Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Everett Center during CMS and state inspections, most recent first.
The facility failed to properly log, investigate, and resolve resident grievances and resident council concerns. Residents reported delayed call light response, toileting and brief-change delays, food issues, laundry problems, and poor staff follow-up, but the council minutes were incomplete, unnamed, and often vague, and the grievance log did not include the council concerns. Staff acknowledged the concerns were not clarified, written follow-up was not provided, and individual grievances did not document specific details, staff involvement, or whether abuse or neglect was ruled out.
Care plans for 3 residents were not updated to match current needs and documented recommendations. One resident with ESRD was observed using oxygen, but the care plan did not reflect respiratory needs or oxygen use. Another resident taking clonazepam had no care plan area for monitoring adverse medication effects. A third resident with impaired gait had PT recommendations for ambulation and strength exercises with nursing support, but the care plan and task records did not show those interventions.
Failure to provide ambulation and exercise support for a resident with osteoarthritis and impaired gait. PT discharge recommendations called for a walker-based ambulation HEP with nursing staff and independent strengthening exercises, but the resident said walking and gym bike use stopped after therapy ended, nursing said they did not have time, and records showed no care plan or task for restorative ambulation or exercise support.
Failure to provide individualized recreation and sensory stimulation for a resident in a persistent vegetative state. The resident’s recreation assessment noted music and TV/movies were somewhat important, but the care plan had no goal and left the preferred music field blank. Survey observations repeatedly found the resident lying in bed with no TV, no music, and a dark room, while recreation records showed only a few activity entries and staff reported limited 1:1 visits and no contact with family.
The facility did not provide required written bed hold notices to residents or their representatives during hospital transfers, with staff often marking 'refused' without documenting who was contacted or when, and some staff were unaware of the bed hold policy. In several cases, residents or their families reported not being informed about the bed hold option, and documentation was incomplete or inaccurate.
Improper storage and labeling of insulin was found in multiple med carts when several insulin pens and vials were observed at room temperature without dates, and some were acknowledged by an LPN as expired. Staff stated insulin should be dated when removed from the refrigerator and stored in the med cart, but multiple residents’ insulin products were undated or beyond the manufacturer’s open-use timeframe.
A facility failed to keep complete medical records for two residents. One resident receiving restorative ROM had no documented restorative evaluations in the EHR even though staff said weekly restorative review meetings occurred and the resident was on a restorative program. Another resident’s chart lacked documentation of a change in condition and the sequence of events around provider lab orders, including the resident’s nausea, staff calls to the provider for clarification, and a delay in obtaining labs.
A resident who was cognitively intact and unable to move their limbs did not have the call light kept within reach. The resident’s care plan directed staff to clip a soft touch call light near the head, but it was repeatedly observed on the abdomen or placed too far away for the resident to activate by turning the head. Staff acknowledged the call light needed to be positioned close to the resident’s head.
Fall mats were not in place for a resident with fall management interventions. The Kardex indicated fall mats should be at the bedside, but repeated observations found none on either side of the bed. An RN, CNA, and an LPN/interim RCM all confirmed the mats were not present and could not be located in the room.
The facility failed to provide adequate staffing to meet resident needs, resulting in delayed call light responses and untimely medication administration. Residents and family members reported long wait times, particularly on weekends, leading to unmet care needs and frustration. Despite in-service training efforts, staffing shortages and high dependency needs persisted, contributing to repeated citations.
The facility failed to conduct thorough investigations for several residents, including incidents of falls, pressure injuries, and allegations of abuse. Investigations lacked critical details such as medication information, witness statements, and predisposing factors. Allegations of neglect, such as rough handling and delayed care, were not adequately addressed, compromising resident safety and care quality.
The facility failed to complete timely and comprehensive Resident Assessment Instruments (RAIs) for several residents, impacting individualized care plans. CAAs lacked necessary information, and MDS assessments were not completed within required timeframes. Staff interviews revealed a lack of awareness regarding assessment deadlines and documentation requirements.
The facility did not develop or communicate baseline care plans with essential healthcare information within 48 hours of admission for several residents. Key needs such as communication methods and dietary requirements were not documented, and residents or their representatives were not informed of the initial care plan in a timely manner. Care conferences were delayed, and written copies of care plans were not provided, resulting in incomplete documentation and inconsistent care processes.
The facility did not act on pharmacist medication regimen review (MRR) recommendations within the required timeframe, resulting in delayed completion of assessments and medication changes for several residents. For example, a resident on antipsychotic medication did not receive a timely AIMS assessment, and multiple residents experienced delays in discontinuation or clarification of anticoagulant medications. Staff and leadership were unaware of these delays, which were not in accordance with facility policy.
