Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Crystal Cove Post Acute during CMS and state inspections, most recent first.
Resident room temperatures were found above the acceptable range in several rooms during a tour, with readings up to 84.5 degrees F. Multiple residents stated their rooms were too warm, and one resident reported a fan had burned out and had not been replaced. The Maintenance Director acknowledged that resident rooms did not have AC units and that the facility did not have fans available at the time, while the Administrator later acknowledged that several rooms were above 81 degrees F.
Failure to develop and timely implement fall interventions and provide adequate supervision for residents with fall risk. A resident with dementia and another resident with diabetes, spinal stenosis, fibromyalgia, and cognitive impairment had repeated unwitnessed falls, including one resident being left unattended in the shower and another lacking a posted reminder sign during observation. A third resident with ESRD, DM, and dementia had multiple falls, and the record showed interventions were not timely added after some of the falls.
Dishwasher temperature logs were completed incorrectly, chemical sanitation testing was not documented, and food was served below the required temperature on multiple halls. A Dietary Manager found the wrong test strips in use and acknowledged the missing chemical testing log, while dining observations showed trays with chicken and other items below 135 degrees, including one tray already served to a resident before temperatures were checked.
Inaccurate PBJ Staffing Submission: The facility failed to submit complete and accurate PBJ direct care staffing data for Q3. Review of the submitted staffing information showed a reported shortage of 0.06 HPRD, and after additional information was provided, the HPRD was adjusted to 3.4, confirming the original submission was inaccurate. The acting Administrator confirmed the inaccurate PBJ submission during interview.
A resident admitted after a fall with rib fractures and a PE developed an acute decline with snoring respirations, inability to awaken, and abnormal GCS findings. Staff monitored in-house for hours, obtained STAT labs, and delayed calling 911 despite persistent unresponsiveness and worsening neuro status. EMS later found the resident unconscious with decorticate posturing and unequal, non-reactive pupils; the resident was diagnosed with a large intracranial hemorrhage and herniation.
The facility failed to follow its bed-hold policy by not providing written bed-hold notices to two residents when they were transferred to the hospital, and by not maintaining signed copies in their medical records. One cognitively intact resident requested hospital transfer, and later hospital staff reported that when the resident was ready for discharge, the facility stated the prior semi-private bed was no longer available and only a four-bed room could be offered, which the resident declined, leading the hospital to find another facility. Another resident with mild cognitive impairment was transferred to the hospital by ambulance without any documented bed-hold notice. The DNS acknowledged that no bed-hold forms were signed or documented for these residents and that nursing staff were responsible for providing such notices when a return was expected.
A resident with a right below-the-knee amputation, mild cognitive impairment, and dependence on staff for ADLs, transfers, and mobility was discharged from PT with a documented recommendation for a Restorative Nursing Program (RNP) and prosthetic follow-up. Facility policy required that residents identified as needing restorative services receive interventions such as ROM, mobility training, and amputation/prosthesis care, and that the discharging therapist or nurse communicate the restorative plan to restorative aides. Record review showed no MD order for RNP services and no documentation that restorative nursing services were provided, which was confirmed by the PT during interview.
The facility changed its dining schedule to create a 15‑hour gap between dinner and breakfast without allowing the resident council to vote on or approve the new mealtimes, although residents were informed via a flyer. A resident council member reported they would have opposed the change, and several residents stated that evening snacks were inconsistent, with some being told there were no snacks or that staff were out of them. Dietary and activities staff described snack trays, an activities cart, and a stocked refrigerator, but acknowledged that residents, including those who were bedbound, often had to request snacks and that staff might not be going room to room. The Administrator reported that CNAs and activities staff were supposed to offer snacks and water in the evening but confirmed there was no documentation of this, and the RD stated she was unaware that a nourishing snack was required when the interval between meals exceeded 14 hours.
Shower rooms on Hall A and Hall C were observed with peeling paint, stained flooring, debris, and other unsanitary conditions. A resident said the shower rooms were dirty and gross, and staff later found a small brown item that appeared to be stool in one shower room after a resident's shower. The MDS confirmed peeling tiles and baseboards and said one floor needed deep cleaning or resealing.
Psychotropic meds were not consistently monitored or linked to resident-specific target behaviors for three residents. One resident had multiple antidepressant, antipsychotic, and sedative orders, but the care plan used broad behaviors and did not identify bipolar-specific symptoms, making it hard to tell which med was effective. Another resident had Zoloft, propranolol, and Seroquel with one behavior monitor that did not separate the meds, missing NPI documentation and delayed AIMS monitoring. A third resident had hydroxyzine and mirtazapine, but the EHR did not show target behavior monitoring.
Surveyors found multiple incomplete and non-person-centered care plans for several residents. Psychotropic medication plans did not identify the specific meds, diagnoses, or target behaviors, one resident had no care plans for dementia, depression, or smoking, another had no schizophrenia care plan and an unindividualized restorative plan, and other records missed needed plans for HOB elevation, feeding assistance, dialysis details, anxiety treatment, and fluid overload monitoring.
The facility failed to keep residents free from unnecessary drugs for three residents. A resident with cancer and pain had PRN pain orders with non-pharmacological interventions, but the MAR did not document that those interventions were provided. A resident with chronic lung disease remained on O2 despite repeated room-air SpO2 checks above the ordered threshold, and the RCM confirmed the physician was not contacted to trial RA. Another resident with chronic pain received oxycodone outside ordered pain parameters, and documentation of non-pharmacological interventions was inconsistent or unavailable.
Medication storage was not maintained according to accepted professional principles in the A&B med room and on two med carts. An LPN found a PPD vial without an open date, an emergency kit with expired medication, and missing refrigerator temperature checks for vaccines. On one cart, opened rectal suppositories were stored with oral meds, a resident's pill packets were mixed with treatment supplies, and an opened liquid pain med lacked an open date. On the other cart, batteries, tape, scissors, unlabeled confiscated gummies, and eye drops were stored with meds or treatment supplies instead of being kept separately.
Failure to document COVID-19 vaccine education and consent for two residents. Two cognitively intact residents had MDSs showing their COVID-19 vaccination was not up to date, but their EHRs had no documentation that they were educated on the risks and benefits of the vaccine. The IP stated informed consent forms should have been completed and filed, but they were not.
The deficiency concerns unsecured smoking materials, incomplete smoking assessment, and inadequate lighting in the smoking area and access path. A resident who was cognitively intact and used tobacco kept cigarettes unsecured in a bedside drawer instead of having them locked in the treatment cart, and the resident’s smoking assessment lacked documentation on medications, behaviors, and nursing safety assessment. Staff acknowledged the assessment was incomplete. In addition, residents accessed a smoking area via a narrow sidewalk with an S-curve and 2–6-inch drop-offs or ruts at the edges, where wheel tracks were visible. Staff and residents reported that management stopped turning on the flood lights after dark due to substance use concerns, yet residents continued to use the area in the dark; one resident reported a fall while returning from the smoking area when it was “pitch black,” and others described the area as dangerous due to uneven surfaces and lack of lighting.
Failure to maintain resident dignity during billing discussions. Two cognitively intact residents reported feeling harassed by the BOM when asked about unpaid bills. The BOM stated they jokingly told residents, "I want your money, it is rent day," during monthly billing conversations, and the facility investigation noted the language used could benefit from additional training.
Resident council concerns were not communicated back to members, and meeting minutes for multiple months showed blank old business and new business sections. The Activities Director said she did not document follow-up on prior concerns and only asked if the council still had the same concerns, while the Administrator confirmed the council was not informed of grievance results.
A resident’s personal funds were not returned within the required 30-day timeframe after discharge. The BOM confirmed the resident was discharged and the check to return the money was not written within 30 days, and the Administrator verified the funds were released late despite the facility policy requiring timely return of resident funds.
A resident who was cognitively intact, ambulatory with a walker, and identified as a high fall risk sustained an unwitnessed fall while returning from the smoking area, with minor head and extremity injuries. The facility’s investigation did not identify the exact fall location, did not assess environmental factors such as darkness or the smoking-area lighting being off, and did not interview the resident who found the fall or other staff/residents with possible knowledge. The resident later reported the area was pitch black, and a staff member reported the walker got caught, but these details were not fully incorporated into the investigation.
The facility failed to ensure accurate MDS assessments for two residents. One resident’s MDS did not reflect documented dental pain, missing and broken teeth, or difficulty chewing/swallowing, despite the resident’s report and dental records showing poor oral health and a care plan noting chewing/swallowing problems. Another resident’s MDS incorrectly showed no OT services even though OT sessions were documented in the record, and staff confirmed the assessment should have reflected those services.
Failure to follow orders and accurately document care: Staff gave oxygen above the ordered rate and signed as if the ordered rate had been provided, administered a beta blocker despite hold parameters, documented behavior and anticoagulant monitoring without recording the required details, signed daily splint care that had not been completed, and charted ordered high-protein snacks as given when the resident did not always receive them. These actions involved residents with chronic lung disease, severe cognitive impairment, anticoagulant therapy, and orthopedic splint orders, and included staff signing tasks they had not actually completed.
A resident with paraplegia, malnutrition, and stage 4 pressure ulcers had a low air loss mattress repeatedly observed with incorrect weight settings, static mode, and a low-pressure alarm/light, while staff confirmed the settings were not matching the resident’s weight and the pump was fluctuating. The resident also had ordered high-protein snacks for wound healing, but staff reported giving chips or other items instead of the ordered PB and tuna snacks, and the resident said the snacks were not being received.
Therapeutic Diet and Fluid Restriction Monitoring Failures: A resident on a renal diet was sent the same dialysis sack lunch despite stating they did not eat poultry, and staff confirmed no food preference eval had been completed before the resident signed a refusal form. Staff also acknowledged the meal was not appropriate and that no alternative was offered. In addition, two residents with fluid restriction orders did not have complete documentation of total 24-hr fluid intake, including missing meal fluid records and incomplete shift reconciliation.
An LPN administered an IV antibiotic through a resident’s PICC line without aspirating for blood return before the infusion. The resident had MRSA, was moderately cognitively impaired, and had central line IV access for IV meds. The DON later stated the LPN should have aspirated for blood return per facility policy.
A resident with chronic lung disease had orders for continuous O2 at 2 L/min via NC, but staff repeatedly documented O2 at 3 L/min without a documented respiratory assessment or physician order. The resident’s SpO2 readings were mostly in the mid to high 90s, and oxygen tubing/NC changes were not consistently done per the weekly order.
The facility failed to maintain complete dialysis communication and follow-up for two residents receiving HD. One resident with ESRD had repeated missing dialysis transfer form details, absent post-dialysis assessments, missing lab attachments, and no documented fluid monitor or fluid restriction despite dialysis recommendations and a nutrition assessment calling for fluid intake/output monitoring. Staff also could not locate the nephrologist in the record. For the second resident, the record showed dialysis was occurring, but dialysis communication documentation was missing or incomplete, including required pre- and post-dialysis weight information.
