Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Emerald Care during CMS and state inspections, most recent first.
A resident with quadriplegia, intact cognition, and decreased lower-extremity sensation, who required set-up assistance for eating, sustained burn injuries with redness and fluid-filled blisters on the thigh after hot coffee spilled in their lap. Dietary staff reported targeting coffee temperatures of 155°F and logging only one of four pots before sending a coffee cart to common areas, and the DON later measured coffee from the cart at 168.8°F with visible steam. The resident stated someone else obtained the coffee from a front station, and there was no established assessment or process to ensure residents could safely handle hot liquids, despite facility policy requiring risk identification and mitigation for accident prevention.
The facility failed to ensure the Dietary Manager had the competencies and skill sets needed to run food and nutrition services when there was no full-time RD. The DM was still in training, had not passed the Certified DM exam, and had been working since June 2024 with oversight informally provided by the Kitchen Manager, who had no certifications, while the RD only consulted a few days per week.
Expired, unlabeled, and undated foods were found in the stand-alone refrigerator, dry storage, and walk-in refrigerator, including fruit cups, salads, lunch meat, dairy items, dressings, bacon, ground beef, and dry goods. Staff gave inconsistent answers about thawing and dating requirements, and a cook served pureed foods without checking temperatures; the cold pasta salad measured 69.3 F and was not documented. Temperature logs also showed multiple missed checks for breakfast, lunch, dinner, and pureed foods.
Surveyors found that the facility did not follow its abuse/neglect policy when multiple grievances involving potential abuse and neglect were logged only as staff concerns and not treated as reportable incidents. A resident reported lack of assistance and care from an LPN, another resident experienced a verbal confrontation with a CNA, and a third resident was observed by a representative to have a soiled face and clothing and a urine-saturated brief dripping down the hallway. These events were not entered into the incident reporting log, were not promptly or thoroughly investigated as abuse/neglect allegations, and the residents were not protected from possible ongoing abuse or neglect, as confirmed by the administrator and DON.
The facility failed to report multiple potential allegations of abuse and neglect to the State Agency. One cognitively intact resident with ALS alleged a staff member withheld their eyeglasses and reported feeling unsafe and poorly cared for, including concerns about staff’s ability to manage choking and positioning. Another resident with dementia and Parkinson’s was found by their representative with dried toothpaste on their clothing and face and so wet with urine that it left a trail down the hallway, prompting concerns about dignity and care. A third resident reported that a NA spoke to them in an unprofessional and unnecessary manner regarding a locked bathroom door, constituting a potential allegation of verbal abuse. These concerns were handled as internal grievances, were not entered into the reporting log as abuse/neglect allegations, and were not reported to the State Agency, with the DON stating they did not view the incidents as purposeful or willful abuse or neglect.
The facility failed to thoroughly investigate multiple allegations of abuse and neglect involving three cognitively intact residents with significant care needs. One resident with ALS reported that an LPN ignored a request for help with eyeglasses and left without assisting or communicating. Another resident with dementia and incontinence was reportedly found by a representative with dried toothpaste on their face and clothing and a urine-soaked brief that leaked down the hallway, yet no staff statements, additional resident interviews, skin checks, or care plan changes were documented. A third resident with heart and lung disease reported that a NA spoke to them in an unprofessional, scolding manner about a locked shared bathroom door and then left while the resident was speaking, but the investigation lacked root cause analysis, interviews with other residents, or monitoring for adverse effects. None of these allegations appeared on the incident reporting log, and documentation did not show complete analyses to rule out abuse or neglect.
PASARR assessments were not updated for 3 residents after significant changes in cognition, behavior, and psychotropic medication use. One resident with stroke deficits and dementia developed worsening agitation, yelling, hitting, and refusals of care, while two other residents with dementia showed aggressive, impulsive, and sexual behaviors and were started on antipsychotic, antidepressant, and anticonvulsant meds. The facility’s records showed no updated PASARRs to reflect these changes.
Missing competency documentation for licensed nurses: The facility failed to evaluate and document demonstrated competencies and skill sets for 3 of 3 sampled nurses, including an RN, an LPN, and the LPN Staff Development Director. Personnel files contained no competency, skills, or performance evaluation records, and the DON stated no nurse competency or skills evaluations had been completed and prior evaluations could not be found.
Call Light and Bedside Table Left Out of Reach: A resident with anoxic brain injury, hemiplegia, limited vision, and moderate cognitive impairment was observed multiple times sitting in a wheelchair with the call light on the bed and the bedside table behind the chair, both out of reach. The resident could not locate the call light or access a bedside drink, and staff acknowledged the call light and table needed to be placed within reach.
PASARR screening forms were not properly reviewed and validated for two residents with mental health diagnoses. One resident had dementia, psychotic disturbance, mood disturbance, anxiety, and PTSD, and another had ALS with depression, anxiety, and PTSD. In both cases, the Level I PASARR forms initially failed to identify the SMI indicators in Section IA, and staff later corrected the forms while still indicating that a Level 2 eval was not needed.