Surveyors found expired medications in multiple medication carts, incomplete temperature monitoring for medication refrigerators, and improper storage of controlled substances that were not in permanently affixed, locked compartments. Additionally, a resident with no cognitive impairment was observed self-administering medications at bedside without an assessment, physician order, or care plan for self-medication, contrary to facility policy.
The facility failed to maintain complete and accurate medical records for several residents, including missing documentation of medication monitoring, incomplete assessments after falls, and lack of restorative care notes. Staff interviews confirmed that required documentation was not consistently entered into the electronic health record, leading to gaps in resident care records.
A facility failed to assist three residents with routine ADLs, including repositioning and transferring. One resident was not transferred to a wheelchair as required, while two others were not repositioned according to their care plans. Staff interviews revealed inconsistencies in following care plans, with some staff citing time constraints. Observations showed residents lying in bed for extended periods without repositioning, contrary to facility standards.
A resident in a vegetative state was repeatedly exposed to loud, sexually explicit audio and video from their roommate's laptop, with the content audible from the hallway. Multiple staff members noticed the situation but did not intervene or update care plans, and leadership was unaware until the survey. The facility failed to uphold the resident's right to a dignified and respectful environment.
Three residents with significant medical and communication needs were repeatedly found without accessible call lights, despite facility policy and staff expectations. Observations and interviews showed that call lights were left out of reach, sometimes purposefully, and staff did not consistently correct this, even after entering residents' rooms. Family members and residents reported ongoing issues, and administration was unaware of the problem until informed by surveyors.
The facility did not complete or update required PASRR assessments for two residents with mental health conditions who remained in the facility beyond the exempted hospital discharge period. Both residents continued to receive psychotropic medications without the necessary Level II PASRR referrals or evaluations, and required documentation was incomplete or missing.
The facility did not update care plans for three residents to reflect their current needs and preferences. One resident with a swallowing disorder and mental health diagnoses had concerns about medication administration and feeding tube handling that were not addressed in their care plan. Another resident, who was severely cognitively impaired, fell from their wheelchair after staff failed to remove a Hoyer sling post-transfer, with the care plan lacking instructions for sling removal. These omissions resulted in care plans that did not accurately guide staff in meeting residents' needs.
A nurse prepared and attempted to administer medications to a resident with cognitive impairment, but after the resident refused, the medications were left unlabelled and later given to another nurse to administer without proper oversight. Additionally, blood pressure readings were not documented before administering antihypertensive medications to another resident, despite physician orders. Staff interviews confirmed inconsistent adherence to medication administration policies and monitoring requirements.
A resident with severe cognitive impairment was not assisted by staff to participate in activities as outlined in their care plan. Despite documented preferences for social engagement and sensory stimulation, the resident was repeatedly observed alone in their room, not participating in group activities, and not provided with planned sensory items or assistance. The Activities Director confirmed that the resident had not been included in activities or received room visits during the week due to staff being too busy.
A resident with a midline IV was found with an old, non-intact dressing and visible discoloration at the insertion site. Staff had not performed required dressing changes or IV flushes, and the IV remained in place despite a physician's order to discontinue it. Facility policies for vascular access device care were not followed, and staff were unaware of the necessary care steps.
A resident with communication and swallowing difficulties did not receive timely social services due to the social worker's extended absence and lack of effective coverage. The initial social work assessment and care conference were delayed, and there was no documentation regarding advance directives or efforts to inform the resident about their care plan.
Sharps containers in a medication cart, shower room, and resident room were observed to be filled above the full line, with items such as insulin pens, lancets, and razors present above the limit. Staff interviews revealed confusion about who was responsible for replacing the containers, with conflicting statements from an RN, IP nurse, Resident Care Manager, and DON. The containers remained overfilled during the survey period.
The facility failed to complete required PASRR evaluations for three residents with mental disorders, including a resident with severe major depressive disorder and another with bipolar disorder. Despite indications for Level II evaluations, there was a lack of documentation and follow-up communication with PASRR evaluators, leading to deficiencies in ensuring appropriate care and services.
The facility failed to assist residents with activities of daily living, including grooming, repositioning, and oral care. A resident was observed with unkempt hair and facial hair, while others were not repositioned as required, leading to potential risks of skin breakdown. Two residents reported not receiving oral care, with no supplies found in their rooms, despite staff expectations for daily hygiene assistance.