The facility failed to complete the required annual performance review for an NA with veteran status and did not provide education based on the review outcome. The personnel file showed the NA was hired in 2023, but no annual performance review was completed during the following review period, and the Administrator confirmed the missing review.
The facility failed to provide prompt dental services for two residents. One cognitively intact resident reported broken and missing teeth, pain with chewing, and no dental follow-up despite a prior dental evaluation showing decayed, broken, and missing teeth with recommended x-rays and extractions. Another severely cognitively impaired resident had facial swelling, signs of pain while chewing, and a tooth abscess, but staff interviews showed confusion over who was responsible for arranging the dental consult, and no appointment had been secured.
Failure to provide ordered and preferred foods: A cognitively intact resident on a renal diet received a dialysis sack lunch containing turkey despite not eating poultry, and no food preference eval had been completed at admission. Another resident with an order for whole milk was observed receiving orange juice only or 2% milk instead of whole milk. A third resident on dialysis and a renal diet was served sweet potatoes even though they were not listed on the meal ticket.
Improper Refrigerator Temperature Monitoring: A resident refrigerator in the dining room was observed at 51 degrees instead of 41 degrees or below, and staff confirmed the reading. The thermometer was later found missing from the refrigerator after a new unit had been placed, and the Admissions Director stated it had been removed after being dropped and was not returned. The report also noted that the inner kitchen refrigerator thermometer did not function.
A resident admission process failed to ensure arbitration agreements were reviewed and explained in a way residents could understand. Three residents reported they did not know they were giving up the right to court action or that they could cancel the agreement within 30 days, and one said they were told to sign papers with an explanation promised later. The admission coordinator stated residents may sign or decline the agreement and that staff should explain it, answer questions, and break down the wording, but the residents’ interviews showed they did not understand what they signed.
Missing Hospice Coordination and Visit Documentation: The facility lacked a system to coordinate hospice care for a resident with a terminal dx and hospice services. The resident’s EHR did not contain the current or prior coordinated hospice POC, and no hospice RN, aide, SW, or chaplain visit notes were available. Staff said there was no hospice binder, no sign-in process, no designated hospice liaison, and no clear person responsible for tracking hospice visits or maintaining the hospice POC.
Staff failed to follow IPCP practices during wound care, contact precautions, EBP, and catheter equipment handling. A nurse changed a wound dressing without hand hygiene or glove changes, staff entered a resident’s contact room without gowns or gloves and provided therapy without PPE, a physician entered another contact room without proper PPE and with gown ties dragging on the floor, precaution signage listed the wrong resident, and a urinal used for catheter drainage was left with urine and visible residue.
Failure to Implement Effective Antibiotic Stewardship: Three residents were given antibiotics for presumed UTIs without the expected diagnostic support. One resident had bacteria noted on UA but no C&S was found before Bactrim DS was started, while two other residents were started on Cefpodoxime and Augmentin without a UA, C&S, or documented McGeer’s criteria supporting a UTI. Staff confirmed the missing testing and noted that one antibiotic had been prescribed by an outside specialist and another may have come from dialysis.
A NA did not receive the required 12 hours of annual in-service training, including dementia care, abuse prevention, and care for individuals with cognitive impairment. Record review showed the NA received only 6 hours of training during the review period, and the training did not include abuse prevention. The Administrator confirmed the NA had only completed 6 of the required 12 hours.
A resident with end stage renal disease, atrial fibrillation, and significant balance deficits was repeatedly left unsupervised at the edge of the bed despite requiring substantial staff assistance for mobility and transfers. The resident experienced multiple unwitnessed falls, including one after returning from dialysis when they were left unattended at the bedside for a meal, resulting in fractures to the right wrist and hospitalization. Staff interviews confirmed awareness of the resident's high fall risk and the need for supervision, but interventions were not consistently implemented.
The facility did not maintain required room temperatures, with multiple resident rooms recorded well below the mandated 71-81°F range. Residents and their families reported persistent cold conditions, and staff confirmed that many room heaters were not activated or maintained. Maintenance acknowledged that the HVAC system was not fully operational and that previous staff had not ensured proper heater upkeep, resulting in ongoing discomfort for residents.
A resident admitted with multiple fractures, a subarachnoid hemorrhage, an external fixator, and an indwelling catheter did not receive timely wound or catheter care as required by physician orders and facility policy. Orders for wound and catheter care were delayed, and documentation showed that care was not provided or recorded for several days after admission, resulting in the resident leaving the facility against medical advice.
Insufficient dietary staff training and oversight led to missing food temp logs, use of a broken thermometer, and service of undercooked food to a resident. Surveyors also found improper dishwasher and sanitizer testing, lack of documentation for the 3-compartment sink and sanitizer bucket, and staff who could not demonstrate correct chemical testing or state required food temp standards.
Food safety practices were deficient when staff failed to consistently document food temperatures, used a broken thermometer, and served or prepared foods below required temperatures, including undercooked chicken, a cheeseburger, and a lunch tray with items below standard. Staff were also observed handling food with gloves without sanitizing hands after glove removal, and the kitchen showed poor sanitation with uncompleted cleaning tasks, debris on cooking equipment, and a leaking walk-in refrigerator. The DON and dietary leadership acknowledged staff turnover and incomplete training in the kitchen.
Administration failed to maintain active oversight of pressure injury care, dietary operations, and kitchen sanitation after internal audit findings identified gaps in skin checks, wound measurements, enhanced barrier precautions, food temperature documentation, chemical sanitation, and meal timing. Observations also noted standing water, towels on the floor, and a dirty kitchen hood, while the Administrator acknowledged staff turnover, ongoing training, and responsibility for kitchen oversight.
A facility failed to provide timely wound assessments and to follow/document ordered wound care for two residents with pressure ulcers and other wounds. One resident with diabetes, PVD, and ESRD had incomplete skin assessments, delayed wound measurements, a later wound consult showing a buttocks DTPI with signs of infection, and missed documentation of ordered treatment. Another resident with MS, cellulitis, and a left buttock pressure ulcer had multiple wound care orders that were not signed as completed on several occasions, and the RCM and DON acknowledged the gaps in assessment and documentation.
A facility failed to provide ordered nutritional supplements and menu items for two residents. One resident with MS and a pressure ulcer had meal trays that did not match the menu and was missing ordered Mighty Shakes, while another resident with AD and dementia did not receive ordered Magic Cup/Mighty Shakes with meals. The Dietary Manager reported the facility ran out of supplements, and the DON acknowledged multiple residents missed supplements at breakfast and lunch.
A resident with quadriplegia and a positive lab result for OXA-235 like CRAB was placed on contact precautions, but the room had no precaution signage and a CNA entered the room without a gown or gloves while assisting the resident. The CNA said they knew the resident was on contact precautions but did not realize PPE was needed, and the DON and Infection Preventionist later acknowledged the lack of signage and PPE use.
A resident with complex medical needs did not have required admission or weekly weights obtained, despite physician orders and care plan directives. The dietician's recommendation for a nutritional supplement was not communicated to the physician, resulting in the resident not receiving the supplement. The DON confirmed these lapses in care.
Two residents with chronic pain conditions missed multiple consecutive doses of their prescribed narcotic pain medications due to the facility not receiving the medications from the pharmacy in a timely manner. Documentation and interviews with residents, an LPN, and the DON confirmed the missed doses and the delay in pharmacy delivery.
A resident with a physician's order for CPR was found unresponsive, but staff failed to initiate CPR or call emergency services, violating the facility's emergency response policy. The resident's POLST indicated full resuscitation, but staff did not follow protocol, leading to the resident's death. The facility's investigation revealed that several staff members lacked current CPR certifications.
The facility failed to provide adequate care for pressure ulcers, resulting in harm to residents. A resident developed an unstageable pressure ulcer due to delayed treatment, while another did not receive necessary equipment to prevent ulcer worsening. Incomplete skin assessments and lack of timely interventions were noted for multiple residents, highlighting significant deficiencies in wound care management.
A resident with a gastrostomy tube was not properly assessed for tube placement before enteral feeding, and the prescribed hydration orders were not followed. The LPN administered 50 ml of water instead of the prescribed 100 ml after feeding, placing the resident at risk for nutritional issues.
The facility failed to monitor and address significant weight loss and fluid restrictions for several residents, leading to potential harm. A resident experienced significant weight loss due to inadequate weight monitoring and lack of communication with the physician. Another resident faced similar issues with supplement intake and dietary interventions. Additionally, fluid restrictions were not consistently documented or communicated, resulting in potential non-adherence.
Resident Room Temperatures Above Acceptable Range
Penalty
Summary
The facility failed to ensure a comfortable homelike environment by not maintaining adequate temperatures in resident rooms in one of four hallways reviewed. During the facility tour with the Maintenance Director, room temperatures were measured at 84.4 degrees F, 80 degrees F, 80.2 degrees F, 82.2 degrees F, 84.5 degrees F, 82 degrees F, and 84 degrees F in multiple rooms. During interviews, a resident stated her room was too warm, another resident stated the room was too hot and requested the window be opened, and another resident stated the room was too warm and reported the fan in the room had burned out and had not been replaced. The Maintenance Director acknowledged that hallway air conditioning was present but resident rooms did not have air conditioning units, that outside temperatures had been warm, that the facility did not have fans available for resident rooms at that time, and that he had just ordered 10 fans. The Administrator later acknowledged that resident room temperatures were to be maintained between 71 and 81 degrees F and that several resident rooms were above 81 degrees.
Failure to Develop and Timely Implement Fall Interventions
Penalty
Summary
The facility failed to ensure new fall interventions were appropriately developed or timely initiated and failed to supervise residents to prevent falls for 3 of 4 sampled residents. The facility policy titled Fall Management stated residents are to be assessed on admission/readmission, quarterly, with significant change in condition, and with any fall event, and that interventions to reduce fall risk should be individualized based on risk factors and fall history. Resident 1 was admitted with dementia with behavior disturbance for respite care, was forgetful, ambulated with a cane, and required limited assistance/supervision to go to the bathroom for safety. A fall risk assessment showed moderate fall risk, but the care plan documented the resident as low risk and included only an intervention to encourage use of the call light. The resident later had an unwitnessed fall in the room and sustained numerous skin tears to the right side of the body. Resident 2 had diagnoses including diabetes, spinal stenosis, and fibromyalgia, with mild cognitive impairment and a need for staff supervision for transfers, ambulation, and bathing/showers. The resident had repeated unwitnessed falls in the shower, bathroom, and room; one investigation showed the resident was taken to the shower room and left unattended, another fall led only to a medication review, another led to a reminder sign in the room that was not present during observation, and another fall had a care plan revision documenting not to leave the resident unattended in the bathroom 13 days after the fall. Resident 3 had end stage renal disease, diabetes, and dementia, with cognitive impairment, upper extremity impairment, dependence on staff for transfers, bathing, and toileting, and high fall risk. The resident had 5 falls over the review period, including unwitnessed and witnessed falls in the room, and the record showed no timely intervention was implemented on the care plan after falls on 05/02/2026 and 06/13/2026.