Failure to provide appropriate treatment and care occurred when a resident with an RC, kidney disease, and hospice services developed new burning with urination, reddish urine, and thick sediment in the catheter tubing. Staff observed nonverbal signs of pain, but nursing notes did not document the changes, ongoing monitoring, or hospice notification, and staff were unaware of the resident’s Acetic Acid irrigation order and did not assess the resident using the AD pain tool despite communication barriers.
A resident with L hemiplegia and a hx of stroke was not thoroughly assessed or monitored for ROM needs in the affected hand. Although the resident was identified as at risk for contractures and later had documented L hand contracture and weakness, the restorative program focused on the upper arms, and the restorative director stated the L hand had never been assessed for signs of contracture. The resident reported not wearing a splint or brace and having trouble remembering finger stretches, with the L thumb unable to fully extend.
Incorrect Therapeutic Diet and Liquid Consistency Served: A resident with a hx of stroke, hemiplegia, cognitive impairment, and coughing/choking during meals was ordered a mechanical soft diet with ground meat and nectar thick liquids after a trial period. However, observations showed the resident still had regular ice water at bedside, was served juice that was not thickened, and was given food that was harder to chew than expected. Staff stated the diet change was not fully updated on the EHR/dashboard and the kitchen diet card remained incorrect.
A resident with stroke, R-sided hemiplegia, and dysphagia had an order for oral suctioning PRN, but the bedside suction machine was repeatedly observed with a canister labeled from an earlier date and half full of light-yellow liquid with white particles. Staff said LNs were responsible for cleaning the equipment, and the IP and DON stated the canister, liners, and tubing should have been discarded and replaced after use.
The facility failed to discard expired foods and did not consistently monitor refrigerator temperatures, increasing the risk of food-borne illnesses. Expired tortillas were served, and temperature logs were missing for two refrigerators. Staff acknowledged these lapses, with the Dietary Manager noting the small black refrigerator was not in use.
A resident with a history of dementia and neurogenic bladder was at risk for UTIs due to inadequate catheter care. The facility failed to implement physician orders for regular catheter changes and monitoring, resulting in compromised catheter integrity and increased infection risk. Staff interviews confirmed the oversight in managing the resident's IUC, highlighting a deficiency in care protocols.
The facility failed to secure the medication room, allowing unauthorized access by the Maintenance Director, who used a key obtained from a predecessor to enter the room monthly for air conditioner checks. This was against the facility's policy, which restricts access to licensed nursing personnel and authorized staff.
The facility failed to ensure the Director of Nursing (DNS) maintained an active RN license, as required by their job description. The DNS, identified as Staff R, worked for 17 days after their license expired. The Administrator, Staff A, was informed by Staff R that the license was believed to be renewed but later found it was expired.
The facility failed to implement proper infection control practices for urinary catheters, as observed with two residents whose catheter bags were seen touching the floor, contrary to facility policy and CDC guidelines. This oversight placed the residents at risk for infections, as confirmed by staff interviews.
The facility failed to thoroughly investigate and address resident-to-resident altercations involving four residents, lacking root cause analysis, witness statements, and care plan updates. Staff were unaware of incidents, and responsibilities for follow-up were unclear, leaving residents at risk for further altercations.
The facility failed to maintain proper infection control practices during hydration passes and resident care. Staff did not change gloves or perform hand hygiene between dirty and clean tasks, increasing the risk of cross-contamination for two residents. The Infection Preventionist and Director of Nursing Services acknowledged the deficiencies and emphasized the need to follow infection control policies and physician orders.
The facility failed to update care plans for two residents, leading to discrepancies in their documented care needs. One resident's dental care and dietary refusals were not reflected, while another's transfer and meal assistance needs were outdated. Staff acknowledged the need for updates but had not made the necessary revisions.
The facility failed to ensure ongoing communication and collaboration with the dialysis center for three residents requiring dialysis services, leading to risks of unnoticed health changes and delays in care. Despite multiple dialysis sessions, there was minimal documented communication with the dialysis center, and staff acknowledged the lack of a proper communication system.
Burn Injury from Overheated Coffee and Lack of Hot-Liquid Safety Process
Penalty
Summary
The deficiency involves the facility’s failure to ensure hot liquids were provided at a safe drinking temperature, resulting in a resident sustaining burn injuries. The facility’s policy titled “Free of Hazards/Supervision and Devices” required an interdisciplinary approach to identify, evaluate, and mitigate risks to maintain resident safety. Washington State Department of Labor and Industries guidance indicated that water at 155°F can cause a third-degree burn in one second. Despite this, dietary staff reported they ensured brewed coffee was at 155°F before taking the coffee cart to resident areas and kept logs to make sure it was not over 155°F. Resident 1, who had quadriplegia, heart failure, anxiety, intact cognition, and required set-up assistance for eating and dependence for other ADLs, reported spilling hot coffee on their lap. Due to decreased sensation in their legs, the resident did not feel the burn and did not report the incident immediately. A nursing progress note documented an area of redness on the right thigh measuring 4.5 cm by 13.0 cm with multiple fluid-filled blisters, and the facility’s investigation noted a red area with blisters after the resident stated they had spilled a hot beverage earlier in the day and forgotten about it until nighttime care. Surveyor observation showed the resident seated in a common area with a cup of coffee with a lid on the table and a sweatshirt over their lap, and the resident stated they had obtained coffee from the front coffee station with assistance from someone else. During the survey, the DON measured coffee from a pot on the coffee cart in the common area and found it to be 168.8°F, with visible steam rising from the cup. The dietary manager later confirmed that staff were only checking the temperature of one of four coffee pots before leaving the kitchen and were unsure whether temperatures were taken directly from the pot or from a pitcher. The DON and administrator acknowledged that there was no process or assessments in place to ensure residents were safe in handling hot liquids, and that staff were expected to check coffee temperatures before sending and before serving, but this was not being carried out as described.
