Above average — CMS composite of the measures below.
The next survey window likely opens around January 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 Cottesmore Of Life Care during CMS and state inspections, most recent first.
Failure to monitor fluid restrictions for 3 residents with orders limiting intake. One resident with HF and dysphagia, another with HF, kidney disease, and edema, and a third with ESRD on dialysis and diabetes all had ordered fluid limits, but MARs did not show daily totals of fluids from nursing and dietary/kitchen. Observations found water pitchers at bedside for two residents, and staff interviews showed some CNAs were unaware of the restrictions while others relied on a blue cup sign and care plan notation.
Failure to Investigate Possible Neglect Allegation: A resident who could make needs known reported waiting about 3 hours after asking for a brief change following a BM. The grievance and resident council notes documented the concern, and staff described it as possible neglect, but the record did not show a full abuse/neglect investigation with resident or staff interviews, skin assessment, or social services evaluation.
MDS assessments were inaccurate for two residents. One resident was receiving hospice services with an active terminal prognosis care plan, but the quarterly MDS coded hospice as No. Another resident had an active order and treatment for a stage 4 pressure ulcer, but the quarterly MDS coded the wound as stage 3. Staff confirmed both coding errors.
A resident with left foot pain, DM, and PVD had an order for PRN oxycodone, which was given frequently, but the record had no documentation that NPI such as ice or repositioning were offered before administration. The RCM and DON stated staff should have documented the resident's pain level, attempted interventions, and whether the NPI met the resident's needs.
Medication storage and self-administration were not maintained as required in the TCU. The med refrigerator/freezer log had missing entries, out-of-range temperatures, and unclear corrections while vaccines and other meds were stored inside. A resident with epilepsy, DM, and kidney disease was observed with pill cups at bedside even though the resident was only assessed to self-administer eye drops, and both a treatment cart and a med cart were left unlocked and unattended.
A resident with CHF and dysphagia requested smaller meal portions, and the RD note and provider order both reflected small portions with meals. However, the meal tray card did not list the portion-size preference, and the resident reported still receiving large meal portions despite discussing the issue with the RD. The Dietary Manager stated the portion-size information had been missed when transferring it to the meal card.
Survey results were not clearly posted for resident and visitor access. Residents stated they were unaware of the location of the state inspection records, and observation showed the survey binder lying on its side at the front reception desk without signage identifying it. The receptionist confirmed no sign was posted, and the ADM stated a prior sign had been removed during a remodel.
Surveyors found that the facility failed to follow its fall management protocol for multiple high-risk residents, including not maintaining beds in low position, not ensuring call lights and assistive devices were within reach, and not updating at least one fall risk assessment as required. Several residents with conditions such as dementia, hemiplegia, muscle weakness, repeated falls, and epilepsy were observed in high (waist-level) beds, and some reported that staff routinely left beds elevated after care despite their fear of falling. One resident with a history of brain hemorrhage and prior falls, assessed as high fall risk, fell from bed shortly after admission and was found on the floor with seizure activity, while another resident with repeated falls had a care plan for call light within reach but was observed with the call light hanging behind the bed. Staff, including CNAs, an LPN, the RCM/RN, and the DON, acknowledged that high fall risk residents’ beds should be low and call lights within reach, yet observations and records showed these practices were not consistently implemented.
The facility failed to maintain sanitary conditions in the kitchen and resident refrigerators, with missing temperature logs, undated food items, and improper hygiene practices by staff. Observations showed cooked meals left without temperature control and unlabeled food in storage. Interviews confirmed these practices did not meet facility expectations.
The facility failed to provide written notification to the SLTCO and residents or their representatives for hospital transfers of four residents. Interviews and record reviews revealed that required notifications were not documented, placing residents at risk of inappropriate discharge and lack of advocacy. Staff acknowledged the oversight, with the Social Services Director admitting that SLTCO notifications had not been completed in recent months.
The facility failed to provide written bed-hold notices to residents or their representatives during hospital transfers, affecting three residents with various medical conditions. The Director of Nursing Services acknowledged the oversight, and the Social Service Director confirmed the nursing department's responsibility for this documentation.
The facility failed to complete accurate PASARR assessments for three residents, leading to a lack of necessary Level II evaluations. One resident with mental health conditions did not receive a timely Level II evaluation due to an incorrect PASARR Level I assessment. Another resident's PASARR Level I was not transmitted, resulting in no Level II evaluation, and a third resident was not referred for a Level II evaluation despite a change in condition. Staff interviews confirmed these deficiencies.
The facility failed to update care plans and conduct timely care conferences for three residents, leading to discrepancies in care. A resident's care plan inaccurately indicated a PICC line and lacked detailed fluid restriction instructions. Two other residents did not have care conferences after their quarterly assessments, as confirmed by staff.