Dishwasher Testing and Food Temperature Deficiencies
Penalty
Summary
The facility failed to document timely dishwasher temperatures, failed to complete dishwasher chemical sanitation testing, and failed to serve food at appropriate temperatures for 2 of 4 halls reviewed. The facility policy required low-temperature dishwasher chemical sanitation testing with the correct chlorine concentration, with results recorded at least once per shift, and required water temperatures to be measured and recorded prior to each meal or after the dishwasher was emptied or refilled. During observation of the kitchen, a dishwasher temperature log for June 2026 was present, but no log for chemical testing was found. The Dietary Manager and a Dietary Aide searched for the chemical strips, and the Dietary Manager acknowledged the wrong test strips had been used and that the chemical testing log was missing. The Dietary Manager also acknowledged the temperature logs had been filled out incorrectly before the temperatures were taken. During dining observations, food temperatures were below 135 degrees on multiple trays. In the dining room, the last tray served to a resident included chicken at 131 degrees and was served to the resident. On Hall B, the tray cart was delivered and food temperatures on numerous items were below 135 degrees, requiring the cart to be returned to the kitchen to be reheated. On Hall D, chicken on a tray measured 129 degrees and numerous food items on several trays were below 135 degrees; one tray had already been delivered to a resident before temperatures were checked, and the cart was returned to the kitchen to be reheated. A resident stated the food was under or overcooked, served cold, and sometimes the dishes were dirty.
Inaccurate PBJ Staffing Submission
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS for Q3 PBJ reporting. The report states that, based on interview and record review, the facility did not ensure the staffing data submitted for July 1, 2025 through September 30, 2025 was accurate, even though PBJ reporting is required to be based on payroll and other verifiable and auditable data. The June 2022 CMS Long-Term Care Facility PBJ Policy Manual required submission of direct care staffing information, the category of work for each direct care staff member, resident census data, and direct care staff turnover and tenure by the required deadline. Review of the PBJ data submitted by the facility showed a reported shortage of 0.06 hours per resident day. After the facility provided additional information to the department, the hours per resident day were adjusted to 3.4, which met the threshold and eliminated the associated fine, but also showed the originally reported PBJ data was inaccurate. During a telephone interview on 06/10/2026, Staff A, acting Administrator, confirmed the facility failed to ensure accurate PBJ data was submitted for Q3 2025.
Delayed Response to Acute Neurological Decline
Penalty
Summary
The facility failed to timely recognize and respond to an acute change in condition for a resident who had been admitted with rib fractures from a prior fall and a pulmonary embolus. The resident had been alert, oriented, and verbally appropriate on admission and was documented the next day as alert and oriented times three, making wants and needs known and showering with assistance. On the morning of the event, staff found the resident sleeping through breakfast and unable to be awakened, with snoring respirations and stable vital signs. Staff documented that the resident did not respond to touch, water on the lips, or routine care, and a neurological assessment using the Glasgow Coma Scale showed no eye opening, no verbal response, and abnormal extension with stimulation. Staff notified the medical provider, who ordered STAT labs and instructed the facility to continue monitoring and call back if vital signs became abnormal. The resident remained difficult to arouse throughout the day, slept through meals, and could not be awakened for medication administration. Nursing notes later documented continued unresponsiveness to voice, touch, and external stimuli before 911 was finally called. Staff interviews showed that the nurse believed the resident was exhausted and continued to monitor in-house despite the resident’s inability to wake, snoring respirations, and abnormal neurological findings. The on-call provider later stated that if the resident had truly been reported as unable to wake, with a GCS of four and extension when touched, the resident would have been sent immediately to the emergency room and the situation would have been considered a medical emergency. Emergency responders found the resident unconscious with sonorous respirations, unequal and non-reactive pupils, and decorticate posturing, and the resident was transported critically ill. Hospital records showed a large subdural hematoma, intraparenchymal hemorrhage, and herniation, and the hemorrhage was determined to be non-surgical and non-survivable.
Failure to Provide Required Bed-Hold Notices at Time of Hospital Transfer
Penalty
Summary
The facility failed to provide required written bed-hold notices to residents at the time of hospital transfer, as required by its own policy and state regulations. The facility’s undated "Bed Hold Notice" policy stated that in the event of an emergency transfer, written notice of the facility’s bed-hold policies must be provided to the resident and/or resident representative within 24 hours, and a signed and dated copy must be kept in the resident’s record. For one resident who was cognitively intact, the medical record documented that the resident requested transfer to the hospital for treatment and evaluation, but there was no documentation that a bed-hold notice was provided at the time of transfer. For another resident with mild cognitive impairment who was transferred and admitted to the hospital by ambulance, review of the medical record likewise showed no documentation that a bed-hold notice was provided. A hospital staff member reported that the first resident had previously occupied a semi-private room, and when the hospital notified the facility that the resident was ready for discharge, the facility stated only a four-bed room was available because the prior semi-private bed was no longer available; the resident did not want to return to a four-bed room, and the hospital had to locate another facility for discharge. The DNS confirmed that bed-hold forms were not signed and there was no documentation that bed-hold notices were provided to these two residents, and acknowledged that nursing staff were responsible for ensuring bed-hold notices were given when residents were transferred to the hospital with an expected return.
Failure to Implement Recommended Restorative Nursing Program After PT Discharge
Penalty
Summary
The facility failed to provide restorative nursing services as recommended for a resident with a right below-the-knee amputation. Facility policy stated that residents identified through the comprehensive assessment process as needing restorative nursing services would receive them, including interventions such as passive or active ROM, splint or brace assistance, bed mobility, transfer and walking training, dressing and grooming training, eating and swallowing training, amputation/prosthesis care, and communication training. The policy also required the discharging therapist, Restorative Nurse, or designated licensed nurse to communicate the restorative nursing plan to the appropriate restorative aide and provide necessary training. The resident was admitted with a diagnosis including a right below-the-knee amputation and, per a quarterly MDS, had mild cognitive impairment, no behaviors, required staff assistance for ADLs, transfers, and mobility, and used a wheelchair. A PT Discharge Summary covering services from 08/18/2025 through 09/30/2025 documented recommendations for a Restorative Nursing Program and follow-up with a prosthetic company for further fittings. Review of the medical record showed no physician’s order for restorative nursing program services for this resident, and during interview the PT confirmed there was a recommendation for restorative services but no documentation that the resident received them.
Failure to Obtain Resident Input and Provide Consistent Nourishing Bedtime Snacks During 15‑Hour Meal Interval
Penalty
Summary
The facility implemented a new meal schedule that created a 15‑hour interval between the evening and morning meals for all dining locations, with dinner times ranging from 4:30 PM to 6:00 PM and corresponding breakfast times from 7:30 AM to 9:00 AM. Resident Council minutes documented the new schedule and indicated that a flyer explaining the change was distributed by the Activities Director; however, a resident council member reported that residents were only informed of the new mealtimes and were not given the opportunity to vote on or approve the 15‑hour gap. The resident stated they would have voted against the change if given the option and indicated that snacks were put out but residents had to ask for them. Multiple residents reported inconsistent access to evening snacks, with one resident describing snack availability as “hit and miss” and stating staff sometimes said there were no snacks, and another resident reporting they had to ask for snacks but never received them because staff said they were out. The Dietary Manager stated that CNAs and residents could request snacks at the kitchen door and that snack trays were placed out after breakfast and again at night, but acknowledged uncertainty about whether staff went room to room, particularly for bedbound residents. The Activities Director and Activity Aide described snack offerings from an activities cart during the day and evening and mentioned a stocked refrigerator accessible at night, while the Administrator stated that CNAs and activities staff were supposed to offer snacks and water after dinner, with no documentation of the evening snack pass. The Registered Dietician reported she was not informed of the 15‑hour gap between dinner and breakfast and was unaware that a nourishing snack was required when the interval between meals exceeded 14 hours. The facility later indicated its snack policy was under revision.
Shower Rooms Not Kept Clean and in Good Condition
Penalty
Summary
The facility failed to ensure the shower rooms were clean and in good condition in 4 of 4 shower rooms reviewed on Hall A and Hall C. During an interview, a resident stated the shower rooms were dirty and said that if someone went into any of them, they would see how dirty they were. The resident also said they had asked for garbage bags to be put on their feet because of how gross the shower rooms were. Observations showed peeling paint on the shower tiles and baseboards, dark brown/black staining on the flooring and between tile textures, a large stain near the shower head and floor drain, and yellow staining down the wall near the shower controls. Trash was seen on the floor in one shower room, including what appeared to be a seal flap and debris from peeling wall material. In another observation, a shower room had towels draped over the shower wall, a plastic cup on the floor, and a small brown item near the drain that staff said looked like stool. The Maintenance Director confirmed peeling baseboards and peeling painted shower tiles, and said one floor needed deep cleaning, better cleaning, or resealing. A CNA stated they had cleaned the shower after the prior resident's shower and had not seen the brown item.
Psychotropic medications were not consistently monitored or tied to resident-specific target behaviors
Penalty
Summary
The facility failed to ensure psychotropic medications were regularly monitored and documented for three residents reviewed for unnecessary medication use. The deficiency involved Residents 22, 6, and 9, all of whom had diagnoses including bipolar disorder, depression, anxiety, and related psychiatric conditions, and all of whom were receiving psychotropic medications such as antidepressants, antipsychotics, sedative hypnotics, or anxiety-related medications. For Resident 22, the record showed multiple psychotropic medication orders, including Wellbutrin, Lexapro, eszopiclone, Seroquel, and melatonin, along with monitoring orders for adverse side effects and behavior monitoring. The care plan identified broad target behaviors such as tearfulness, unrealistic worries, refusal of care, and no behaviors observed, but did not include diagnosis-specific symptom identification or bipolar-related behaviors. Staff interviews confirmed that resident-specific manic behaviors, such as becoming hyper focused on obtaining medications, more sexual behavior, reduced sleep, and increased focus on appearance, were known but were not included on the care plan. Staff also acknowledged that using the same behaviors for multiple psychotropic medications made it difficult to determine which medication was effective or needed continued use. For Resident 6, the record showed orders for Zoloft, propranolol, and Seroquel, but the behavior monitor did not differentiate which medication was being monitored for which behavior. The listed behaviors included upset, un-redirectable, sleeplessness, sad, and no behavior observed, and the monitor also listed non-pharmacological interventions such as music, going outside, and ear plugs. The December 2025 TAR lacked a place for licensed nurses to document NPIs, and several behavior entries had no documentation. The AIMS assessment was not completed around admission and was not done until months later, despite staff acknowledging it should have been completed on admission. For Resident 9, the record showed orders for hydroxyzine and mirtazapine, but the EHR did not show documentation that target behaviors were being monitored for either medication. Staff confirmed that target behaviors should have been monitored and that the record did not show such monitoring. The deficiency was cited under F656 and WAC 388-97-0620(1)(a).