Dietary Manager Lacked Required Competency and Certification
Penalty
Summary
The facility failed to ensure that, unless it had a full-time Registered Dietitian, the Dietary Manager had the competencies and skill sets needed to carry out food and nutrition services for the resident population. During interview, the Dietary Manager stated they were in training and hoped to have the required certification by March 2026. The Kitchen Manager stated they would assist the Dietary Manager if needed, but also stated they were not the oversight of the Dietary Manager and assumed the RD provided that oversight. The Kitchen Manager further stated they had no certifications, and the RD worked two to three days per week as a consultant. The Dietary Manager later stated they had completed the Certified Dietary Manager course but did not pass the test taken in September 2025, and had not yet rescheduled because work was busy and they had not had time to review or prepare. The Dietary Manager stated they had been the Dietary Manager since June 2024 with the Kitchen Manager supervising them because of the Kitchen Manager's greater experience. The Administrator and DON stated the Dietary Manager had not passed the certification test, that the Kitchen Manager was the oversight of the Dietary Manager, and that the Dietary Manager and Kitchen Manager worked side by side in the kitchen with help from the RD. The Administrator also stated the Dietary Manager had not retaken the test because of the $500 rescheduling cost and concerns about being ready.
Expired Foods and Inconsistent Food Temperature Monitoring
Penalty
Summary
The facility failed to discard expired foods and failed to consistently label, date, and monitor food items stored in the kitchen. During the initial kitchen tour, expired and undated items were found in the stand-alone refrigerator, dry storage area, and walk-in refrigerator, including prepared fruit cups, salads, lunch meat, sour cream, cottage cheese, cranberry cocktail, salad dressings, tartar sauce, bacon, ground beef, turkey breast, ham, and dry goods such as breadcrumbs and vinegar. Several items were uncovered, unlabeled, or missing open dates and use-by dates, and some were found past expiration while still being stored for resident use. The report also identified problems with thawing and food temperature monitoring. A policy titled Thawing Frozen Food stated specific time frames for thawed ground beef and bacon or sausage, but staff interviews showed inconsistent understanding of those requirements. Staff stated lunch meat should be dated when removed from the freezer and used within seven days, while another staff member stated opened salad dressings had different time frames depending on whether they contained dairy. Staff also stated expired foods were supposed to be checked and discarded twice weekly, but those checks were not documented. During observation, a cook prepared pureed cheeseburger casserole and pureed cold pasta salad without checking temperatures before serving. The cold pasta salad measured 69.3 F, and the temperature was not documented on the food log. Review of temperature logs showed multiple dates in January when required breakfast, lunch, dinner, or pureed food temperatures were not recorded. The administrator stated staff should document receipt and opening dates for products, document when thawed foods expire, and consistently check temperatures before each meal.
Failure to Identify and Investigate Allegations of Abuse and Neglect
Penalty
Summary
Surveyors identified that the facility failed to implement its abuse, neglect, and exploitation policy for three residents when allegations were documented but not treated as reportable abuse/neglect events. The written policy dated 01/2026 required the facility to prohibit and prevent abuse, neglect, and exploitation of residents with ongoing oversight and supervision of staff to ensure policies were implemented. Review of the grievance log from 07/01/2025 through 01/25/2026 showed multiple entries that involved potential abuse or neglect concerns, but these were only logged as staff concerns or grievances and not identified, reported, or investigated as allegations of abuse or neglect. For one resident, a staff concern was logged regarding lack of assistance and care from an LPN when asked. For another resident, a staff concern was logged regarding a verbal confrontation with a nursing assistant. For a third resident, the resident’s representative reported the resident was left with a soiled face and clothing and a brief so saturated with urine that it dripped down the hallway. Record review showed that none of these three incidents were entered into the facility’s reporting log, which is used to document incidents that may involve abuse, neglect, or mistreatment of residents, and there was no evidence of thorough investigation to rule out abuse or neglect. Completion dates on the grievance log, when present, were several days after the concerns were reported, and one concern had no completion date at all. During interviews, the administrator and DON acknowledged confusion among staff about which concerns should be placed on the grievance log versus the reporting log and confirmed that the concerns involving these three residents were not identified as allegations of abuse or neglect and were not investigated as such, meaning the residents were not provided protection from the possibility of ongoing abuse or neglect.