The facility failed to provide adequate care for residents with CHF, edema, and bowel management needs, leading to deficiencies. Two residents with CHF did not receive proper weight monitoring or provider notification of changes, and their recliners were unplugged, preventing leg elevation. Additionally, four residents did not receive timely bowel management interventions, and one resident lacked a hospice care plan. Another resident did not receive a speech evaluation upon readmission, despite hospital orders. These failures highlight the facility's lack of adherence to care protocols and documentation.
The facility failed to securely store medications and biologicals for three residents, as required by policy. A resident with multiple diagnoses had unsecured medications in their room over several days. Another resident with asthma and lung cancer had an inhaler unsecured, and a third resident with chronic kidney disease had a topical pain patch unsecured. The DON acknowledged the expectation for secure storage, indicating a policy adherence failure.
A facility failed to periodically review a resident's advanced directive (AD) as required. The resident, who had heart and kidney failure, received information about establishing an AD but did not have it reviewed until nearly a year later. The Social Services Director and Regional President confirmed the oversight, despite the facility's policy to review ADs quarterly.
The facility failed to ensure the safety of personal items for a resident with dementia, who lost their glasses and was unable to read without them. No grievance was logged for the missing glasses, contrary to protocol. Additionally, another resident's room was not maintained in a homelike manner, as a plastic bag was tied to a light fixture pull cord, which was not a cleanable surface.
The facility failed to provide appropriate pressure ulcer care for two residents. One resident continued outdated treatment due to unimplemented new orders, while another developed new pressure injuries that were not documented or addressed. The lack of communication and documentation led to deficiencies in care.
The facility failed to provide adequate hydration for a resident at risk of dehydration and did not properly monitor or document fluid intake for another resident on fluid restriction due to heart and kidney failure. Observations showed a lack of available fluids for one resident, while documentation for the other resident's fluid intake was incomplete, leading to inadequate monitoring.
The facility failed to manage oxygen therapy for two residents, one with CHF and another with COPD, by not following provider orders or initiating care plans. Observations showed discrepancies in oxygen administration, with one resident receiving less than the ordered amount and another receiving oxygen without any documented order. The DON acknowledged these deficiencies.
A resident with chronic pain and a provider's order for MS Contin did not receive the medication from November 2024 through January 2025, despite frequently reporting high pain levels. The facility failed to adhere to the care plan and provider's order, resulting in unmet needs and potential delays in treatment.
A facility failed to secure a contract with a dialysis provider for a resident with heart and kidney failure, who required dialysis three times a week. Despite having a provider order detailing the dialysis schedule and location, the facility's Regional President confirmed the absence of a necessary contract to ensure proper care coordination.
The facility failed to implement non-pharmacological interventions before administering as-needed pain medication to two residents, leading to unnecessary medication use. One resident with chronic pain received Roxicodone multiple times without documented non-pharmacological attempts, while another resident with infections and diabetes received oxycodone without such documentation. Staff interviews confirmed the lack of adherence to the facility's pain management policy.
A resident with multiple health issues, including dysphagia and broken teeth, did not receive necessary dental care after admission to the facility. Despite a provider's order for dental care as needed and an MDS assessment indicating dental issues, no referral was made. Interviews with staff revealed an expectation for a referral that was not fulfilled, placing the resident at risk of difficulty eating and reduced quality of life.
A resident with malnutrition, diabetes, and depression experienced delays in receiving necessary dental services, including new dentures, despite expressing discomfort and the need for dental care. The facility's records showed missed and rescheduled dental appointments, and a denture request form lacked a dentist's signature. Staff acknowledged the delay in addressing the resident's dental issues.
The facility failed to maintain accurate medical records for two residents, leading to potential risks. A resident was incorrectly documented as being on droplet precautions for RSV, which had resolved, while another was inaccurately noted as needing isolation precautions for RSV and MRSA. Staff confirmed these errors were due to incorrect documentation practices.
The facility failed to meet professional standards for two residents with PICC lines, leading to potential medical complications. Required measurements and proper securement were not documented or performed, resulting in one resident being hospitalized with septic shock, acute renal failure, and pneumonia.
Failure to Monitor Fluid Restrictions
Penalty
Summary
The facility failed to ensure residents with fluid restrictions had fluid intake monitoring to avoid fluid overload for 3 of 3 sampled residents, including Residents 94, 100, and 111. Resident 94 had diagnoses including heart failure and dysphagia and was ordered a 2000 milliliter per 24-hour fluid restriction split between nursing and dietary, but the MAR did not show totals of all fluids provided by both departments. During observation, Resident 94 had a water pitcher within reach, and a CNA stated they had provided a full pitcher of water and were unaware of the fluid restriction. Resident 100 had diagnoses including heart failure, kidney disease, and edema and also had a 2000 milliliter per 24-hour fluid restriction split between nursing and dietary, but the MAR did not show totals of all fluids provided by both nursing and dietary. Resident 100 was observed with a full water pitcher at bedside and stated they had been receiving one until the prior evening and were unaware of the restriction. Resident 111 had ESRD, dialysis dependence, and diabetes and was ordered a 1200 milliliter per 24-hour fluid restriction with specific amounts assigned to kitchen and nursing, but the MAR only tracked nursing fluids and did not show tracking of kitchen fluids or daily totals. Staff interviews showed inconsistent awareness of the blue cup sign used to indicate fluid restriction, and staff stated the MAR did not include totaling of fluids consumed.