Incomplete and Non-Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for multiple sampled residents, including residents with psychotropic medication use, mental health diagnoses, smoking status, dialysis needs, restorative needs, feeding assistance, head-of-bed positioning, and fluid overload monitoring. Surveyors reviewed records, observed care, and interviewed staff, and found that several care plans did not reflect current diagnoses, medications, target behaviors, or required monitoring. Staff repeatedly confirmed that the care plans were incomplete, not individualized, or not updated to match the residents’ current conditions and orders. For one resident with bipolar disorder, depression, anxiety, insomnia, and other psychiatric diagnoses, the psychotropic care plans did not identify the specific medications, the diagnoses associated with each medication, or the resident-specific behaviors the medications were intended to target. The care plan also did not address AIMS testing for antipsychotic use, and an antibiotic-related care plan for an infected toe did not establish a goal related to resolution of the infection. Another resident with unspecified dementia and major depressive disorder had no care plans for either diagnosis and no smoking care plan, and staff confirmed both were needed. A resident with schizophrenia also had no mental health care plan for that diagnosis, and the restorative care plan lacked individualized goals and details. Additional findings showed a resident who required the head of bed elevated had no corresponding care plan, and the resident’s ADL care plan was outdated because it still described self-feeding of finger foods despite observation of one-on-one feeding assistance. A dialysis resident’s care plan listed an incorrect dialysis schedule, referenced a graft or fistula that the resident did not have, and lacked details about the port and other dialysis-related monitoring. Another resident’s psychotropic care plans used the same behaviors and interventions for different medications without distinguishing the antidepressant, antipsychotic, or beta blocker use, and there was no care plan for anxiety treatment. A final resident had an order to monitor closely for signs of fluid overload twice daily, but the comprehensive care plan did not include that monitoring.
Unnecessary drug regimen management and documentation failures
Penalty
Summary
The facility failed to ensure residents remained free from unnecessary drugs for 3 of 5 residents reviewed. For Resident 7, who was admitted with a malignant neoplasm of the large intestines and was cognitively intact with pain that occasionally affected sleep, therapy, and daily activities, the record showed orders to monitor pain each shift and use non-pharmacological interventions such as repositioning, rest, ice, quiet environment, or other measures. The January 2026 MAR did not document that non-pharmacological interventions were provided with either pain order, and the DON stated staff were not documenting them and should be. For Resident 22, who had chronic lung disease and was receiving oxygen therapy, the record showed orders for oxygen at 2 L/min via nasal cannula, to administer oxygen to maintain SpO2 greater than 90%, and to check SpO2 on room air on the 27th and 28th of each month. The record showed repeated room-air SpO2 checks from November 2025 through January 2026, with readings consistently above 90% on multiple occasions, including 19 consecutive room-air checks above the ordered threshold. During interview, the Resident Care Manager stated that if a resident maintained the ordered SpO2 level on room air, the physician would be contacted to trial the resident on room air, but confirmed that this did not occur for Resident 22. For Resident 6, who was admitted with chronic pain and was cognitively intact, the record showed an oxycodone order with parameters for 2 tablets for pain rated 7-10/10 and 1 tablet for pain rated 3-6/10, with non-pharmacological interventions such as ice, redirection, repositioning, and a quiet environment to be attempted. The November and December 2025 MARs showed multiple administrations of 2 tablets when pain scores were below 7/10, including several doses given for pain ratings of 0/10, 4/10, 5/10, and 6/10. The MAR also showed x marks for non-pharmacological interventions in November, but no place for licensed nursing staff to document interventions in December, and the DON stated staff were expected to attempt and document non-pharmacological interventions and follow the medication parameters.
Improper Medication Storage and Labeling
Penalty
Summary
Medication storage was not maintained in accordance with accepted professional principles in the A&B Medication Room and on the C Hall and B Hall medication carts. During observation of the A&B Medication Room, a PPD multiuse vial was missing an open date, an emergency kit contained medication with an expiration date of 12/2025, and the medication refrigerator log for January 2026 showed missing morning temperature entries for the 1st, 3rd, and 4th even though the log required morning and night checks because vaccines were stored in the refrigerator. Staff C confirmed the missing open date, the expired emergency kit medication, and the gaps in the temperature log. On the C Hall medication cart, a previously opened container of rectal suppositories was stored with oral medications in the top drawer, seven pill packets for a resident were stored in the bottom drawer with treatment cart supplies and creams, and an opened liquid pain medication in the narcotic drawer had no open date listed. On the B Hall medication cart, batteries were stored with oral medications, tape and scissors were kept in the medication drawer, a confiscated hair, skin, and nails gummies container had no resident label, and one resident's six boxes of eye drops were stored in the bottom drawer with treatment supplies. Staff P and Staff Q confirmed the storage conditions, and Staff B stated that suppositories and oral medications should have been separated, treatment supplies should not have been in medication cart drawers, the pain medication should have been dated when opened, batteries and tape/scissors should not have been stored in medication drawers, and the gummies should have been labeled with the resident's name.
Failure to Document COVID-19 Vaccine Education and Consent
Penalty
Summary
The facility failed to have a system that ensured residents were screened, educated, and offered the COVID-19 vaccine for 2 of 5 residents reviewed for immunizations. The facility’s undated Infection Prevention and Control Program policy stated residents would be screened for prior immunization status or medical contraindications before being offered the COVID-19 vaccination, and that education about the vaccine’s risks, benefits, and potential side effects would be provided to the resident or resident representative before consent and administration. The policy also stated the EHR would document the education provided, any refusal or contraindication, and each COVID-19 vaccination administered. Resident 7 was admitted to the facility and the admission MDS showed the resident was cognitively intact and the COVID-19 vaccination was not up to date. Review of the EHR showed no documentation that Resident 7 was provided education about the risks and benefits of the COVID-19 vaccination. Resident 15 was also admitted to the facility, and the admission MDS showed the resident was cognitively intact and the COVID-19 vaccination was not up to date. Review of Resident 15’s EHR also showed no documentation that the resident was provided education about the risks and benefits of the COVID-19 vaccination. When asked, the Infection Preventionist stated there was no documentation showing either resident received education, and acknowledged that a COVID-19 vaccination informed consent form should have been completed and filed in both residents’ EHRs but was not.
Unsecured Smoking Materials and Inadequate Lighting in Smoking Area
Penalty
Summary
The deficiency involves the facility’s failure to secure cigarettes and complete a smoking assessment for one resident, and failure to maintain adequate lighting in the smoking area and access pathway. One cognitively intact resident with current tobacco use had cigarettes stored unsecured in the top drawer of the bedside cabinet. The resident stated they kept their cigarettes in the drawer, and the cigarettes were later collected by an LPN, who stated they should have been locked in the treatment cart labeled with the resident’s name. The DON reported that residents were expected to give staff their cigarettes when purchased so they could be locked in the treatment cart. The same resident’s smoking assessment, dated several days prior to the MDS, was incomplete, with blanks under the sections for medications, resident behaviors, and nursing assessment of smoking safety. A Resident Care Manager/RN confirmed that the smoking assessment was not complete and stated they would need to reevaluate the resident. These omissions meant that the resident’s smoking-related risks and safety needs were not fully documented or assessed as required by the facility’s process. The facility also failed to provide adequate lighting for residents using the designated smoking area and the sidewalk leading to it. Residents accessed the smoking area by exiting through the dining room door and proceeding along a concrete area and then a sidewalk with a small S-curve, where there were 2–6-inch drop-offs or ruts between the sidewalk edge and adjacent planters or ground, with visible wheel tracks in the mud. Staff who supervised smoking and multiple residents reported that management had stopped turning on the flood lights after dark due to concerns about residents smoking marijuana and a whiskey bottle found near the area, but residents continued to use the smoking area in the dark. One resident reported falling while walking back from the smoking area when it was “pitch black,” and other residents and staff described the area as dangerous due to the narrow sidewalk, uneven surfaces, and lack of lighting. Observations confirmed that the string of flood lights along the fence was the sole effective light source when on, that solar lights provided only a faint glow, and that ruts along the sidewalk had trapped residents’ electric wheelchairs, sometimes requiring assistance to get back onto the path.
Failure to Maintain Resident Dignity During Billing Discussions
Penalty
Summary
The facility failed to ensure dignity was provided to 2 of 2 residents reviewed for resident rights during a Resident Council meeting. Resident 6, who was cognitively intact per the quarterly MDS dated 12/16/2025, said on 01/07/2026 at 11:00 AM that they felt harassed when the Business Office Manager asked, "why aren't you paying your bill?" Resident 6 stated that if a bill is not paid, the staff member would hassle them. Resident 79, who was also documented as cognitively intact on the quarterly MDS, said on 01/07/2026 at 11:00 AM that they also felt harassed by the Business Office Manager when asking about a bill not being paid one month. At 3:14 PM the same day, the Business Office Manager stated that on the third and fifth of the month they would jokingly say, "I want your money, it is rent day." The facility investigation dated 01/07/2026 documented that the Business Office Manager could benefit from additional training regarding the language used when discussing the billing process with residents and resident representatives.
Resident Council Concerns Were Not Communicated Back to Members
Penalty
Summary
The facility failed to communicate resolutions about concerns brought forward by the resident council for 6 of 6 months reviewed, covering July through December 2025. During an interview on 01/07/2026, the Resident Council President stated that Staff H, Activities Director, notified the facility of the council's concerns, but the council was not informed of what happened, what the results were, or whether any changes were made. On 01/09/2026, the Administrator and Market Resource Leader stated they did not notify the resident council of grievance results and said they could start having another meeting with residents to review the results of their specific concerns. On 01/13/2026, the Administrator, Activities Director, and Social Services staff were asked for documentation showing that the results of the resident council's specific grievances had been reviewed with the council. Review of resident council meeting minutes dated 07/17/2025, 8/18/2025, 09/15/2025, 10/13/2025, 11/17/2025, and 12/26/2025 showed the Discussion of Old Business and Discussion of New Business sections were blank. The Activities Director stated she did not document anything on the form about concerns from the previous month and said she only asked the council if they still had the same concerns. She later provided copies of the same forms with added documentation that had not been observed earlier, including a note that the previous month's minutes were read aloud and approved and a handwritten statement to read the previous/follow-up form.
Delayed Return of Resident Personal Funds After Discharge
Penalty
Summary
The facility failed to ensure that a resident received personal funds kept by the facility within 30 days of discharge. Resident 107 was discharged on 06/24/2025, and the facility’s copy of the check used to return the resident’s money was written on 07/29/2025, which was beyond the 30-day timeframe required by facility policy. During interview, the Business Office Manager confirmed the discharge date and that the check was not written within 30 days. The Administrator also reviewed the calendar and confirmed that Resident 107’s personal funds were not released within 30 days. The facility policy titled Resident Personal Funds stated that upon discharge, eviction, or death, a resident with personal funds deposited with the facility would receive those funds and a final account within 30 days.