Failure to Report Allegations of Abuse and Neglect to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report potential allegations of abuse and neglect to the State Agency (SA) for three residents whose cases were reviewed. For one resident with ALS who was cognitively intact and dependent on staff for all ADLs, a grievance log and incident reports showed that the resident alleged a staff member did not place their eyeglasses on as requested, instead holding them out of reach for a couple of minutes before setting them on a table and leaving the room. The resident expressed concerns about how the staff member treated them and requested that this staff member no longer provide their care. The Social Services Director later learned, via an email from a community health reporter, that the resident had complained that staff did not know how to care for a person with ALS, did not feel cared for or safe, and felt staff did not know how to manage episodes of choking or position their head upright. Although this concern was investigated internally, the facility’s reporting log showed that this potential allegation of abuse and/or neglect was not entered into the reporting log and was not reported to the SA. A second deficiency component involved another resident with dementia and Parkinson’s disease, who was cognitively intact and required substantial to maximum assistance with toileting and dressing and was frequently incontinent of urine. A grievance form documented that the resident’s representative reported finding the resident in their wheelchair with dried toothpaste on their shirt, pants, and face, and that when they assisted the resident to the dayroom, the resident was so wet with urine that a trail of urine was left down the hallway. The representative stated they wanted the resident treated with dignity. This concern, which constituted a potential allegation of neglect, was handled as a grievance within the facility. Review of the reporting log showed that this potential allegation of neglect was not reported to the SA. The third component of the deficiency involved a resident with heart failure and depression, who was cognitively intact, independent with toilet transfers, and required substantial to maximum assistance with toileting hygiene. A grievance form documented that the resident reported being upset with the way a nursing assistant spoke to them, blaming them for locking a shared bathroom door and saying, “Would you stop locking the dang door?” The resident stated that the way they were spoken to was unprofessional and unnecessary. This concern, a potential allegation of verbal abuse, was investigated as a grievance rather than as an allegation of abuse. Review of the reporting log showed that no potential allegation of abuse for this resident was reported to the SA. In an interview, the DON stated they did not report the concerns for two of the residents as allegations of abuse or neglect because they did not believe the staff actions were purposeful or willful.
Failure to Thoroughly Investigate Multiple Abuse and Neglect Allegations
Penalty
Summary
The facility failed to conduct complete and thorough investigations into multiple reported allegations of abuse and neglect. For one resident with ALS, intact cognition, and total dependence on staff for all ADLs, a grievance was filed after the resident reported that an LPN did not respond to their request to have their glasses put on, instead holding the glasses out silently for several minutes, then placing them down and leaving the room without assisting or explaining. The resident reported feeling unsupported and mistreated and requested that this staff member no longer enter their room or provide care. Although the concern was reported to the DNS, the investigation as documented focused on educating the staff member, without evidence of a root cause analysis, contributing factors review, or measures to rule out abuse or neglect. For another resident with dementia, heart failure, urge incontinence, intact cognition, and frequent urinary incontinence, the resident’s representative reported finding the resident with dried toothpaste on their face, shirt, and pants and with a brief so saturated with urine that it leaked down the hallway when the representative assisted the resident to the day room. The grievance documentation showed the resident was interviewed and reported no concerns, and the DNS concluded that lack of dignity and timely care could not be substantiated and that abuse and neglect were ruled out. However, the grievance file contained no interviews with other residents, no identification of the staff involved in the incident, no staff statements, no care plan changes, no alert charting, and no skin checks to assess the resident after sitting in urine. The investigation lacked any documented root cause or analysis explaining why the resident was soaked with urine or why personal hygiene needs were not met. For a third resident with heart failure, lung disease, intact cognition, and frequent urinary incontinence, a grievance was filed after the resident reported that a nursing assistant entered their room and told them to stop locking the “dang” door, blaming them for locking a shared bathroom door. The resident reported being upset by the unprofessional tone, feeling as if they were being scolded and accused of lying when they tried to explain they had not used the restroom that day, and described the staff member throwing their hands up and leaving the room while the resident was talking. The grievance conclusion documented removal of the staff member from the room and unit and referenced education about sharing information on other residents, but there was no documented root cause or analysis to rule out abuse or neglect, no interviews with other residents about the staff member’s interactions, no care plan changes, and no alert charting to monitor for adverse reactions. Additionally, the facility’s reporting incident log contained no entries for these allegations, and the administrator and DNS acknowledged staff confusion about what should be entered on the grievance log versus the reporting log.
PASARR assessments not updated after significant behavioral and medication changes
Penalty
Summary
The facility failed to ensure PASARR assessments were completed for residents after significant changes in status or when newly evident or possible serious mental disorders were identified. Surveyors found this issue for 3 of 7 residents reviewed for unnecessary medications: Resident 31, Resident 23, and Resident 59. The report states this failure resulted in a potential delay in access to Level 2 PASARR services and decreased quality of life. Resident 31 was admitted with heart failure and stroke deficits, and the comprehensive assessment showed severely impaired cognition, dementia, and use of an antidepressant. Provider notes documented cognitive decline, increased behaviors, concern for vascular dementia, yelling, cussing, hitting staff, refusal of meals and care, angry outbursts, agitation, and the addition of antidepressant medications for dementia with behaviors and weight loss. The resident’s Level 1 PASARR dated 02/03/2023 had not been updated to reflect the significant change, new diagnosis, behaviors, or medications. Resident 23 was admitted and re-admitted with diagnoses including a broken collar bone, repeated falls, and dementia without behavioral disturbances. The resident later had severe cognitive impairment and was taking antidepressant and anticonvulsant medications. Provider notes documented aggressive behaviors toward staff, refusals of care, impulsive behaviors, and a new diagnosis of dementia with behavioral disturbance, followed by an antipsychotic medication and later a taper off that medication with initiation of an anticonvulsant. Resident 59 was admitted with dementia without behavior, DVT history, and arthritis, and later had severe cognitive impairment while receiving antipsychotic, antidepressant, and anticonvulsant medications. Provider notes documented increased aggressive and sexual behaviors and the addition of anticonvulsant and antidepressant medications for dementia with behavioral disturbance. The record showed no updated PASARR completed for these residents after these changes.