Failure to Investigate Possible Neglect Allegation
Penalty
Summary
The facility failed to implement its Abuse Prohibition policies and procedures for Resident 1, including identification, investigation, protection, and reporting of a possible allegation of neglect. Resident 1 was readmitted with diagnoses including chronic kidney disease, anxiety, and Parkinson's disease, and was able to make needs known. The resident reported that after informing a CNA at about 10 PM that they had a bowel movement and needed a brief change, the CNA turned off the call light and said they would notify the assigned CNA, who did not respond until approximately 3 hours later. The resident council minutes and grievance form documented the complaint that night shift staff were not managing their time effectively in regard to brief changes and that the resident was not attended to in a timely fashion. Staff L, the Activities Director, stated the incident was believed to be neglect and reported to the Administrator, who was also the Abuse Coordinator. However, the documentation reviewed did not show an interview with Resident 1 to determine whether neglect occurred, nor interviews with other residents or staff. The Administrator stated the resident and staff were interviewed, while the DON stated an investigation including interviews, a skin assessment, social services evaluation, and determination of whether neglect occurred should have been completed and that the lack of investigation did not meet expectations.
MDS assessments inaccurately coded hospice and pressure ulcer status
Penalty
Summary
The facility failed to ensure the minimum data set (MDS) accurately reflected resident status for 2 of 19 sampled residents. Resident 11 was readmitted with diagnoses of dementia, chronic obstructive pulmonary disease, and anxiety disorder, and had an active focused care plan for terminal prognosis with hospice services being provided and documented under an active provider order. However, the quarterly MDS coded hospice services as No even though staff confirmed the resident was receiving hospice and stated the MDS should have been coded Yes. Resident 8 was admitted with diagnoses of dementia, stage 4 pressure ulcer, and anemia, and was unable to communicate needs. The record showed an active provider order for daily treatment of a stage 4 pressure ulcer to the left lower back, and the treatment was being provided as ordered. Despite this, the quarterly MDS coded the wound as a stage 3 pressure ulcer instead of a stage 4 pressure ulcer. Staff confirmed the resident had a stage 4 pressure ulcer and stated the MDS was coded incorrectly.
Failure to Document Nonpharmacological Pain Interventions Before PRN Opioid Use
Penalty
Summary
The facility failed to provide nonpharmacological interventions before giving as needed pain medication to Resident 7, who was readmitted with left foot pain, diabetes, and peripheral vascular disease and was able to make needs known. The resident had a provider order dated 01/27/2026 for oxycodone every four hours as needed for pain, and the February 2026 MAR showed the medication was administered 20 out of 28 days. Review of the record found no documentation that nonpharmacological interventions were offered or provided before oxycodone was administered. During interview, the Resident Care Manager stated nursing staff should have offered ice and repositioning before giving the PRN pain medication and should have documented the resident's pain level and attempted interventions. The DON stated that when a PRN pain medication order was entered into the EHR, staff should also have indicated on the MAR that a nonpharmacological intervention was offered and whether it met the resident's needs.
Medication Storage and Self-Administration Deficiencies
Penalty
Summary
Drugs and biologicals were not consistently stored and monitored in accordance with accepted principles in the Transitional Care Unit medication room. During observation, the medication refrigerator contained liquid medications, a TB test solution vial, an Arexvy vaccine kit, and influenza vaccine syringes, while the freezer contained frozen ice packs. Review of the February 2026 refrigerator/freezer temperature log showed multiple missing temperature entries, temperatures documented outside the stated refrigerator and freezer parameters, and several instances where temperatures were recorded only once per day. The notes/corrections section also contained illegible entries on multiple dates, and there was no documentation for several out-of-range temperatures. Staff stated the temperatures were not being documented twice daily as required and that the log contained gaps and unclear corrections. Resident 6, who had diagnoses including epilepsy, diabetes, and kidney disease, was observed in bed with two pill cups of medication on the bedside table and no staff present. The resident consumed both cups during the observation. The resident's medication self-administration review showed the resident was only assessed to self-administer medicated eye drops, not pill medications, and the care plan reflected the same limitation. Staff stated the resident was not assessed to self-administer any medications and that medications should not be left at bedside without such an assessment. In addition, a treatment cart and a medication cart on the TCU were observed unlocked and unattended, and staff confirmed both carts should have been locked when not attended by licensed nurses.