Incomplete Fall Investigation With Injury
Penalty
Summary
The facility failed to thoroughly investigate a fall with injury involving a resident who was cognitively intact, independent with activities of daily living, ambulated independently with a walker, and had a prior fall history. The resident had been admitted to the facility and, according to the quarterly MDS, was a high fall risk after a stroke and was directed to be kept in a well-lit space. The incident involved an unwitnessed fall outside while the resident was walking back from the smoking area, resulting in mild swelling and scrapes above the left eyebrow, an abrasion to the left deltoid, a small bump on the left elbow, and a minor cut on the left knee. The investigation documented that the resident fell outside and that the cause was unknown, but it did not identify or assess the exact location of the fall along the path back from the smoking area. The investigation also did not address environmental conditions present at the time, including that the fall occurred after dark and that the facility had stopped turning on the lights for the smoking area. Although the resident reported that it was pitch black because the lights were off, and a staff member later reported the resident said their walker got caught, these details were not incorporated into the investigation. The report also states that the investigation did not include a statement from the resident who first found the injured resident and reported the fall, and it did not include interviews with other residents or staff who may have had knowledge of the incident. Facility leadership acknowledged that the lights for the smoking area had been turned off and that solar lights had been placed but later malfunctioned, yet this was not documented in the investigation. The incident log incorrectly stated that the cause of the fall was established and that care plan revisions were made, while the investigation itself concluded the cause was unknown and documented only resident education about changing positions slowly.
Inaccurate MDS assessments for dental status and OT services
Penalty
Summary
The facility failed to ensure Minimum Data Set (MDS) assessments were accurate for 2 of 21 sampled residents, Resident 33 and Resident 6. Resident 33’s quarterly MDS documented that the resident was cognitively intact, relied on staff for all cares, and did not complain of or have difficulty or pain with swallowing or chewing food. However, during an interview, Resident 33 reported missing and broken teeth, teeth that had fallen out, pain when eating, inability to chew meat unless it was cut very small, and no dental follow-up for almost a year. The electronic health record showed the resident’s last dental visit documented multiple decayed, broken, and missing teeth, with a recommendation for x-rays, evaluation, and extraction of all upper teeth, and the dental care plan had been revised to document swallowing problems related to difficulty or pain with chewing/swallowing. Staff later confirmed the MDS should have documented pain and difficulty chewing/swallowing and was incorrect. Resident 6’s quarterly MDS documented that the resident was not receiving any therapy, including OT. Review of December 2025 OT records showed the resident received OT sessions on multiple dates during that month. The MDS Coordinator stated the therapy minutes should have appeared on the assessment and that the MDS would need to be amended, and the DON confirmed the MDS should have shown the resident was receiving OT services.
Failure to Follow Orders and Accurately Document Care
Penalty
Summary
The facility failed to ensure services met professional standards of practice for multiple residents by not following physician orders and by documenting tasks as completed when they were not. The report identified deficiencies involving oxygen administration, medication administration, behavior monitoring, anticoagulant monitoring, splint care, and ordered snacks for six residents. Surveyors reviewed observations, interviews, and records and found that staff actions and documentation did not match the residents’ orders or the care actually provided. Resident 22 had chronic lung disease and received oxygen therapy. Although the order was for continuous oxygen at 2 L/min via nasal cannula, staff documented administration at 3 L/min on several shifts and also signed that they had given 2 L/min on the same dates and shifts. The resident was observed receiving oxygen at 3 L/min, and the resident’s oxygen tubing was dated inconsistently with the charted care. Staff confirmed that nurses signed as if they had changed and dated the oxygen tubing when they had not, and that oxygen had been administered above the ordered rate without a physician order or documented respiratory assessment. Resident 87 had an order for propranolol twice daily with instructions to hold the medication for systolic blood pressure less than 110 or pulse less than 60. The December 2025 MAR showed multiple doses were administered even when the systolic blood pressure was below the ordered hold parameter. Resident 21 had an order to monitor target behaviors such as hallucinations, paranoia, and delusions every shift and to use non-pharmacological interventions, but the MAR showed staff documented the behavior monitoring as completed without documenting the specific behavior or intervention. Resident 8 had an anticoagulant monitoring order requiring staff to document whether side effects were observed, but staff signed the task without marking Y or N and without progress note findings. Resident 12 had a long leg splint order requiring daily removal, skin checks, and reapplication, yet the splints were found stored under the bed and the resident said they had not worn them in weeks, while the TAR showed daily completion. Resident 72 had an order for high-protein snacks twice daily, but staff signed the MAR as completed even though one nurse stated the resident did not always receive the ordered snacks and sometimes received different items.
Pressure Ulcer Care and Nutrition Orders Not Followed
Penalty
Summary
The facility failed to ensure interventions to prevent pressure ulcer development or promote healing were implemented as ordered for one resident with malnutrition, spinal stenosis, anemia, paraplegia, multiple sclerosis, and two stage 4 pressure ulcers. The facility policy required pressure redistribution, minimizing moisture exposure, and maintaining or improving nutrition when applicable. The resident’s record showed an order for a low air loss mattress related to spine surgery and a sacral wound, along with an order for licensed nurses to check that the air mattress was functioning properly every shift. Observations and interviews showed the resident’s mattress pump was repeatedly set between 160-240 lbs. even though the resident said they weighed 126 lbs. The mattress was also observed in static mode, and the low-pressure light was on during multiple observations. The resident stated the mattress was not keeping pressure and that they were paralyzed and unable to feel their lower body. Staff later confirmed the mattress settings were incorrect, changed the setting to under 160 lbs. and switched the mode to alternating, and noted the pump had no lock on it. The pump then fluctuated between normal and low pressure, and staff stated it would need to be fixed. The resident also had an order for high protein snacks twice daily for wound healing, with peanut butter and saltines at 10:00 AM and tuna salad and saltines at 2:00 PM. The nutrition evaluation documented increased protein needs related to wound healing. During interview, the resident said they did not receive the ordered snacks. Staff stated the resident was usually given potato chips, sometimes yogurt, sometimes help with their own candy or a sandwich, and only occasionally a peanut butter sandwich; staff said they would not usually get tuna salad. The resident’s ordered snack regimen was therefore not consistently provided as documented.
Therapeutic Diet and Fluid Restriction Monitoring Failures
Penalty
Summary
The facility failed to follow a prescribed therapeutic diet and failed to offer alternatives to a resident on a renal diet. Resident 12 was admitted with cognitive intactness and was placed on a renal diet. The resident’s nutritional assessment documented a food preference evaluation, but the electronic health record showed no food preference evaluation had ever been completed. A nutrition progress note stated the resident was reportedly non-compliant with the renal diet and became upset with the kitchen about the contents of the dialysis lunch bags. During interview, Resident 12 stated the dialysis meal sent on dialysis days was a turkey sandwich with only two pieces of turkey and no other sandwich contents, crackers or a cereal bar, a Nutri-Grain bar, one cup of Jello, and a small bottle of water. The resident stated they did not eat poultry, had complained about the dialysis sack lunch, and had not been offered an alternative meal. Staff later observed the dialysis lunch bag contained a turkey sandwich, a cereal bar, a Nutri-Grain bar, Jello, and an 8-ounce bottle of water. Staff acknowledged that the meal was not appropriate for the resident, that the resident should have been offered an alternative meal, and that the resident was never offered one. Staff also confirmed the food preference evaluation had not been completed before the resident signed the refusal of recommended diet restriction form. The facility also failed to monitor and document fluid restrictions for two residents. Resident 12 had a physician order for no more than 1500 ml of fluid in 24 hours, broken down into 250 ml at breakfast, lunch, and dinner, but the January 2026 TAR showed only day and evening fluid intake entries and did not account for night shift documentation. Resident 94 had an order for a 1200 ml per day fluid restriction, with nursing to provide 200 ml per shift and dietary to provide 200 ml per meal, but staff did not record meal fluid intake or reconcile meal fluids with nursing-provided fluids to determine the total 24-hour intake. A water pitcher with clear liquid was also observed on Resident 94’s overbed table, and staff stated there was no documentation showing meal fluids were recorded or totaled with nursing fluids.
PICC Line IV Antibiotic Given Without Blood Return Check
Penalty
Summary
Provide for the safe, appropriate administration of IV fluids when needed was not met for one resident with a PICC line. Resident 76 was admitted with a diagnosis of Methicillin Resistant Staphylococcus Aureus infection and, on the admission MDS dated 12/18/2025, was documented as moderately cognitively impaired with central line IV access and receiving IV medications. During an observation on 01/08/2026 at 8:09 AM, an LPN administered the resident’s antibiotic through the PICC line but did not aspirate to check for blood return before giving the IV antibiotic. Later that morning, the LPN stated she used the start-stop, push-and-go method to check patency and looked for skin changes such as redness and irritation. On 01/13/2026, the DON stated the LPN should also have aspirated for blood return according to facility policy for a resident with a PICC line.
Oxygen Therapy Not Provided as Ordered
Penalty
Summary
The facility failed to ensure oxygen therapy was provided according to physician orders and accepted professional standards for one resident with chronic lung disease who received oxygen therapy. The resident’s care plan directed continuous oxygen at 2-3 L/min via nasal cannula and monitoring for signs and symptoms of respiratory distress. The resident also had orders for oxygen at 2 L/min via nasal cannula, SpO2 checks twice daily, oxygen to maintain SpO2 greater than 90%, room-air SpO2 checks on the 27th and 28th of each month, and changing and dating oxygen tubing and nasal cannula every Wednesday on night shift. During observation, the resident was seen receiving oxygen at 3 L/min via nasal cannula instead of the ordered 2 L/min, and staff documented multiple instances of oxygen being administered at 3 L/min without a documented respiratory assessment or physician order to support the higher rate. Review of records showed the resident’s SpO2 readings ranged from 91% to 98%, with no documented readings below 90%. The resident’s oxygen tubing was also observed dated inconsistently with the ordered weekly change schedule, and the resident stated the tubing was changed about once a month. The resident care manager confirmed the resident had no order to titrate oxygen based on SpO2 and that staff administered oxygen at 3 L/min without a documented clinical indication.