The facility failed to adhere to professional standards in medication management and lab testing for several residents. A resident with cardiac issues received blood pressure medications despite a low heart rate, and another with hypotension was given Midodrine outside prescribed parameters. Additionally, a resident missed an insulin dose during dialysis, and another experienced a delayed referral to a GI specialist. These deficiencies indicate significant lapses in care coordination and adherence to medical orders.
A facility failed to maintain a medication error rate below five percent, resulting in a 15% error rate. An RN administered a liquid multivitamin instead of a tablet, and an LPN left medications at a resident's bedside, contrary to policy. Neither resident was on a self-medication program, highlighting protocol breaches.
The facility failed to secure and properly administer medications, with several residents found with unattended medications despite not being on self-medication programs. Staff interviews revealed a lack of adherence to medication policies, and the narcotic reconciliation process was disorganized, risking errors. The DNS acknowledged these issues, noting a pharmacy switch contributed to the disorganized reconciliation.
The facility failed to report potential abuse and neglect for three residents. A resident with cognitive impairment had concerns about care that were dismissed without investigation. Another resident with a traumatic brain injury suffered bruising from a blood pressure cuff, but no report or investigation was made. A third resident reported verbal abuse involving racial slurs, but no formal investigation or report was conducted.
The facility failed to thoroughly investigate allegations of abuse and neglect for two residents, compromising their safety and quality of life. A resident with cognitive impairment reported rough handling by a staff member, but the investigation had inconsistencies. Another resident reported racial slurs from a roommate, but no formal investigation was conducted. The facility's policy requires thorough investigations, which were not completed in these cases.
A resident with a physician's order for supplemental oxygen was found using undated oxygen equipment, and the facility failed to maintain, change, or document the oxygen tubing and nasal cannula as per standards. Staff interviews revealed inconsistencies in monitoring and maintaining the resident's oxygen therapy, leading to a deficiency in care.
A resident was prescribed an antidepressant without a documented diagnosis of depression, and the facility failed to monitor behaviors or adverse effects. Staff interviews confirmed the lack of necessary documentation and monitoring for the psychotropic medication, placing the resident at risk for unnecessary medication use.
Incomplete grievance investigation and resolution
Penalty
Summary
The facility failed to ensure grievances were thoroughly investigated, logged, and resolved for two individual residents and for resident council concerns. The grievance policy required the Administrator or designee to document grievances on the grievance log, have the appropriate department manager investigate, and provide a written resolution with a summary of the grievance, investigation, findings, and any corrective action. Review of resident council records showed missing or incomplete documentation across several months, including no September 2025 minutes, October 2025 minutes without resident names, a resident concern response form that did not include investigation of the stated concerns, November 2025 with no meeting, December 2025 minutes listing multiple vague group concerns without clarification, and January 2026 minutes with unnamed residents and unresolved concerns. The facility grievance log from October 2025 through February 2026 did not include the resident council grievances. During a group interview, residents described ongoing problems with follow-up on concerns, including call lights, food, laundry, and staff responsiveness, and stated they were not told the outcomes of their concerns. Staff A stated grievances from resident council meetings were being handled as one group grievance rather than individual grievances, acknowledged vague concerns had not been clarified, and acknowledged written follow-up had not been provided. Staff A also acknowledged the grievances did not show documentation that each specific concern was identified, investigated, resolved, and communicated to the appropriate residents, and that resident council grievances were not being logged. Resident 87 reported waiting two hours for toileting assistance after a call light was answered and being told to wait for the next shift. The care team note documented that the resident verbalized waiting for care and that a grievance would be filed, but the grievance log initially did not show it. The grievance filed later lacked specific details, did not identify staff involved, did not rule out abuse or neglect, and focused on educating evening shift NACs even though the concern involved day shift care. Resident 46, who was cognitively intact, reported waiting one hour for a brief change after using the call light. The grievance record documented only customer service and call light wait time, without the resident’s detailed statement, without documentation that abuse or neglect was ruled out, and without documentation that staff involved provided information.