Meal Portion Preference Not Reflected on Tray Card
Penalty
Summary
Food was not provided in accordance with a resident’s stated preference for smaller meal portions. Resident 94 was admitted with congestive heart failure, right ankle pain, and dysphagia, and was able to make needs known. The record showed a registered dietician note documenting the resident’s request for small portions and a provider order for a heart healthy diet with regular texture, thin consistency, no salt packets, and small portions with meals. However, observation of the resident’s meal tray card showed regular texture, heart health, no salt packet, and a fluid restriction, with no preferences listed. During interview, the resident stated they had discussed receiving smaller portion sizes with the dietician but were still receiving large meal portions and at times felt overwhelmed by the amount of food. The Dietary Manager stated the facility must have missed transferring the portion-size information to the resident’s meal card.
Survey Results Binder Not Clearly Posted
Penalty
Summary
The facility failed to post the location of the survey results and failed to place the survey binder in an identifiable location. During a Resident Council interview, Residents 1, 10, and 16 stated they were not aware of the location of the state survey inspections. An observation showed the state inspection binder at the front reception desk, lying on its side, with the desk height higher than a tabletop, making it difficult for a person in a wheelchair to view the title on the binder. No signage was posted to identify that the binder was there. The receptionist stated there was no signage showing where the survey binder could be located, and the administrator stated the facility previously had a sign posted but it was removed during a remodel and that the lack of signage did not meet expectations.
Failure to Follow Fall Management Protocol for High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents, specifically by not following its own fall management protocol. The facility’s policy required completion of fall risk assessments on admission, readmission, quarterly, with changes in condition, and after any fall, and referenced Lippincott procedures that directed staff to keep beds in the lowest position and call lights within reach. Surveyors found multiple instances where residents identified as high fall risk had beds left in a high (waist-level) position and call lights not within reach, and one resident had an outdated fall risk assessment. Staff interviews confirmed that the expectation was for high fall risk residents to have beds in low position and call lights within reach, and that these practices were considered standard of care. One resident with a history of subdural and subarachnoid hemorrhage, prior falls, muscle weakness, difficulty walking, and restlessness/agitation was admitted to the facility, assessed with a high fall risk score of 20, and care planned for bed in lowest position, use of a mechanical lift, appropriate footwear, and PT evaluation. Progress notes documented that this resident arrived confused and, later that same day, was found on the floor next to the bed with their head against the wall and legs tangled in bed sheets, experiencing seizure activity after a fall from bed. The risk management document noted the bed was in low position and the resident was agitated and confused, and the resident was sent back to the hospital for evaluation and treatment. Another resident with altered mental status, muscle weakness, repeated falls, and spinal stenosis had multiple documented falls, including rolling out of bed and being found on a floor mat with fecal matter on their face and floor. This resident had a high fall risk score of 20 and was care planned for call light within reach and other fall interventions, including bilateral mobility rails and floor mats. However, observation showed the bed placed against the wall with the call light hanging down behind the bed and not within reach, despite the resident being on the facility’s falling star protocol as indicated by a star on the door. A resident with cognitive impairment, muscle weakness, repeated falls, and unsteadiness on feet had multiple documented falls while attempting to use a urinal independently, exercising, and sliding from a chair in the dining room. This resident had a high fall risk score of 24 and a care plan requiring the call light and a reacher to be within reach. Observations on two separate days showed the resident sitting in a wheelchair next to a bed placed against the wall, with the call light hanging behind the bed and no reacher within reach, despite a falling star indicator on the door. The resident reported being unable to reach the call light and not knowing where the reacher was. Additional residents with diagnoses including adult failure to thrive, vascular dementia, muscle weakness, difficulty walking, hemiplegia/hemiparesis, repeated falls, unsteadiness on feet, chronic pain, epilepsy, and severe cognitive impairment were all assessed as high fall risk with fall risk scores ranging from 12 to 16. For several of these residents, surveyors observed beds in a high, waist-level position while the residents were in bed. Cognitively intact residents reported that staff left their beds at that height after providing care and one resident stated they feared falling while in bed and preferred the bed to be lower. For one severely cognitively impaired resident with epilepsy and vascular dementia, the most recent fall risk evaluation in the EHR was dated several years earlier and had not been updated quarterly as required by policy. Staff interviews with CNAs, an LPN, the Resident Care Manager/RN, and the DON/RN confirmed that high fall risk residents should have beds in low position, doors open, frequent checks, and call lights within reach, and that these expectations applied to all residents, including those not on the falling star program. The DON stated it was standard practice for all beds to be at sitting level or lower and that call lights should be within reach of all residents. Despite these stated expectations and policies, survey observations and record reviews showed that for multiple high fall risk residents, beds were left in high positions, call lights and assistive devices were not within reach, and at least one resident’s fall risk assessment was not updated per policy, constituting the identified deficiency.