Incomplete Dialysis Communication and Follow-Up
Penalty
Summary
The facility failed to provide safe, appropriate dialysis care/services for two residents receiving hemodialysis by not maintaining ongoing communication and collaboration with the dialysis center, not obtaining complete dialysis communication documentation, and not following up on dialysis recommendations. The facility policy required communication with the dialysis facility using a dialysis communication form or similar documentation that included bloodwork results, vital signs, nutritional/fluid management, and recommendations for follow-up observations and monitoring. The policy also required ongoing assessment and oversight before, during, and after dialysis treatments, and that the dialysis order include the nephrologist’s name and number and any fluid restriction if ordered. Resident 15 had end stage renal disease, was cognitively intact, and was scheduled for dialysis three times weekly. Review of multiple dialysis transfer forms showed repeated missing information, including absent post-dialysis nursing evaluations, missing mentation on return, missing medication change information, missing laboratory testing information, missing pre-dialysis weights, and blank dialysis report sections. One transfer form noted bloodwork had been done, but the results were not attached. The resident’s dialysis transfer forms also documented recommendations to limit oral fluid intake and avoid foods high in potassium, and later to limit oral fluid intake, while the resident’s nutrition assessment called for fluid intake and output monitoring. The electronic record showed no fluid intake monitor and no fluid restriction for Resident 15, and the resident stated they did not know if they were on a fluid restriction. Staff interviews confirmed the documentation was incomplete and that staff expected the dialysis center to provide the missing information or be called for it. Staff also could not locate the resident’s nephrologist in the record and acknowledged the need to validate and update that information. For Resident 12, the record showed dialysis was being received, and a physician order required the facility to obtain the dialysis information sheet documenting pre- and post-dialysis weights or call the dialysis center if it was not obtained; however, the report documented missing dialysis communication forms for dialysis days and incomplete transfer form documentation in the record.
Failure to Complete Required Annual Staff Performance Review
Penalty
Summary
The facility failed to complete annual staff performance reviews yearly as required and failed to provide education based on the outcomes of those reviews for 1 of 1 sampled veteran staff member, Staff BB. Review of Staff BB’s Nursing Assistant personnel file showed they were hired on 07/18/2023, and the file did not contain an annual performance review completed from July 2024 through July 2025. On 01/12/2026 at 12:50 PM, the Administrator stated there was not a performance review for Staff BB as required.
Delayed Dental Services and Communication Breakdown
Penalty
Summary
The facility failed to ensure prompt dental services were provided for 2 of 2 sampled residents reviewed for dental services. Resident 33, who was cognitively intact and dependent on staff for all cares, reported missing and broken teeth, teeth that had fallen out, and pain when eating because of missing fillings and poor dentition. The resident said it had been almost a year since seeing a dentist and that meat had to be cut into very small pieces, or sugar caused pain. The record showed the last dental visit was on 05/09/2025, when the resident was found to have five decayed teeth, one broken tooth, and multiple missing teeth, with referral recommendations for x-rays, evaluation, and extraction of all upper teeth. The dental care plan also documented swallowing problems related to difficulty or pain with chewing/swallowing, and staff later confirmed there had been no follow-up to the dental recommendations. Resident 11, who was severely cognitively impaired and required substantial to maximal assistance with activities of daily living including eating, had swelling on the right side of the face and nonverbal signs of pain such as grimacing, groaning, and holding the right side of the face when trying to chew food. The resident was started on an antibiotic and pain medication was ordered before meals. The family member reported the resident had a tooth abscess and was supposed to go to the dentist for x-rays. Documentation and staff interviews showed confusion over who was responsible for arranging the dental consult: social services said only in-house dentist appointments were scheduled, the RCM/RN and CNA were expected to arrange the consult, the CNA said she did not know she was responsible, and the RCM/RN stated there was no appointment and that he thought the CNA was doing it. The DON later stated there was a communication breakdown and staff did not know who was doing what.
Failure to Provide Ordered and Preferred Foods
Penalty
Summary
The facility failed to ensure that residents received foods that matched their allergies, intolerances, preferences, and ordered diet types for 3 of 8 sampled residents. Resident 12 was cognitively intact and on a renal diet. The resident stated they did not eat poultry and reported that the dialysis sack lunch sent on dialysis days was a turkey sandwich with crackers or a cereal bar, a Nutri-Grain bar, Jello, and water, and that the facility refused to offer an alternative meal. When the lunch was reviewed with the DNS, the DNS acknowledged that the meal was not appropriate for the resident's preferences and needed to be addressed. Record review showed Resident 12's nutritional assessment referenced a food preference evaluation, but no food preference evaluation had ever been completed in the EHR. A food preference evaluation was later created and documented that the resident did not eat poultry. Staff later confirmed that no food preference evaluation had been completed on admission, and the DNS stated that a food preference evaluation was not completed and should have been. Resident 66 had an order for whole milk for breakfast and lunch, and the nutrition assessment documented a preference for whole milk with breakfast and lunch. However, observations showed the resident was sometimes served only orange juice, sometimes 2% milk instead of whole milk, and at other times no milk was present on the tray. Resident 66 stated they preferred whole milk, and the RCM/RN confirmed the order called for whole milk and that staff should have been following it. Resident 15 was on dialysis and had a renal diet order, yet during a meal observation sweet potato pieces were seen on the tray even though the meal ticket did not list sweet potatoes. The RD confirmed the sweet potatoes should not have been on the tray because they did not match the meal ticket.
Improper Refrigerator Temperature Monitoring
Penalty
Summary
The facility failed to ensure food was stored under sanitary conditions when a resident refrigerator in the dining room was observed on 01/06/2026 with a thermometer reading of 51 degrees Fahrenheit, above the required 41 degrees. Staff G confirmed the reading and, when asked what would be done, stated she would throw everything away and began removing food items from the refrigerator. On 01/07/2026, Staff G showed a new resident refrigerator had been placed on 01/06/2026, but the thermometer could not be located in the refrigerator. Staff G then asked the Admissions Director about it, and Staff I stated the thermometer had been dropped that morning, placed on top of the refrigerator with the intention of cleaning it and putting it back, but it had been forgotten. On 01/12/2026, Staff G stated that a resident refrigerator temperature of 51 degrees did not meet expectations, and that the thermometer not being in place also did not meet expectations. The report also noted that the inner kitchen refrigerator thermometer did not function.
Arbitration Agreement Not Explained in Understandable Form
Penalty
Summary
The facility failed to ensure its binding arbitration agreements were reviewed and explained in a form, manner, and/or language understood by the resident and/or legal representative for 3 of 3 sampled residents reviewed for arbitration agreements. During interviews, Resident 46 stated they did not know what the arbitration process was, did not know they were giving up the right to pursue litigation in court, and did not know they could terminate the agreement within 30 days. Resident 46 also stated they were not alert or aware when admitted and signed the agreement. Resident 60 stated they did not know they had given up the right to take legal action against the facility or that they had the right to cancel the agreement within 30 days, and said they did not remember what they filled out because it was just "sign here, here and here." Resident 60 also stated the agreement was not explained in a way they understood. Resident 79 stated they did not know whether the arbitration process had been covered, were not aware they were giving up any rights to court action, and said they were handed a stack of papers and asked to sign them. Resident 79 also stated they were not aware they had 30 days to terminate the agreement and reported being told, "Just sign it, if you don't understand it, I'll explain it to you later." Staff I, the admission coordinator, stated residents have the right to sign or decline the arbitration agreement and said staff explain it, answer questions, and break down wording to ensure understanding, including the right to terminate within 30 days and that it is not part of the admission agreement. When asked if it was acceptable for staff to say, "sign this and I will explain it later," Staff I stated, "Absolutely not."
Missing Hospice Coordination and Visit Documentation
Penalty
Summary
The facility failed to have a system in place to ensure effective communication, collaboration, and coordination of care with the hospice provider for one resident receiving hospice services. The resident was admitted with a terminal diagnosis and had a physician order for hospice referral. The initial hospice coordinated plan of care showed hospice services were in place for a certification period beginning 05/28/2025, with a registered nurse case manager, hospice aide, social worker, and chaplain assigned at specified frequencies. Record review showed the resident’s electronic health record did not contain a current coordinated hospice plan of care for the later certification period, and it also did not contain the prior certification period plan of care. Although hospice medication orders were present, no visit notes from the hospice RN, aide, chaplain, or social worker were found. Staff stated the facility might have a hospice binder, then later confirmed there was no copy of the current coordinated hospice plan of care, no hospice visit notes, no hospice sign-in process, and no identified hospice liaison. Staff also could not identify who was responsible for ensuring the facility had the current hospice plan of care or for confirming that the resident was visited by the hospice disciplines at the required frequency.
Infection Control Failures During Wound Care, Precautions, and Catheter Equipment Handling
Penalty
Summary
The facility failed to operationalize its infection prevention and control program when staff did not perform required hand hygiene and glove changes during wound care. During an observation of wound care for a resident with a coccyx pressure ulcer/injury, a registered nurse removed the soiled dressing and discarded it, then continued wound care without removing gloves, performing hand hygiene, or putting on new gloves. The nurse cleansed the wound with gauze and normal saline while still wearing the same gloves. When asked what should happen after removing a dirty dressing, the nurse stated she did not know that hands should be washed after removing a dirty dressing. The facility also failed to follow contact precautions and enhanced barrier precautions for residents with wounds and a history of MRSA. One resident with open wounds and a history of MRSA had a contact sign posted, but staff entered the room without gowns or gloves to deliver items and provide care. The resident stated staff repeatedly came into the room without gowns. The resident was also observed using handrails in the hallway, entering the dining room, and moving to another seat at a table shared with another resident. The resident was later observed receiving therapy in the therapy room while the occupational therapist touched the exercise equipment and the resident without wearing a gown or gloves. During interview, the infection preventionist and ADON gave differing explanations of contact precautions, strict contact, and when gowns were required. A second resident with two stage 4 pressure ulcers and an indwelling catheter was also on contact precautions. A physician entered the room without a gown or gloves, spoke with the resident, left without performing hand hygiene, and touched a computer. The physician later returned to the room during wound care while wearing a gown with sleeves dangling over the hands and gown ties dragging on the floor. In addition, the facility’s precaution signage outside a room listed the wrong resident on EBP precautions. For catheter maintenance, a urinal used for emptying a catheter drainage bag was observed with urine remaining in it and dark brown spots on the bottom, and staff stated urinals should be emptied, rinsed, and cleaned after use.
Failure to Implement Effective Antibiotic Stewardship
Penalty
Summary
The facility failed to implement an effective Antibiotic Stewardship Program for 3 of 5 residents reviewed for antibiotic stewardship: Residents 74, 25, and 32. Resident 74 had a urinalysis on 11/05/2025 showing many bacteria, but the lab did not include a culture and sensitivity. Despite the lack of a C&S, Resident 74 was started on Bactrim DS on 11/08/2025 for a UTI/kidney infection. The facility’s infection control line listing for November 2025 did not identify the causative organism, and Staff C, IP, stated she could not find a C&S and that one should have been performed to ensure the bacteria was susceptible to Bactrim. Resident 25 was started on Cefpodoxime daily for 14 days for a UTI, but the EHR showed no urinalysis had been performed and no documented McGeer’s criteria for UTI were present. Staff C, IP, confirmed there were no signs and symptoms documented to support a UTI and stated the resident had a virtual appointment with a urologist who prescribed the antibiotic; she also stated she informed the facility provider that the criteria for UTI were not met, but the provider chose to continue the antibiotic, with no documentation of that notification provided. Resident 32 was ordered Augmentin once daily for 5 days for a UTI, but no UA or C&S was performed and no McGeer’s criteria were documented. The infection control line listing for November 2025 did not identify the causative bacteria, and Staff C, IP, confirmed the testing had not been done and acknowledged a UA with C&S should have been completed to determine whether the resident had a UTI and whether the organism was susceptible to Augmentin.