Missing Competency Documentation for Licensed Nurses
Penalty
Summary
The facility failed to develop and implement a system to evaluate and document demonstrated competencies and skill sets for 3 of 3 licensed nurses reviewed: Staff D, an RN hired on 10/18/2018; Staff M, an LPN hired on 12/19/2024; and Staff Q, an LPN and Staff Development Director hired on 07/26/2020. Review of their personnel files showed no documentation of demonstrated competencies, skills, or performance evaluations for any of the three nurses. The facility assessment, updated January 2026, stated that the facility maintains an ongoing process for staff training, education, and competency validation, and that staff education and competency needs are assessed through observation, quality assurance activities, incident review, and interdisciplinary team feedback. During interview, the DNS stated they were new to the role and had not completed any competencies or skills evaluations of the LNs, and that after meeting with HR they were unable to find any previous evaluations for the sampled LN staff. The DNS stated this was a process they needed to work on.
Call Light and Bedside Table Left Out of Reach
Penalty
Summary
The facility failed to ensure that Resident 13’s call light and bedside table were within reach and easily accessible. Resident 13 had diagnoses of anoxic brain injury, left-sided hemiplegia, and loss of vision in the left eye, and the comprehensive assessment showed moderate cognitive impairment with dependence on one to two people for dressing, hygiene, incontinent care, bathing, and mechanical lift transfers. The care plan stated that Resident 13 was blind in the left eye, had limited vision in the right eye, was able to use the call light appropriately, and that the call light was to be left within reach; it also noted that Resident 13 liked to drink a Diet Coke daily. During multiple observations, Resident 13 was sitting in a wheelchair in the room with the left side closest to the bed, while the bedside table was behind the wheelchair. The call light was on the bed and the bedside beverage was on the bedside table, both out of reach. During a concurrent observation and interview, Resident 13 stated they would use their button to request assistance and asked where the call light was, but was unable to locate it and could not access personal belongings on the bedside table because the table was behind the wheelchair. Staff K stated the call light needed to be intentionally placed within Resident 13’s reach due to limited reaching ability and limited vision, and that the bedside table needed to be placed in front of Resident 13 within reach. Staff B stated all residents should have their call light and bedside table within reach.
PASARR Screening Forms Not Reviewed or Validated for Two Residents
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not reviewed and validated for 2 of 7 residents reviewed, Residents 4 and 9. Resident 4 was admitted with diagnoses including dementia, psychotic disturbance, mood disturbance, anxiety, and PTSD. The medical record showed a comprehensive assessment indicating the resident was cognitively intact and needed minimum assistance with ADLs. A Level 1 PASARR form from the discharging hospital dated 4/18/2025 did not have SMI indicators checked in Section IA, although dementia was written on the form, and Section IV indicated a Level 2 evaluation was not indicated. Facility staff later corrected the Level 1 form on 04/23/2025 to show mood disorder and PTSD in Section A1, with Section IV still indicating no Level 2 evaluation was indicated. Resident 9 was admitted with ALS, depression, anxiety, and PTSD. The comprehensive assessment showed cognition was intact and the resident required total assistance with ADLs. A Level I PASARR screening form dated 08/21/2025 showed no SMI diagnoses checked in Section 1A by the physician, even though depression, anxiety, and PTSD were listed on the admission paperwork. Facility staff corrected the PASARR form the same day to add depression, anxiety, and PTSD in Section IA, and Section IV continued to show that a Level 2 evaluation was not indicated. During interview, the Social Services Director and Administrator stated the SSD was responsible for assuring PASARR forms were completed prior to admission and corrected or updated if inaccurate, and they stated they believed the process only applied to new admissions or residents with a change in condition or medications.