Sanitation and Food Storage Deficiencies in Kitchen and Resident Refrigerators
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen and resident refrigerators, leading to potential health risks for residents. Observations revealed missing temperature logs for refrigerators, undated and improperly stored food items, and cooked meals left without temperature control. Additionally, dry storage areas contained unlabeled and open food items. Staff were observed not adhering to hygiene protocols, such as touching garbage cans after hand hygiene and not wearing hairnets properly. Interviews with the Food Service Director and Regional President confirmed that these practices did not meet the facility's expectations. They acknowledged that food should be dated and sealed once opened, and that proper temperature controls should be maintained. The staff's failure to follow hygiene protocols and the improper storage and labeling of food items were identified as deficiencies that could compromise resident safety.
Failure to Notify SLTCO and Residents of Hospital Transfers
Penalty
Summary
The facility failed to provide written notification of the reason for transfer to the hospital to the Office of State Long-Term Care Ombudsman (SLTCO) and/or to the resident or their representative for four residents reviewed for hospitalization and/or discharge. This deficiency was identified through interviews and record reviews, which revealed that the facility did not document the required notifications for Residents 32, 54, 95, and 26. Resident 32, who had diagnoses including heart failure and diabetes, was hospitalized multiple times without SLTCO notification. Similarly, Resident 54, with congestive heart failure and kidney disease, was discharged to the hospital without written notification to the resident or SLTCO. Interviews with facility staff, including the Director of Nursing Services and the Social Services Director, confirmed that the SLTCO notifications were not completed as required. Staff members acknowledged the oversight, with the Social Services Director admitting that SLTCO notifications had not been done in recent months. The Director of Nursing Services also recognized the lack of documentation as unacceptable practice. These failures placed residents at risk of being inappropriately discharged and without access to an advocate who could inform them of their options and rights.
Failure to Provide Bed-Hold Notices
Penalty
Summary
The facility failed to provide written bed-hold notices to residents or their representatives at the time of transfer or discharge to the hospital, as required by regulations. This deficiency was identified for three residents who were reviewed for hospitalization or discharge. Resident 32, who had diagnoses including heart failure, kidney failure, and diabetes, was hospitalized twice, but there was no documentation in the electronic health record (EHR) indicating that a bed-hold was offered during these transfers. Staff B, the Director of Nursing Services, acknowledged that the bed-hold notices were not provided as they should have been. Similarly, Resident 95, who had conditions such as postprocedural hemorrhage and pancreatic cancer, and Resident 26, with diagnoses including cellulitis and atrial fibrillation, were both discharged with the anticipation of return, yet their EHRs lacked documentation of bed-hold notices. Staff F, the Social Service Director, confirmed that the nursing department was responsible for this documentation but could not provide any records of bed-holds for these residents. Staff B reiterated that the absence of bed-hold documentation was not acceptable practice.
Failure to Complete PASARR Assessments
Penalty
Summary
The facility failed to ensure accurate completion of Pre-Admission Screening and Resident Review (PASARR) assessments for three residents, which placed them at risk for unidentified mental health care needs. Resident 29 was admitted with multiple mental health conditions, including bipolar disorder, depression, and PTSD. The PASARR Level I assessment indicated no need for a Level II evaluation due to an exempted hospital discharge, but the resident did not discharge within the designated 30 days, necessitating a correction of the PASARR. Staff interviews confirmed the PASARR was incorrect and needed to be redone to ensure a Level II evaluation by the state evaluator. Resident 49, diagnosed with hemiplegia, dementia, and depression, required a PASARR Level II evaluation as indicated by the Level I assessment. However, the PASARR Level I was not transmitted to the PASARR coordinator, resulting in the absence of a Level II evaluation. Similarly, Resident 40, with diagnoses including dementia and traumatic subarachnoid hemorrhage, was recommended for a PASARR Level II evaluation due to a change in condition, but no documentation of a Level II evaluation was found. Staff interviews revealed that the necessary referrals for Level II evaluations were not completed, failing to meet the facility's expectations.
Failure to Update Care Plans and Conduct Timely Care Conferences
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised after each quarterly assessment for three of four sampled residents, which placed them at risk of not receiving required care. Resident 32, who was admitted with diagnoses including heart failure, kidney failure, and diabetes, had discrepancies in their care plan. The resident was unaware of being on a fluid restriction, despite a provider order for an 1800 ml fluid restriction. Additionally, the care plan inaccurately indicated the presence of a PICC line on the chest, which was not the case, and the care plan lacked detailed instructions on fluid distribution per shift. Resident 50 did not recall attending a care conference, and the records showed that the most recent care conference was held several months prior, with no subsequent conference after the quarterly MDS assessment. Similarly, Resident 22 reported that it had been several months since their last care conference, and the records confirmed that a care conference had not been held following their most recent quarterly MDS assessment. The facility's Social Services Director acknowledged difficulties in maintaining the care conference schedule, resulting in missed conferences for some residents. The Director of Nursing Services and other staff members confirmed that the care plans for these residents did not meet expectations, as they were not updated to reflect current needs and conditions. The lack of timely care conferences and inaccurate care plans could lead to residents not receiving appropriate care, as evidenced by the discrepancies found in Resident 32's care plan and the absence of care conferences for Residents 50 and 22.