Care plans did not reflect current oxygen use, medication monitoring, or therapy recommendations
Penalty
Summary
The facility failed to ensure resident care plans were revised and accurately reflected care needs for 3 of 18 sampled residents. The facility policy titled, Person-Centered Care Plan, stated the care plan must be developed and implemented for each resident and reviewed and revised by the interdisciplinary team after each assessment. Review of the records showed that the care plans for Residents 8, 9, and 38 did not reflect current needs or documented recommendations from assessments and therapy records. Resident 38 was admitted with end stage renal disease and dependence on renal dialysis. The admission MDS showed no supplemental oxygen was required, but a later quarterly MDS showed the resident now required oxygen. Despite repeated observations of the resident with oxygen tubing to the nares and oxygen equipment running at 2 liters per minute, the care plan printout showed no documentation of a respiratory deficit or oxygen supplementation. Staff interviews confirmed that oxygen use should have been reflected in the physician orders and care plan, and the DON stated the care plan should have been updated. Resident 8 had diagnoses including panic disorder, generalized anxiety disorder, and major depressive disorder, and was prescribed clonazepam with several dose changes. The care plan did not include monitoring for adverse side effects of the anti-anxiety medication, and staff confirmed this was missing. Resident 9 had osteoarthritis and impaired gait, and a PT discharge summary stated the resident had met a walking goal and recommended an ambulation home exercise program with nursing staff using a walker, independent strength exercises, and assistance as needed. However, the care plan and task records did not show any program or task for ambulation or exercises, and staff were unable to explain how the therapy recommendations were being implemented.
Failure to Provide Ambulation and Exercise Support
Penalty
Summary
The facility failed to ensure Resident 9 received assistance with ADLs, specifically ambulation and exercise, consistent with the resident’s needs, choices, therapy recommendations, and stated goals. Resident 9 was admitted with osteoarthritis and impaired gait. The most recent PT discharge summary stated the resident had met the goal of walking 100 feet using a walker with supervision/stand by staff assistance and recommended an ambulation home exercise program with nursing staff using a walker, independent strength exercises, and 24/7 assistance as needed. A provider note also recommended encouraging restorative exercises as tolerated, and another note documented the resident’s frustration and desire for more exercise and weight loss. During interview, Resident 9 stated they had previously walked around the unit with therapy, but it stopped after they were doing well. The resident said they wanted to use the therapy gym bike and walk more to lose weight, but were told they could not use the bike because they were no longer on therapy and there was nobody to watch them. The resident also stated they were not allowed to walk without someone with them and that nursing staff said they did not have time, so they were only walking once in a while and felt they had lost strength. Record review showed the quarterly MDS documented walker use as no and walking 10 feet as not attempted, and the care plan and task records did not show a program or task for ambulation assistance or exercises. Staff interviews confirmed Resident 9 was not receiving restorative nursing services, and staff were unsure how the therapy and provider recommendations were being implemented.
Failure to Provide Individualized Recreation and Sensory Stimulation
Penalty
Summary
The facility failed to ensure that Resident 16 had an accurate assessment of recreational care needs and received an ongoing program of activities to meet the resident’s physical and mental needs. Resident 16 was admitted to the facility and, according to the Minimum Data Set dated 02/02/2026, was in a persistent vegetative state. The recreation assessment dated 02/03/2026 documented that the resident was usually understood and that listening to music and watching TV/movies were somewhat important to the resident. The care plan focus area stated that it was important for the resident to have the opportunity to engage in daily routines that were meaningful and relative to preferences, but no goal was listed, and the intervention to specify preferred music was left blank. Observations on 02/18/2026, 02/19/2026, and 02/20/2026 showed Resident 16 lying in bed in the room with no TV on or music playing during each observation. The room was repeatedly observed to be dark, with no lights on during most observations. The recreation participation record from 01/27/2026 through 02/20/2026 showed activities only on 01/29/2026, 02/03/2026, 02/09/2026, and 02/17/2026. Staff interviews indicated the resident was seen by nursing assistants several times a week, but recreation staff reported 1:1 visits were scheduled about once every two weeks and lasted 10 minutes for residents in a vegetative state. Staff also stated they had not seen the TV on or heard music in the resident’s room and had not been in contact with the resident’s family since admission.
Failure to Provide Proper Bed Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to provide written bed hold notices to residents or their representatives at the time of transfer to the hospital for three of four sampled residents reviewed for hospitalization. For one resident, documentation showed that the bed hold notice was signed by a staff member, but there was no time recorded, and the section for the resident or representative was marked as 'refused' without specifying who refused or the date and time of contact. Another resident, who was cognitively intact, denied being offered a bed hold notice, and their family member confirmed not being contacted. Staff interviews revealed a lack of understanding of the bed hold policy, with some staff unaware of the requirement and others indicating that they would mark 'refused' if unable to reach the resident or representative, without documenting attempts or details of contact. For a third resident, who was cognitively impaired, multiple hospital transfers were documented, but there was no evidence that the representative was provided with written information about the bed hold policy or their decisions. Bed hold notices for this resident were signed by staff, with 'refused' written in the resident or representative section, again without documentation of who refused or when contact was attempted. Staff confirmed that they did not document the details of their attempts to contact representatives and acknowledged that the documentation should have reflected unsuccessful contact attempts rather than refusals.