NA In-Service Training Deficiency
Penalty
Summary
The facility failed to ensure Nursing Assistants received the required minimum of 12 hours of annual in-service training, including dementia management, abuse prevention, and care for individuals with cognitive impairment, for 1 of 1 sampled veteran NA, Staff BB. Review of the personnel file showed Staff BB was hired on 07/18/2023, and review of the training records showed she received only 6 hours of in-service training from July 2024 through July 2025, with no abuse prevention training included. On 01/12/2026 at 12:50 PM, the Administrator stated that Staff BB only received 6 of the 12 required in-service hours for that period.
Failure to Supervise High Fall Risk Resident Resulting in Injury
Penalty
Summary
The facility failed to provide adequate supervision and implement effective fall prevention strategies for a resident assessed as high risk for falls. The resident, who had diagnoses including end stage renal disease and atrial fibrillation, was cognitively intact but required substantial to maximal staff assistance for mobility and transfers, and was dependent on staff for chair to bed transfers. Despite documented balance deficits, decreased safety awareness, and a history of multiple unwitnessed falls from bed, the resident was repeatedly left unsupervised at the edge of the bed, contrary to care plan interventions and staff knowledge of the resident's needs. The resident experienced at least four unwitnessed falls, each time being found on the floor after being left at the edge of the bed or in bed without adequate supervision. After each fall, interventions such as ensuring the resident was not left at the edge of the bed, frequent checks, and securing the mattress were documented, but these were not consistently implemented. On one occasion, after returning from dialysis and expressing fatigue, the resident was positioned at the edge of the bed for a meal and left unattended, resulting in a fall that caused multiple fractures to the right wrist and required hospital transfer. Interviews with staff confirmed that the resident required two staff and a mechanical lift for transfers, had significant balance issues, and was not safe to be left at the edge of the bed unattended. Staff acknowledged that the resident was frequently drowsy, especially after dialysis, and that leaving the resident unsupervised at the bedside was unsafe. The Director of Nursing Services also confirmed that the resident was high risk for falls and should not have been left unattended at the edge of the bed, especially given the resident's history and condition at the time.
Failure to Maintain Adequate Room Temperatures for Residents
Penalty
Summary
The facility failed to provide a comfortable and homelike environment by not maintaining adequate heat in resident rooms across three of four hallways reviewed. Facility documentation required ambient temperatures in resident and patient care areas to be maintained between 71 and 81 degrees Fahrenheit, or as required by state or local regulations. However, multiple temperature readings taken in various resident rooms showed temperatures significantly below this range, with some rooms as low as 58.1 degrees Fahrenheit. Residents and their families reported ongoing issues with cold rooms, and several residents confirmed during interviews that their rooms were cold. Staff interviews revealed that the heating system required manual intervention by maintenance to activate heaters in individual rooms, and that many heaters had not been cleaned or turned on. The maintenance director acknowledged that most resident rooms in the affected hallways did not have heaters operating at the time of the survey and that the HVAC system was still awaiting repairs and parts replacement. Staff also reported that there had been heat outages, particularly over weekends, and that residents had complained about the cold. In response, staff provided extra blankets, but residents continued to express discomfort, with one resident stating that it was so cold she did not want to take a shower. The maintenance director further acknowledged that previous maintenance staff had not ensured that resident heaters were properly cleaned and maintained, contributing to the ongoing issue of inadequate room temperatures.
Failure to Provide Timely Wound and Catheter Care
Penalty
Summary
The facility failed to provide wound and indwelling catheter care according to physician orders and facility policy for a resident who was admitted with multiple fractures, a subarachnoid hemorrhage, an external fixator, and an indwelling catheter. Upon admission, the resident required staff assistance for most activities of daily living and had documented needs for surgical wound care and catheter care. However, wound care orders for the external fixator were not obtained until four days after admission, and catheter care orders were not obtained until seven days after admission, coinciding with the resident's discharge. Documentation showed that wound care for the external fixator was not completed for the first four days, and there was no documented catheter care during the resident's stay. Collateral contact reported that the resident's surgical dressing was not changed for extended periods and catheter care was not performed, leading to the resident leaving the facility against medical advice. The Director of Nursing confirmed that although the catheter and external fixator were identified on the care plan and admission assessment, treatment orders were not promptly obtained, and there was no documentation of care provided for the indwelling catheter or the external fixator until several days after admission.
Insufficient Dietary Staff Training and Monitoring
Penalty
Summary
The facility failed to ensure sufficient dietary staff were trained and competent to carry out food and nutrition services. Surveyors found missing documentation of food temperatures on multiple dates across breakfast, lunch, and dinner meals, despite facility policy requiring temperatures to be checked and recorded for all food items prepared in the dietary department. During kitchen observations, staff used a purple thermometer that was described as broken, and one staff member stated she brought her own thermometer from home because the facility thermometer did not work. Staff also reported having very little training and having taken food temperatures only once before. During an observation on 08/05/2025, staff removed chicken from the oven and measured it at 117 degrees F, then attempted to take it to the food chopper even though it appeared undercooked. A staff member intervened and instructed that raw chicken could not be served and that it needed to be returned to the oven. Later that same day, a cheeseburger served to a resident was measured at 126 degrees F, and the staff member acknowledged it should have been 165 degrees F but stated the resident wanted it. On 08/06/2025, another hamburger patty was measured at 112 degrees F, and the staff member could not state the correct food temperature standard and acknowledged there was no other working thermometer in the kitchen until the Administrator brought one. Surveyors also found problems with dishwasher and sanitation procedures. A chemical test for the dishwasher did not show adequate concentration, and staff stated the sanitizer bucket was filled with water and chemical but the strip reading was 10 when it should have been 200 to 275. Staff acknowledged daily use of the three-compartment sink without documentation of temperature or chemical testing. The lab technician stated the facility had run out of the correct product and had connected a chlorine-based product, but staff were using the wrong test strips. Staff were unable to demonstrate proper chemical testing for the dishwasher or sanitizer bucket, and the Dietary Manager reported having little training and limited involvement from the consultant dietician. The Administrator acknowledged recent kitchen staff turnover and that staff were still in training, and stated he was responsible for oversight in the kitchen.
Food Safety, Temperature Control, Hand Hygiene, and Kitchen Sanitation Deficiencies
Penalty
Summary
Food temperatures were not consistently taken or documented, and several observations showed food being held or served below required temperatures. Facility policy required hot foods to be held at 135 degrees Fahrenheit or greater and food temperatures to be checked and recorded for all items prepared in the dietary department. Weekly temperature logs from 06/08/2025 through 08/22/2025 showed multiple missing entries for breakfast, lunch, and dinner on several dates. During kitchen observations, staff used a purple thermometer that was reported to be broken, and one staff member stated she brought her own thermometer from home because the facility thermometer did not work. During meal preparation and service, staff observed chicken at 117 degrees Fahrenheit being taken from the oven and moved toward chopping even though it appeared undercooked. A cheeseburger served to a resident was measured at 126 degrees Fahrenheit, and the staff member stated the resident wanted it despite acknowledging it should be 165 degrees Fahrenheit. On another occasion, a hamburger patty measured 112 degrees Fahrenheit, and staff could not state the correct food temperature requirement. During lunch tray observation, mashed potatoes measured 133 degrees Fahrenheit and pot roast measured 127 degrees Fahrenheit, yet the tray was still delivered to the resident after staff stated meat should be 135 degrees. Handwashing and kitchen sanitation practices were also observed to be deficient. Staff handled frozen chicken and other food items with gloved hands, left the station, returned with the same gloves, and changed gloves without sanitizing hands. Other staff similarly handled sandwich ingredients and cooked food with gloved hands, removed gloves, and did not sanitize hands before continuing food preparation. Kitchen cleaning schedules showed no completed tasks, and the stove, oven, grill area, and walk-in refrigerator were observed with debris, black liquid, and wet blankets on the refrigerator floor due to a leak that staff said had been ongoing for about two weeks. The dietary manager acknowledged cleaning tasks had not been completed regularly, and the administrator acknowledged recent kitchen staff turnover and that staff were still in training.
Administration Failed to Maintain Oversight of Pressure Injury Care, Dietary Operations, and Kitchen Sanitation
Penalty
Summary
Administration failed to ensure active oversight and a monitoring system were in place to correct findings from an internal mock survey related to pressure ulcer prevention and treatment, food procurement, dietary staffing, and kitchen sanitation. The report states the facility had findings from a mock survey dated 07/28/2025 and 07/29/2025 that included failure to ensure residents received care consistent with professional standards to prevent pressure injuries, failure to complete skin checks every 7 days, and failure to measure a wound after admission measurements. The facility also had findings related to infection prevention and control, including failure to follow enhanced barrier precautions for residents, standing water on the floor between the walk-in fridge and freezer, towels on the floor under food racks, and a dirty kitchen hood with dust and debris. During the complaint investigation, observation, interview, and record review showed the facility was aware of these issues and had not taken action to correct them. The Administration acknowledged staff turnover with kitchen staff and Dietary Managers over the previous several months, that new staff were still in training, and that the facility had an internal audit with findings. The Administrator also acknowledged responsibility for oversight in the kitchen and stated the Dietician Consultant visited weekly but did not oversee the kitchen. The report further states the facility failed to ensure sufficient dietary staff were trained and competent in recognizing and documenting food temperatures, chemical sanitation of the dishwasher, sanitizer bucket, and three-compartment sink, and in providing meals at established mealtimes.
Delayed wound assessments and missed wound treatment documentation
Penalty
Summary
The facility failed to ensure adequate wound care and timely wound assessment for two residents with pressure ulcers and other wounds. Facility policy required full body skin assessments on admission, weekly, and with any change in condition or newly identified pressure injury, and wound treatments were to be provided according to physician orders and documented in the record. The cited deficiency involved delayed wound assessment, incomplete wound descriptions and measurements, and missed documentation of ordered treatments. One resident was admitted with diabetes, peripheral vascular disease, and end stage renal disease, and the admission assessment documented multiple wounds including suspected deep tissue injuries to the left heel and left toe, a skin tear, and discolored lower extremities. The facility’s skin assessment did not document a buttocks pressure ulcer, and the 07/27/2025 skin assessment did not include wound measurements or descriptions. A wound consultant later documented a left heel DTPI, a buttocks DTPI with signs of infection, and a diabetic ulcer to the left great toe. The consultant also recommended referral to a vascular surgeon, but the facility had not made the referral. The EMAR showed no documentation that ordered buttocks treatment was completed on two dates, and the resident stated wound care was only done weekly by the wound group. The other resident was admitted with multiple sclerosis, cellulitis, and a pressure ulcer to the left buttocks. The EMAR showed several wound care orders for the knees, right foot, and left buttock, with multiple missed signatures showing treatments were not documented as completed on several dates. The resident stated wound care was provided sporadically and was not completed on two specific days, though it was done on another day. The RCM acknowledged the wound treatments were not signed as completed, and the DON acknowledged that wound and skin assessments were to be completed weekly and physician orders were to be followed and documented in the medical record.