Deficiencies in Care and Protocols for Residents
Penalty
Summary
The facility failed to provide adequate care and services consistent with standards of quality care for several residents, leading to multiple deficiencies. For Residents 57 and 71, the facility did not have a protocol for managing congestive heart failure (CHF) or edema, resulting in a lack of daily weight monitoring and failure to notify providers of significant weight gains and changes in condition. Resident 57 experienced increased swelling, redness, and drainage in the lower extremities without proper documentation or provider notification, and the resident's recliner was not functional, preventing leg elevation. Similarly, Resident 71 had swollen, red feet with drainage, and the facility's policy of unplugging recliners due to a previous fall incident prevented the resident from elevating their legs, exacerbating their condition. The facility also failed to implement effective bowel management protocols for Residents 7, 40, 57, and 78. Despite having orders for laxatives to be administered after 72 hours without a bowel movement, the facility did not follow through with these orders, leading to prolonged periods without bowel movements for these residents. Resident 40, for instance, experienced abdominal distention due to constipation, and the facility did not administer the prescribed laxatives in a timely manner. Interviews with staff revealed a lack of adherence to the bowel protocol and a failure to notify providers when the protocol was ineffective. Additionally, the facility did not maintain a comprehensive hospice care plan for Resident 40, as there was no hospice provider Plan of Care in the medical record. Furthermore, Resident 32, who was readmitted to the facility with a diagnosis of dysphagia, did not receive a speech evaluation upon return, despite hospital orders indicating the need for such an assessment. The lack of communication and documentation regarding the resident's dietary needs and the absence of a speech evaluation highlight the facility's failure to ensure appropriate care planning and coordination for residents with complex medical needs.
Failure to Securely Store Medications and Biologicals
Penalty
Summary
The facility failed to ensure that medications and biologicals were securely locked, as required by their policy and professional principles. This deficiency was observed in the cases of three residents. Resident 90, who had multiple diagnoses including a fracture of the right leg and respiratory failure, was found with multiple medications in pill form, inhalers, and nebulizing prescriptions unsecured on their nightstand and sink countertop. Despite being able to make their needs known, the medications remained unsecured over a period of observation from January 7, 2024, to January 8, 2025. Similarly, Resident 64, diagnosed with repeated falls, asthma, and lung cancer, was observed with an inhaler medication unsecured on an over-the-bed table. Resident 9, who had undergone a laminectomy and had chronic kidney disease, was found with a topical pain patch unsecured at their bedside. The Director of Nursing Services acknowledged that the expectation was for medications to be securely stored and locked, indicating a failure to adhere to the facility's storage policy.
Failure to Periodically Review Advanced Directive
Penalty
Summary
The facility failed to periodically review the advanced directive (AD) for Resident 32, who was readmitted with diagnoses including heart failure and kidney failure. The resident was capable of expressing their needs. The electronic health record indicated that Resident 32 received information about establishing an AD on February 26, 2024. However, the Social Services Director (SSD) confirmed that there was no periodic review of the AD until January 8, 2025, despite the facility's policy to review ADs during care conferences. The Regional President also stated that ADs were supposed to be reviewed quarterly, which did not occur in this case.
Deficiencies in Personal Property Safety and Homelike Environment
Penalty
Summary
The facility failed to ensure the safety and security of personal items for Resident 64, who was admitted with dementia and a cognitive communication deficit. Despite having adequate vision with corrective lenses, Resident 64 reported losing their glasses approximately a week before the survey. The facility did not log a grievance for the missing glasses, and interviews with staff revealed that no grievance form was initiated, which was against the facility's protocol. This oversight left Resident 64 unable to read, as their glasses were essential for their vision. Additionally, the facility did not maintain a homelike environment for Resident 50, who was admitted with muscle weakness and depression. Observations showed a plastic garbage bag tied to the metal pull cord of the overbed light fixture, which was not a cleanable surface. Resident 50 stated that a staff member had tied the bag to make the cord more accessible. Staff interviews confirmed that the presence of the bag was inappropriate and not in line with maintaining a clean and homelike environment.
