage contained expired orange juice concentrate, thickened cranberry cocktail, various sizes of flour and corn tortillas, Worcestershire sauce, and baking soda. Additionally, the walk-in refrigerator housed a box of oranges that had surpassed their use-by date. Interviews with the facility's dietary staff revealed a lack of adherence to protocols for monitoring and discarding expired foods. Staff BB, a cook, acknowledged that it was the dietary staff's responsibility to ensure expired foods were discarded. Similarly, Staff AA, the Food Service Manager, admitted that the team was collectively responsible for monitoring food expiration dates and discarding expired items. Staff AA further noted that the process of checking expiration dates when receiving and storing new orders had not been consistently followed.
Failure to Provide Bed Hold Notice 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 during a review of hospital transfers. Resident 62, who was admitted with diagnoses including a stroke and heart attack, was transferred to the hospital after complaining of chest pain. The medical record showed no documentation that a notice of bed hold was provided to Resident 62 or their representative. Similarly, Resident 214, who had diagnoses including aftercare for surgery on the digestive system and diabetes, was transferred to the emergency room due to abdominal pain. There was no documentation that a notice of bed hold was given to Resident 214 or their representative. Interviews with facility staff revealed that the responsibility for providing the notice of bed hold was not consistently followed, leading to the deficiency.
Deficiencies in Resident Care and Monitoring
Penalty
Summary
The facility failed to provide ongoing assessments and monitoring in accordance with professional standards of practice for five residents, leading to deficiencies in care. Resident 7, who had peripheral vascular disease and venous/arterial ulcers, experienced a lack of timely dressing changes, resulting in foul-smelling wounds and unchanged dressings for several days. Despite orders for daily dressing changes, these were not consistently followed, and weekly skin checks were often missed. The Director of Nursing Services acknowledged that the nursing staff, including travel nurses, did not adhere to the expected procedures for wound care and skin assessments. Resident 23, with cirrhosis and diabetes, had multiple bruises and a skin tear that were not documented or monitored as required. The facility's policy mandated weekly skin assessments, but these were not completed, and the bruises and skin tear were not recorded in the resident's treatment records. The Director of Nursing Services confirmed that the nursing staff failed to document and monitor the resident's skin issues as expected. Resident 25, with diabetes, heel ulcers, and lymphedema, did not have proper documentation of wound sizes or conditions, making it difficult to assess the effectiveness of treatments. Similarly, Resident 122, with diabetes and severe lymphedema, lacked documentation of wound assessments and edema monitoring. The facility's electronic health record system did not include necessary assessment forms, and staff were not documenting their findings in progress notes. Additionally, Resident 1, who experienced constipation, did not receive appropriate bowel management, with significant gaps in bowel movement documentation and lack of physician notification. Staff interviews revealed inconsistencies in following bowel management protocols and documentation practices.
Failure to Ensure Smoking and Oxygen Safety
Penalty
Summary
The facility failed to ensure the safety of residents who smoked by not properly assessing their ability to smoke safely and not securing their smoking paraphernalia. Resident 23, who had an intact cognition and required assistance for daily living activities, was observed with cigarettes and a lighter in their coat pocket, which was left on an unused wheelchair. The resident stated they had no place to lock up their smoking materials, and the facility was aware that the resident's lock box was missing. Resident 30, with moderately impaired cognition, was found to keep their smoking materials in an unlocked nightstand drawer and in their shirt pocket, despite being evaluated as safe to smoke independently over 17 months ago without a recent reassessment. Resident 164, who had moderately impaired cognition and asthma, was observed smoking unattended and had smoking materials stored openly in their room without a smoking care plan or assessment. The resident's smoking paraphernalia was found in a clear plastic container and in their purse on the nightstand. Staff interviews revealed that residents who smoke should have their materials locked up and be assessed for safety, but this was not consistently done for Resident 164. Additionally, the facility failed to store a portable oxygen tank safely. An unsecured oxygen tank was found in a room previously used for oxygen storage, which had been repurposed for PPE storage. Staff interviews indicated a lack of awareness and education regarding the change in the room's use, leading to the improper storage of the oxygen tank. This oversight placed residents at risk for avoidable accidents and potential fire hazards.
Failure to Document and Address Advanced Directives
Penalty
Summary
The facility failed to properly document and address Advanced Directives (AD) for two residents, which could potentially compromise their end-of-life care preferences. Resident 1, who was cognitively intact and capable of making their own decisions, believed their POLST form was their AD. However, there was no documentation of a Living Will in their medical record, despite having a Durable Power of Attorney for Healthcare. The care plan indicated that the POLST reflected Resident 1's AD wishes, but there was no evidence of further discussion or documentation regarding their end-of-life care preferences. Resident 10, who had severely impaired cognition and was unable to make decisions, also lacked proper documentation and discussion regarding ADs. The facility's Social Services Director mentioned that AD forms were offered upon admission and revisited quarterly, but there was no evidence that Resident 10's AD was formulated or discussed. The resident's representative confirmed that while the POLST form was reviewed, there was no discussion or information provided about formulating an AD. The facility administrator expected ADs to be addressed and documented, but this was not reflected in the records for Resident 10.