Failure to Provide Ordered Nutritional Supplements and Menu Items
Penalty
Summary
The facility failed to provide prescribed nutritional supplements with meals for 2 of 2 residents reviewed for nutrition. Resident 1 was admitted with diagnoses including multiple sclerosis, cellulitis, and a pressure ulcer to the left buttocks. The admission MDS documented that Resident 1 was cognitively intact and required supervision to eat. Physician orders included a regular diet with regular texture and thin consistency, and an order dated 06/30/2025 for mighty shakes with lunch and dinner for wounds. During observations, Resident 1’s breakfast trays did not match the meal tickets: one tray had one egg, a waffle, rice cereal, and a drink instead of two hardboiled eggs, sausage, biscuit, and milk; another breakfast tray was missing coffee cake listed on the ticket. At dinner, the tray contained chicken instead of the baked ham listed on the menu, and the resident stated he was not eating that and wanted what everybody else was having. The Interim Dietary Manager stated the ham ran out about four trays before the end of the run and chicken was substituted. Resident 5 was admitted with diagnoses including Alzheimer’s disease and dementia, and the significant change MDS documented cognitive impairment and the need for staff assistance with eating. Physician orders included a regular diet and later orders for Magic Cup three times per day, then Mighty Shakes three times per day. During observation, Resident 5’s lunch tray did not include the ordered supplement. The Dietary Manager stated she had little training and had not had interaction with the consultant dietician. The dietician stated Magic Cup was a high protein, high calorie supplement she specifically ordered for residents and was unsure why the facility did not have any in stock. The Dietary Manager later stated the facility ran out of Magic Cups and Mighty Shakes and no residents received them with breakfast and lunch, and the DON acknowledged that four residents did not receive Magic Cups and 12 residents did not receive Mighty Shakes on 8/22/2025 for breakfast and lunch meals.
Failure to Use Contact Precautions for Resident with CRAB
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when the facility failed to follow transmission-based precautions for Resident 6. Resident 6 was admitted with diagnoses including quadriplegia, was cognitively intact, and required staff assistance for activities of daily living. The quarterly MDS dated 07/30/2025 documented these conditions, and a rectal swab lab result dated 07/31/2025 showed OXA-235 like detected. A handwritten note on the lab result indicated contact precautions, and the resident’s care plan dated 7/29/2025 showed enhanced barrier precautions related to a suprapubic catheter. During observation and interview on 08/20/2025 at 12:45 PM, Resident 6’s room did not have signage on the door indicating contact precautions. Staff D, a CNA, was observed in the room assisting the resident with the TV remote and did not wear a gown or gloves before exiting the room. Staff D stated awareness that the resident was on contact precautions but said they did not realize PPE was needed. Later interviews showed the DON stated staff had contacted people that day and were going to use PPE for all residents in the room who were on contact precautions, and the Infection Preventionist acknowledged the resident had a positive wound culture and that contact precautions were implemented, while also stating she was unsure why there was no signage on the door.
Failure to Obtain Weights and Provide Recommended Nutritional Supplement
Penalty
Summary
The facility failed to obtain required admission weights for a resident with significant medical conditions, including non-traumatic subarachnoid hemorrhage, cerebral aneurysm, hemiplegia/hemiparesis, and dysphagia. Although physician orders specified that admission weights should be taken for three days, only one weight was documented, and no further weights were recorded until nearly two months later. The resident's care plan also called for weekly weights, but these were not completed as required. Additionally, the dietician recommended a nutritional supplement (Benecalorie) three times daily due to the resident's poor intake and risk for weight loss. However, this recommendation was not forwarded to the physician for an order, and the resident did not receive the supplement. Documentation from the nutrition team repeatedly requested updated weights to confirm adequacy of intake, but these requests were not fulfilled. The DON acknowledged these failures during an interview.
Failure to Ensure Timely Receipt of Ordered Pain Medications
Penalty
Summary
The facility failed to ensure the timely acquisition and receipt of ordered medications for two residents with complex medical conditions and ongoing pain management needs. One resident, who was cognitively intact and had spinal stenosis and thoracic vertebrae fractures, had an active order for Morphine ER 30 mg every 12 hours for pain. This resident did not receive three consecutive doses as documented in the Medication Administration Records, with progress notes indicating the medication was pending or awaiting pharmacy delivery. The resident confirmed missing doses of prescribed pain medication due to the facility running out of the medication. Another resident, also cognitively intact and with lumbar stenosis and back pain, had an order for Norco 5-325 mg three times daily for pain. This resident missed four consecutive doses, with progress notes and staff interviews confirming the medication was not available and was awaiting pharmacy delivery. Both residents and staff acknowledged the missed doses, and the Director of Nursing Services confirmed the failures were due to medications not being received from the pharmacy in a timely manner.
Failure to Perform CPR on Unresponsive Resident
Penalty
Summary
The facility failed to ensure that staff performed CPR on a resident who was found unresponsive, despite having a physician's order for CPR. The resident, who was admitted with diagnoses including bladder cancer and diabetes, was alert and oriented according to the Minimum Data Set. The resident's POLST form indicated a preference for full resuscitation, including CPR and other life-sustaining treatments. However, when the resident was found unresponsive, the staff did not initiate CPR or call emergency services, which was a violation of the facility's emergency response policy. The incident began when a CNA found the resident unresponsive and reported it to a Licensed Practical Nurse (LPN), who also found no signs of life. Instead of initiating CPR, the LPN sought assistance from a Registered Nurse (RN), whose CPR certification could not be verified. The RN assessed the resident and concluded that the resident had passed away without attempting resuscitation. The facility's investigation revealed that the staff involved did not follow the emergency response protocol, which required immediate CPR in the absence of a DNR order. Interviews with the facility's Administrator and Director of Nursing confirmed that the staff failed to initiate CPR or notify emergency services, leading to the resident's death. The investigation also uncovered that several staff members did not have current CPR certifications, contributing to the failure to provide the necessary emergency response. This deficiency was identified as an Immediate Jeopardy situation, placing residents at risk for serious harm or death.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to provide adequate care and services to promote wound healing and prevent the development or worsening of pressure ulcers for four residents. Resident 1 experienced harm due to the lack of timely skin assessments and treatment, resulting in the development of an unstageable pressure ulcer on the left heel. Despite hospice documentation noting a new pressure injury, treatment was not initiated for 12 days. Observations revealed that Resident 1 was often without protective boots, which were intended to relieve pressure on the heels. Resident 2, who was admitted with paraplegia and a fracture, had a care plan that included monitoring and documenting pressure injuries. However, there were significant gaps in skin assessments, and the resident did not receive an air mattress as required. A wound consultant later identified a healing Stage 3 pressure ulcer, indicating a lack of timely intervention and monitoring. Resident 5, at risk for pressure ulcers, also experienced incomplete skin assessments. A skin tear on the upper back was not properly documented or treated, leading to the development of an unstageable pressure ulcer. Resident 6, admitted with cerebral palsy and polyneuropathy, did not receive any skin assessments after the initial admission assessment, despite being at risk for pressure ulcers. The facility's Director of Nursing acknowledged the failure to complete weekly skin assessments for these residents, attributing it to the absence of a wound nurse.
Failure to Verify Gastrostomy Tube Placement and Follow Hydration Orders
Penalty
Summary
The facility failed to properly assess the placement of a gastrostomy tube before initiating enteral feeding for a resident, identified as Resident 7. This resident was admitted with conditions including cerebral infarction, hemiplegia, dysphagia, and severe protein malnutrition, and had a feeding tube in place upon admission. According to the facility's policy, the placement and functioning of the feeding tube should be verified before any feeding, flushing, or medication administration. However, during an observation, a Licensed Practical Nurse (LPN) did not check the placement of the gastrostomy tube before administering 50 ml of water and 250 ml of the prescribed enteral feeding. Additionally, the LPN did not follow the prescribed hydration orders, as she flushed the tube with only 50 ml of water instead of the prescribed 100 ml after the feeding. The LPN acknowledged these oversights during the observation. This failure to adhere to the facility's policy and the physician's orders placed the resident at risk for nutritional alterations and decreased quality of life.
Deficiencies in Monitoring Weight Loss and Fluid Restrictions
Penalty
Summary
The facility failed to adequately monitor and address significant weight loss and fluid restrictions for several residents, leading to potential harm and decreased quality of life. Resident 71 experienced a significant weight loss of 14.41% in 55 days due to the facility's failure to obtain weekly weights as per the care plan, update the physician with the registered dietician's recommendations, and offer supplemental food when the resident consumed less than fifty percent of their meal. The facility did not have orders for weekly weights, and there was a lack of communication with the physician regarding the dietician's recommendations for over five weeks. Resident 65 also experienced harm due to inadequate supplement intake and lack of modification in dietary interventions, resulting in a significant weight loss of 16.64% in 113 days. The facility's documentation showed inconsistencies in meal intake records, with staff failing to offer alternatives or supplements when the resident consumed less than 50% of their meals. Additionally, there were gaps in the medication administration record, indicating a lack of documentation for the resident's liquid nutritional supplement intake. The facility also failed to monitor and implement accurate fluid restrictions for residents with specific medical conditions. For instance, Resident 1 had a fluid restriction order that was not consistently communicated to or documented by staff, leading to incomplete records of fluid intake. Similarly, Resident 6's fluid restriction was inconsistently documented, with discrepancies between the care plan and actual intake records. Resident 12's fluid restriction was not adequately communicated to staff, and there was a lack of documentation to reconcile the resident's total fluid intake, resulting in potential non-adherence to the prescribed fluid restriction.
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Illustrative
What surveyors actually found near you
We read the 546 citations issued within 25 miles in the last 12 months — including the 2 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.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lacey
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Panorama City Conv & Rehab Ctr | 1.9 mi | ★★★★★ | 6 | 0 |
| Woodard Creek Health & Rehabilitation | 2.7 mi | ★★★★★ | 45 | 1 |
| Olympia Transitional Care And Rehabilitation | 2.7 mi | ★★★★★ | 19 | 0 |
| Lacey Post Acute & Rehabilitation | 2.9 mi | ★★★★★ | 11 | 0 |
| Regency Olympia Rehabilitation And Nursing Center | 4.2 mi | ★★★★★ | 15 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.