Failure to Implement Pressure Ulcer Care for Two Residents
Penalty
Summary
The facility failed to implement appropriate pressure ulcer care for two residents, leading to deficiencies in their treatment. Resident 78, who had multiple diagnoses including heart disease and stroke, was admitted with a pressure ulcer on the sacrum. Despite having a care plan and orders for wound treatment, the facility did not update the Treatment Administration Records with the new orders from an outside wound provider. This resulted in the resident continuing with outdated treatment, as the Licensed Practical Nurse (LPN) and other staff were unaware of the changes. The Director of Nursing Services expected the new orders to be implemented, but this did not occur. Resident 72, admitted with conditions such as left tibial vein thrombosis and Alzheimer's disease, initially showed no unhealed pressure injuries. However, weekly skin assessments revealed blanchable redness and a black bruise on the heels, which were not properly documented or addressed. Observations showed worsening conditions, with the resident experiencing drainage and discoloration on the left leg and ankle. Despite these signs, there was no documentation of provider notification or wound assessment for the new pressure injuries on the heels. The Director of Nursing Services was not informed of these developments, and no updates were made to the care plan or orders. The lack of proper documentation, communication, and implementation of updated treatment orders for both residents highlights the facility's failure to adhere to professional standards for pressure ulcer care. This oversight placed the residents at risk for worsening conditions and demonstrated a breakdown in the facility's processes for managing pressure injuries.
Failure to Provide Adequate Hydration and Monitor Fluid Restrictions
Penalty
Summary
The facility failed to provide adequate hydration for Resident 40, who was at risk for dehydration due to dementia and a traumatic subarachnoid hemorrhage. Observations over several days showed that Resident 40 had no fluids available at the bedside, despite having dry lips and expressing thirst. Staff interviews revealed that water pitchers were supposed to be provided during rounds, but this was not done for Resident 40, which did not meet the expectations of the Director of Nursing Services. Additionally, the facility failed to monitor and document fluid intake for Resident 32, who was on a fluid restriction due to heart and kidney failure. Despite a provider order specifying a daily fluid limit, documentation in the medication administration record was incomplete, with many entries missing the amount of fluid consumed. Staff interviews indicated a lack of clarity and communication regarding the documentation of fluid intake, leading to inadequate monitoring of Resident 32's fluid restriction, which did not meet the facility's expectations.
Failure to Manage Oxygen Therapy for Two Residents
Penalty
Summary
The facility failed to manage oxygen therapy according to professional standards and the comprehensive person-centered care plan for two residents. Resident 71, diagnosed with congestive heart failure, had a provider order for continuous oxygen at two liters per minute via nasal cannula. However, observations revealed that the oxygen concentrator was running at one liter per minute, and the tubing was not in use, indicating a lack of adherence to the prescribed order. Additionally, there was no care plan initiated for Resident 71's oxygen use, which was acknowledged as a deficiency by the Director of Nursing Services. Resident 72, with multiple diagnoses including COPD and Alzheimer's disease, was observed receiving oxygen therapy without a corresponding care plan or provider order. The resident was seen with oxygen administered at varying rates, yet no documentation supported this treatment. The Registered Nurse confirmed the absence of a provider's order for Resident 72, and the Director of Nursing Services recognized the lack of a care plan and order as not meeting the facility's expectations.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide adequate pain management for Resident 29, who was admitted with multiple health conditions including heart and kidney disease, osteoarthritis, and chronic pain. The resident's care plan included a focus on pain management with a goal for the resident to express pain relief. Despite having a provider's order for MS Contin, a narcotic pain medication, to be administered as needed for pain levels between 5-10 on a numeric scale, the medication was not administered from November 2024 through January 2025. Observations and interviews revealed that the resident frequently reported a pain level of 8 out of 10 and expressed that the nursing staff did not administer the prescribed MS Contin. Interviews with staff indicated a lack of adherence to the provider's order for administering MS Contin for breakthrough pain, as documented in the resident's MDS pain assessments. The Director of Nursing Services acknowledged that the medication should have been administered according to the provider's order, especially for breakthrough pain. The failure to administer the medication as ordered resulted in a delay in treatment and unmet needs for Resident 29, potentially affecting their quality of life.
Failure to Secure Dialysis Provider Contract
Penalty
Summary
The facility failed to secure an agreement or contract with a dialysis provider for a resident requiring dialysis services, which was necessary to ensure the coordination and provision of all required care and services. This deficiency was identified for a resident who had been readmitted to the facility with diagnoses including heart failure and kidney failure. The resident, who was capable of communicating their needs, was receiving dialysis treatment three times a week at a specified dialysis center. Despite the provider order indicating the dialysis schedule and location, the facility's Regional President acknowledged the absence of a contract with the dialysis center, which should have been in place to ensure proper care coordination.
Failure to Implement Non-Pharmacological Interventions Before Pain Medication
Penalty
Summary
The facility failed to consistently implement non-pharmacological interventions before administering as-needed pain medication to two residents, leading to the risk of unnecessary medication use. Resident 18, who had multiple diagnoses including chronic pain, was prescribed Roxicodone for pain management. However, the resident received the medication on multiple occasions without any documented attempts of non-pharmacological interventions. The facility's pain management policy required such interventions to be attempted prior to administering narcotics, but this was not adhered to, as confirmed by interviews with staff. Similarly, Resident 398, who had a history of infections and diabetes, was prescribed oxycodone for pain. The medication was administered on several occasions without documentation of non-pharmacological interventions being attempted first. Staff interviews revealed that the process for documenting these interventions was not followed, and the order for Resident 398 was missed. The Director of Nursing Services confirmed the expectation for non-pharmacological interventions to be documented, which was not met in these cases.