Failure to Prevent and Monitor Pressure Injuries
Penalty
Summary
The facility failed to adequately assess, monitor, or treat skin conditions to prevent the development of facility-acquired pressure injuries for a resident. The resident, who had a history of diabetes and functional quadriplegia, was admitted with a Stage 3 pressure injury and required substantial assistance for mobility and hygiene. Despite having a care plan that included monitoring and documenting skin conditions, the facility did not consistently follow these protocols. The resident's care plan indicated the need for weekly skin checks and documentation of any skin impairments. However, the September 2024 Treatment Administration Record showed lapses in treatment, with no treatment recorded on specific dates and a lack of documentation for new skin impairments. Observations revealed two open areas on the resident's buttocks, which were not new, yet there was no evidence of updated treatment orders or physician notification. Interviews with staff revealed a breakdown in communication and documentation processes. The Resident Care Manager was unaware of the current skin issues, and the Director of Nursing Services expected weekly assessments and care plan updates, which were not completed. The transition to a new medical record system contributed to the oversight, as assessments were not recreated, leading to missed documentation and treatment opportunities.
Failure to Ensure Proper Enteral Feeding Practices
Penalty
Summary
The facility failed to ensure appropriate treatment and services related to enteral feedings for a resident, identified as Resident 214, who was at risk due to expired and/or inaccurate enteral nutrition. Resident 214 was admitted with a gastrostomy and severe protein-calorie malnutrition, requiring substantial assistance for daily activities and having moderately impaired cognition. Observations revealed that the enteral feeding (EF) pump was not running, and the EF containers and tubing were not properly labeled with the necessary information such as date, time, and initials of the licensed nurse (LN) responsible. Additionally, the facility substituted the prescribed Vital AF 1.2 formula with Jevity 1.2 without notifying the registered dietician or obtaining a physician's order for the substitution, despite having the prescribed formula in stock. The facility's policy required that EF bags and supplies be changed every 24 hours and labeled with specific information to prevent microbial growth and ensure accurate administration. However, observations showed that the EF bags were not labeled correctly, and the resident did not receive the prescribed formula. Interviews with the registered dietician and the facility administrator confirmed that the staff did not follow the physician's orders or professional standards of practice. The administrator expected the nursing staff to adhere to these standards and to contact the physician if a substitution was necessary, which was not done in this case.
Infection Control Deficiencies in Medication Handling and PPE Use
Penalty
Summary
The facility failed to implement proper infection prevention and control measures during medication administration and when entering a contact precautions room. During an observation, a registered nurse (Staff M) was seen handling medications without performing hand hygiene. Staff M picked up a pill that fell onto the medication cart with bare hands and placed it into a medication cup, then handled additional medications without using gloves. After administering the medications to a resident, Staff M did not perform hand hygiene before preparing medications for the next resident. Interviews with the Infection Preventionist and the Director of Nursing Services confirmed that the expectation was for staff to use hand hygiene before and after administering medications and between residents. Additionally, the facility did not ensure the use of personal protective equipment (PPE) in a contact precautions room. Staff N, a nursing assistant, entered a resident's room with a contact precautions sign without wearing gloves or a gown, contrary to the posted instructions. Staff N stated they were informed by the charge nurse and infection preventionist that PPE was not necessary unless providing hands-on care. Similarly, Staff O, the Social Services Director, entered the same room without PPE and acknowledged the mistake after reading the sign. The facility's administrator expected all staff to follow the posted precautions.
Handicap Push Plate Malfunction at Main Entrance
Penalty
Summary
The facility failed to maintain a safe and functional environment for residents, staff, and visitors due to the handicap push plate on the main entrance door being out of service. This issue was identified during an interview with a resident who reported that the push plate had not been working for a long time, requiring them to rely on staff assistance to enter and exit the facility. The resident expressed frustration over the delay in receiving assistance, which hindered their ability to move freely as they wished. Further interviews with facility staff revealed that the Maintenance Director and Administrator were aware of the issue, which had persisted since July 2023. Despite obtaining multiple bids to repair the door, the corporation denied the requests due to cost concerns. Both the Maintenance Director and Administrator acknowledged the importance of fixing the door to ensure residents' safety and autonomy, as well as to facilitate emergency services access.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for a resident identified as a trauma survivor. Specifically, the facility did not identify or document the triggers related to the resident's Post-Traumatic Stress Disorder (PTSD) in their care plan. The resident, who had a history of PTSD, anxiety, and depression, reported triggers such as watching the news, loud noises, and interactions with men, which caused agitation, tearfulness, and anxiety. Despite this, the resident's care plan lacked any trauma-informed interventions or strategies to address these triggers. Interviews with facility staff, including the Social Service Director and the Director of Nursing Services, revealed that the resident's triggers were not assessed or included in the care plan. The staff acknowledged the absence of a trauma assessment and the need for a better system to manage residents with trauma histories. This oversight placed the resident at risk for experiencing unidentified triggers and potential re-traumatization, as the staff was not adequately informed on how to manage the resident's specific needs.
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Illustrative
What surveyors actually found near you
We read the 23 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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Illustrative
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Nursing homes near Wenatchee
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 | 1 mi | ★★★★★ | 3 | 0 |
| Cashmere Post Acute | 10.6 mi | ★★★★★ | 20 | 0 |
| Mountain View Post Acute | 31.5 mi | ★★★★★ | 37 | 0 |
| Columbia Basin Hospital | 36.7 mi | ★★★★★ | 25 | 0 |
| Mckay Healthcare & Rehab Ctr | 38.4 mi | ★★★★★ | 1 | 0 |
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