Failure to Monitor and Communicate Urinary Changes and Pain
Penalty
Summary
Failure to provide appropriate treatment and care according to orders, resident preferences, and goals occurred for a resident with hydronephrosis, kidney stones, kidney disease, severe cognitive impairment, and hospice services for cerebrovascular disease. The resident had an RC and a hospice care plan that allowed the hospice nurse or facility nurse to obtain a dipstick urine test for symptom management and allowed the hospice RN to flush the RC as needed. The physician also had an order dated 12/23/2025 for Acetic Acid irrigation three times a day as needed for RC occlusion or blockage, but this order had not been used since it was written. The resident’s RR reported new burning pain with urination and new reddish urine to nursing staff, and staff observed thick white chunky sediment in the RC tubing with urine above the sediment and no urine below it. The resident was observed lying in bed with nonverbal signs of pain, including grasping the bed rail tightly, wincing, and moaning. Nursing progress notes from 01/25/2026 through 01/27/2026 did not document the RR’s reports, ongoing monitoring of the urine changes and discomfort, the sediment and reddish/yellow urine, or notification to hospice services. The hospice nurse visit note also did not reflect assessment or knowledge of the urine symptoms, catheter sediment, reddish/yellow urine, or increased discomfort. Interviews showed staff did not follow the usual communication process for changes in condition. Staff D stated the RR reported pain and burning with urination and that they saw particles in the RC tubing, but staff were unsure about notifying hospice for a change in condition and did not know about the Acetic Acid irrigation order. Staff C stated they were informed of urine issues but did not assess the resident or communicate to hospice, initiate alert charting, or use the AD pain tool despite the resident’s communication issues and language barrier. The DON and Administrator stated they expected nursing staff to communicate changes in condition to hospice and to provide ongoing monitoring and charting, but that did not occur in this instance.
Failure to Assess and Monitor Left Hand ROM and Contracture Risk
Penalty
Summary
The facility failed to thoroughly assess, monitor, and identify the potential need for positioning and ROM services for a resident with left-sided hemiplegia and a history of stroke. The resident was admitted with moderate cognitive impairment and required assistance from one to two people for dressing, transfers, toileting, incontinent care, and bathing. Facility assessments showed no contractures causing physical limitations, but the resident was identified as at risk for developing contractures due to limited mobility. Provider notes later documented slight movement of the left arm and hand with slight contracture, and then contracture to the left hand with left arm weakness. The resident’s restorative care plan included use of an Omnicycle to prevent contractures and maintain upper body strength, but the restorative director stated the ROM program focused on the upper arms and the left hand had never been assessed for signs of contracture. The restorative director also stated there was no current restorative program specifically focused on the resident’s left hand and that they could not determine whether the hand had worsened because it had never been assessed. During observation, the resident stated they did not wear a splint or brace on the left hand, tried to remember finger stretches but would forget, and was unable to stretch and extend the left thumb, stating it was starting to get stuck.
Incorrect Therapeutic Diet and Liquid Consistency Served
Penalty
Summary
The facility failed to provide Resident 51 with the ordered therapeutic diet texture and liquid consistency. Resident 51 was admitted with left side hemiplegia and a history of stroke, and the comprehensive assessment showed moderate cognitive impairment, a need for supervision while eating, and coughing and choking during meals. After a nursing note documented that the resident was coughing while eating and drinking and eating at a fast pace, a three-day trial was ordered for mechanical soft with ground meat and nectar thick liquids. Following the diet change, observations showed the resident’s bedside beverage cup contained regular ice water instead of nectar thick liquids. Later, the resident was observed eating dinner that included pepperoni pizza cut into one-inch pieces and juice that was not thickened, and the nursing assistant stated the diet card from the kitchen still showed mechanical soft with thin liquids. The resident also stated the bedside beverage cup contained regular ice water. Staff later stated the diet change was communicated to kitchen staff, but the update was not placed on the EHR dashboard, the diet card was not updated on 01/26/2026, and the incorrect diet texture and liquid consistency were served.
Bedside suction machine not maintained in sanitary condition
Penalty
Summary
The facility failed to maintain a bedside suction machine in a clean and sanitary manner that met infection control standards of practice for Resident 60, who was admitted with stroke, right-sided hemiplegia, and dysphagia. The resident had an order for oral suctioning as needed for excessive secretions, and the bedside suction machine was observed on the nightstand next to the resident's bed on multiple occasions. During observations on 01/25/2026, 01/26/2026, 01/27/2026, and 01/28/2026, the suction machine canister was labeled 01/01/26 and was half full with 400 mL of light-yellow liquid containing multiple white particles floating at the top. Staff stated that licensed nurses were responsible for using and cleaning the suction machine, and the Infection Preventionist stated the facility process was to discard the suction machine canister, liners, and tubing after use and replace them with new ones. The Director of Nursing Services stated the licensed nurses should have disposed of and replaced the suction machine materials and set it up for the next use.
Expired Foods and Inadequate Temperature Monitoring in Facility
Penalty
Summary
The facility failed to ensure expired foods were discarded and did not consistently monitor refrigerator temperatures, which increased the risk of food-borne illnesses for residents. During an observation, expired food items, including spinach wraps, white corn tortillas, and flour tortillas, were found in the dry storage area. Staff K, a cook, confirmed that the expired flour tortillas had been served during a lunch meal, mistakenly assuming they were fresh. The Dietary Manager later disposed of the expired items. The facility's policy required food items to be rotated, labeled, dated, and discarded on the expiration date, but this was not adhered to. Additionally, the facility did not maintain temperature logs for two refrigerators. The kitchen snack refrigerator, which stored salads, snacks, juices, and milk, lacked a temperature log. A small black refrigerator, containing nutritional shakes, had only one temperature recorded for the entire month. Staff L, the Dietary Manager, acknowledged the lapse in maintaining temperature logs and stated that the small black refrigerator was not in use. Staff A, the Administrator, was aware of these issues and confirmed the expectation for dietary staff to rotate food items and discard expired food.