Failure to Provide Dental Care for Resident
Penalty
Summary
The facility failed to provide necessary dental services for a resident, identified as Resident 78, who was reviewed for dental care. The resident was admitted with multiple diagnoses, including heart disease, stroke, muscle weakness, dysphagia, and constipation. The Minimum Data Set (MDS) assessment dated November 4, 2024, indicated that the resident had obvious or likely cavities or broken natural teeth and was dependent on staff for activities of daily living. Despite these findings, the resident had not seen a dentist since admission, as confirmed by both observation and interview on January 7, 2025. The resident's care plan, dated November 14, 2024, included interventions for staff to assist with personal hygiene and oral care, yet there was no evidence of a dental referral being made. A provider's order from October 30, 2024, stated that the resident may have dental care as needed, but this was not acted upon. Interviews with facility staff, including a Licensed Practical Nurse and the Director of Nursing Services, revealed that the expectation was for a referral to be made following the MDS assessment, which did not occur. This oversight placed the resident at risk of difficulty eating and a diminished quality of life.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide prompt dental services for Resident 50, who was admitted with conditions including protein-calorie malnutrition, diabetes, and depression. The resident, who was edentulous and had upper dentures, reported that their upper dentures were chipped and caused pain, and they expressed a desire to obtain new lower dentures. Despite these issues being communicated to the staff, the necessary dental services were not provided in a timely manner. The resident's care plan acknowledged their oral health problems, and a dental visit document from September 2024 recommended new upper and lower dentures. However, the facility's records showed that Resident 50 was not included in a scheduled dental visit in December 2024, and a subsequent dental hygiene visit in January 2025 was rescheduled. Additionally, a denture request form lacked the required dentist's signature, although it was signed by a physician. Interviews with facility staff revealed that the resident's denture issues were not addressed promptly, and a referral for dentures should have been obtained sooner. This delay in providing necessary dental care placed the resident at risk for continued dental problems and a diminished quality of life.
Inaccurate Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to ensure accurate documentation of medical records for two residents, leading to potential risks for their care and quality of life. Resident 398, who was readmitted with conditions including MRSA, was incorrectly documented as being on droplet precautions for RSV, a condition that had already resolved. This error was identified through interviews with staff, who confirmed that the alert note was incorrect and that the resident no longer required such precautions. Similarly, Resident 71, admitted with congestive heart failure, was inaccurately documented as being on droplet and contact precautions for RSV and MRSA, despite no signs indicating the need for such measures. Observations confirmed the absence of isolation precautions, and staff interviews revealed that progress notes were inaccurately copied and pasted without proper updates. These documentation errors were acknowledged by the staff, highlighting a failure to maintain accurate medical records according to professional standards.
Failure to Adhere to PICC Line Management Standards
Penalty
Summary
The facility failed to ensure professional standards were met for two residents with PICC lines, leading to potential medical complications. For Resident 1, the facility did not document the required measurements of the upper arm circumference and the length of the external catheter upon admission and during dressing changes. Additionally, the dressing was not properly secured, and when the PICC line was noted to be coming out, a temporary dressing using gauze was applied, which did not meet the standards of care. This resulted in Resident 1 being sent to the hospital with septic shock, acute renal failure, and pneumonia, with the PICC line likely being the source of infection due to improper dressing and securement practices observed by the hospital staff upon arrival in the emergency department. For Resident 2, the facility also failed to document the necessary measurements of the upper arm circumference and the external catheter length upon admission and during dressing changes. The dressing change was not performed on the scheduled day, and the required measurements were marked as non-applicable in the Treatment Administration Record. Staff interviews confirmed that the expected practice was not followed, and the necessary baseline measurements were not obtained or documented, which is crucial for monitoring PICC line migration and preventing complications. The Director of Nursing Services acknowledged that the facility's policy and standards of care were not adhered to in both cases. The lack of proper documentation, measurement, and securement of PICC lines placed the residents at risk for serious complications, including bloodstream infections. The facility's failure to follow physician orders and professional standards of care for PICC line management was evident in the observations, interviews, and record reviews conducted during the survey.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 1,251 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Gig Harbor
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Gig Harbor Health And Rehabilitation | 1.4 mi | ★★★★★ | 44 | 0 |
| Eliseo | 2.4 mi | ★★★★★ | 5 | 0 |
| Avamere Transitional Care Of Puget Sound | 2.8 mi | ★★★★★ | 56 | 0 |
| Park Rose Care Center | 4.4 mi | ★★★★★ | 0 | 0 |
| Heron's Key | 5.4 mi | ★★★★★ | 10 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.