Inadequate Catheter Care Leads to Increased UTI Risk
Penalty
Summary
The facility failed to provide adequate care for a resident with an indwelling urinary catheter (IUC), which placed the resident at risk for urinary tract infections (UTIs). The resident, who had a history of dementia and neurogenic bladder, was readmitted to the facility with an IUC following a hospital stay for septic shock due to a complicated UTI. Despite physician orders to change the catheter every four weeks and follow up with a urologist, the facility did not implement these orders in a timely manner. Observations revealed that the resident's catheter bag was improperly positioned on the floor, causing tension on the drainage tube and compromising the integrity of the closed drainage system. The resident's medical records lacked specific orders regarding the type, size, and maintenance schedule for the IUC, and there was no documentation of monitoring for signs of infection or complications. Interviews with facility staff confirmed that the necessary orders for catheter care were not placed in the resident's chart until much later, and the catheter was not changed as required. The deficiency was further highlighted by staff interviews, where it was acknowledged that the correct process for managing the resident's IUC was not followed. Staff members admitted that the oversight in placing the necessary orders contributed to the increased risk of UTIs for the resident. The facility's failure to adhere to proper catheter management protocols and physician orders resulted in inadequate care for the resident, as evidenced by the lack of timely catheter changes and monitoring for potential infections.
Unauthorized Access to Medication Room
Penalty
Summary
The facility failed to secure all medications in the locked medication room and did not limit access to authorized personnel, which is inconsistent with professional practice. This deficiency was identified when an unauthorized staff member, the Maintenance Director (Staff E), accessed the medication storage room. The facility's policy, dated July 2021, stated that medication should only be accessible to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications, and that medication rooms should be locked when not attended by authorized persons. During an observation and interview, it was noted that Staff H, a Registered Nurse/Resident Care Manager, used their key to open the medication room, stating that only nursing staff had keys and that no controlled medications were stored there. However, Staff E, the Maintenance Director, was observed using a key to open the locked medication room door to allow the State Fire Marshal access. Staff E stated they had obtained the key from the previous Maintenance Director and were unaware they should not have it, using it monthly to check the air conditioner unit. The facility Administrator, Staff A, confirmed they were unaware that Staff E had a key and acknowledged that Staff E should not have access to the medication storage room.
Director of Nursing Worked with Expired License
Penalty
Summary
The facility failed to ensure that the Director of Nursing Services (DNS), identified as Staff R, maintained an active nursing license while providing care to residents. The facility's job description for the DNS position required a current unrestricted license as a Registered Nurse (RN). However, a review of Staff R's personnel records revealed that their RN license had expired, and they continued to work for 17 days after the expiration. During an interview, the facility's Administrator, Staff A, acknowledged that Staff R had informed them of the license renewal prior to its expiration but later discovered it was expired. Consequently, Staff R should not have worked those 17 days without an active license.
Inadequate Infection Control for Urinary Catheters
Penalty
Summary
The facility failed to implement proper infection control practices for indwelling urinary catheter equipment for two residents, leading to a risk of infections. Resident 29, who has a history of urinary tract infections and is cognitively impaired, was observed multiple times with their urinary catheter bag and tubing dragging on the floor while being moved in a wheelchair. The facility's policy and CDC guidelines clearly state that catheter bags should not touch the floor to prevent infection, yet these practices were not followed by the staff, as evidenced by observations and staff interviews. Similarly, Resident 52, who is cognitively intact and has a history of UTIs, was also observed with their catheter bag touching the floor while seated in a wheelchair. Despite holding the catheter tubing to prevent it from dragging, the bag still made contact with the floor. Staff interviews confirmed that catheter bags and tubing should not touch the floor, yet this practice was not adhered to, placing the residents at risk for infections.
Inadequate Investigation of Resident Altercations
Penalty
Summary
The facility failed to conduct a complete and thorough investigation into resident-to-resident altercations, which involved four residents. The incidents included verbal and physical altercations between Residents 4 and 5, and Residents 6 and 7. The investigation reports lacked essential details such as root cause analysis, witness statements, and interventions to prevent further incidents. Additionally, there were no updates or changes made to the care plans of the involved residents to address the altercations. Resident 4 and Resident 5 were involved in a verbal altercation that escalated to a physical confrontation. The incident report did not provide a comprehensive description of the event, including which resident initiated the name-calling or which shoulder was hit. Furthermore, there were no documented interventions or care plan changes to prevent future altercations between these residents, despite their history of issues. Staff interviews revealed a lack of awareness and communication regarding the incident, with responsibilities for follow-up and care plan updates being unclear. Similarly, Residents 6 and 7 were involved in a physical altercation during lunch. The report failed to include a root cause analysis or details about the residents' injuries and did not document any interventions or care plan changes. Staff interviews indicated a lack of awareness of the incident and insufficient monitoring of Resident 7's known aggressive behaviors. The Social Services Director and nursing staff did not collaborate effectively to implement appropriate interventions, leaving the residents at risk for further altercations.
Infection Control Deficiencies in Hydration Pass and Resident Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices for two residents by not performing hand hygiene and glove changes between dirty and clean tasks. Staff E, during hydration passes, repeatedly used the same gloves to handle contaminated resident cups, fill them with ice, and return them to the residents' bedside tables. This practice was observed multiple times, with water from the contaminated cups splashing into the ice chest, further increasing the risk of cross-contamination. Staff E admitted to being trained by a former employee and stated that resident cups were only changed if visibly dirty or during night shifts, contrary to the facility's policy on hand hygiene and glove use. Additionally, the Registered Dietician confirmed that the hydration cart was set up by kitchen staff and that cups were supposed to be changed twice a day, which was not consistently followed by Staff E. The Infection Preventionist acknowledged that the smoking assistants had received hand hygiene training but admitted that the hydration pass was not performed correctly. The Director of Nursing Services emphasized that all staff were expected to follow physician orders and basic hand hygiene procedures when providing care to residents. For Resident 26, who had diagnoses including dementia and required substantial assistance with personal hygiene, Staff K failed to change gloves after cleaning the resident's groin area during incontinent care. Instead, Staff K used the same contaminated gloves to grab clean wipes and continue the care, acknowledging the mistake during the observation. This failure to change gloves between dirty and clean tasks was a direct violation of the facility's infection control policy and increased the risk of cross-contamination for the resident. For Resident 21, who had diagnoses including dementia, localized swelling, and cellulitis, Staff H did not follow proper wound care procedures during a dressing change. Staff H removed the soiled dressing from the resident's right leg without changing gloves or cleaning the wound before applying new ointment and dressing. The same contaminated gloves were used to handle both legs, and hand hygiene was not performed between glove changes. The Infection Preventionist confirmed that the wound care was done incorrectly and that the nurse should have followed the physician's orders, which included cleansing the wound and changing gloves during the dressing change. The Director of Nursing Services reiterated the importance of following physician orders and infection control policies.
Failure to Update Resident Care Plans
Penalty
Summary
The facility failed to ensure resident care plans were reviewed and revised to accurately reflect care needs for two residents. Resident 40, who had all their teeth removed and received dentures, did not have their care plan updated to reflect these changes. Despite the resident's refusal to follow a physician-ordered fluid restriction and ground meat diet, these refusals were not documented in the care plan. Staff responsible for updating the care plan admitted they had not had time to make the necessary updates. Resident 66, who required assistance for transfers and meal assistance, had an outdated care plan that did not reflect their current needs. The care plan indicated one-person assistance for transfers, but staff were using two-person assistance and an underarm lift technique, which was not recommended. Additionally, the care plan stated the resident required one-to-one assistance for eating, but observations showed the resident eating independently without staff assistance. Staff interviews confirmed the care plan was not accurate and needed updating. The facility's policy required care plans to be updated with any changes in the resident's condition or needs. However, the failure to revise the care plans for these residents placed them at risk for inadequate or unsafe care. Staff acknowledged the discrepancies and the need for care plan updates, but the necessary revisions had not been made in a timely manner.
Failure to Ensure Communication with Dialysis Center
Penalty
Summary
The facility failed to ensure ongoing communication and collaboration with the dialysis center for three residents (Resident 40, 44, and 38) who required dialysis services. This failure placed the residents at risk for unnoticed significant changes in their health status, delay in care, and potential death. The facility's policy required communication regarding medication administration, physician orders, laboratory values, vital signs, advance directives, nutritional management, dialysis treatment responses, adverse reactions, and changes in condition. However, the facility did not adhere to this policy, as evidenced by the lack of documented communication with the dialysis center for the residents in question. Resident 40, who had diagnoses including diabetes and end-stage renal disease, received dialysis treatments three times a week. Despite having 13 dialysis sessions each month from December 2023 to February 2024, the medical record showed communication from the dialysis center for only three sessions. Additionally, there was no documentation of communication when the resident refused a dialysis session on January 23, 2024. Similarly, Resident 44, who had end-stage renal disease and fluid overload, also had 13 dialysis sessions each month but only one documented communication from the dialysis center during the same period. An adverse reaction involving blood-saturated dressings at the vascular access site was not communicated to the dialysis center. Resident 38, with end-stage renal disease and dependence on dialysis, had 13 dialysis sessions each month from December 2023 to February 2024. The medical record showed limited communication from the dialysis center, with only a few documented instances. Interviews with staff revealed that there was no system in place for communication with the dialysis center, and the facility did not send any paperwork or communication with the residents when they went to their dialysis sessions. The Director of Nursing Services and other staff acknowledged the lack of a proper communication system and the need for improvement in this area.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Wapato
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Linden Post Acute | 7.4 mi | ★★★★★ | 11 | 0 |
| Parkside Care | 7.6 mi | ★★★★★ | 36 | 0 |
| Garden Village | 11.1 mi | ★★★★★ | 2 | 0 |
| Good Samaritan Health Care Ctr | 12.1 mi | ★★★★★ | 11 | 0 |
| Summitview Rehab And Health Center | 12.2 mi | ★★★★★ | 11 | 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 October 2026) and official state health department websites.