Improper Storage and Labeling of Insulin in Medication Carts
Penalty
Summary
The facility failed to ensure proper storage and labeling of insulin in 3 of 5 medication carts reviewed. During observation of Medication Cart 3, insulin for multiple residents was found stored at room temperature without dates, including an undated Lispro insulin vial and a Humulin N insulin pen dated 06/13/2025 for one resident, an undated NovoLog FlexPen and vial for another resident, an undated NovoLog FlexPen for a third resident, and an undated Lantus SoloSTAR pen for a fourth resident. Staff stated insulin should be dated when removed from the refrigerator and placed in the medication cart, and staff verified that no dates were present on several residents’ insulin and that one resident’s insulin was expired. On Medication Cart 5, a Lispro insulin pen dated 07/14/2025 and a NovoLin N FlexPen dated 07/16/2025 were observed, and the LPN stated the insulin was good for 28 days once removed from the refrigerator and acknowledged both were expired. On Medication Cart 4, a Humalog KwikPen dated 07/22/2025 was observed, and the LPN stated insulin was good for 28 days when opened and removed from the refrigerator and was aware the insulin was expired. The DON stated insulin was to be dated when opened, removed from the refrigerator, placed in individual bags, and stored in the medication cart, and that the LN was expected to check the date before administration and discard insulin according to the manufacturer’s instructions.
Incomplete Documentation of Restorative Services and Change of Condition
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident receiving restorative services. The resident’s comprehensive MDS assessment documented restorative programs, and the care plan showed passive range of motion restorative services. However, review of the resident’s electronic health record from 01/01/2025 through 08/25/2025 showed no documentation of restorative program evaluations. Staff stated the resident had a passive range of motion restorative program three times a week, and the clinical reimbursement coordinator and DON stated they held weekly restorative review meetings with the therapy manager and restorative aide, discussed plans, goals, progression, and modifications, and documented meeting minutes in a binder, but there was no documentation of restorative program evaluations in the record. The facility also failed to document a change-of-condition event for another resident. A family member reported a delay in carrying out provider orders. The resident had a physician order for laboratory tests, and an LPN confirmed the order later that day. The LPN stated the resident was not feeling well and had nausea, the provider saw the resident and entered lab orders, then left without speaking to staff. The LPN said they called the provider twice to clarify and confirm the order because the resident was already on antibiotics, and there was an additional delay because they did not have access to order labs electronically. The progress notes for that day contained no documentation of these events.
Call Light Not Kept Within Reach
Penalty
Summary
The facility failed to ensure call lights were within reach for one resident who was cognitively intact and unable to move their limbs. The resident had a soft touch call light care plan intervention that directed staff to clip the call light to the pillow next to the resident's head, and the resident's family member stated the resident could only use their head to activate the call light and that it was frequently not in place during visits. During multiple observations, the resident's call light was found on top of the abdomen or positioned too far from the resident's head for the resident to reach. The resident demonstrated by turning their head to the right that they could not access the call light when it was placed a few inches away. Staff acknowledged the resident needed the call light placed close to the head so the resident could activate it, and one staff member later moved it closer after observing it was too far away.
Fall mats not in place for resident with fall interventions
Penalty
Summary
The facility failed to ensure that care planned interventions for fall management were in place for Resident 5, who was admitted to the facility on [DATE]. A facility report for the resident’s fall on 06/10/2025 showed there had been a fall mat on the left side of the bed and that the new intervention was to place a fall mat on the right side of the bed in addition to the other fall mat. However, review of the resident’s Kardex dated 08/27/2025 showed fall mat on the right side of the bed and fall matts to floor, while observations on 08/25/2025, 08/26/2025, and 08/27/2025 showed no fall mat on either side of the bed. During an interview and observation on 08/27/2025, Staff N, RN, and Staff O, CNA, stated they had not seen fall mats in the resident’s room, and Staff O checked the closet with no fall mats found. Staff M, LPN/interim Resident Care Manager, reviewed the Kardex and confirmed the resident was to have fall mats at the bedside, then checked the closet and bathroom and could not locate the fall mats.
Staffing Deficiencies Lead to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient qualified staff to meet the needs of its residents, as evidenced by observations, interviews, and record reviews. The facility's assessment indicated that 5-7 nurses and 5-10 Nursing Assistant Certified (NACs) were required to care for an average census of 70 to 75 residents, many of whom had complex medical needs such as tracheostomies and ventilators. However, staffing patterns showed variances, with some shifts having fewer staff than needed, particularly on weekends. This resulted in delayed responses to call lights, untimely medication administration, and inadequate supervision of NACs, leading to unmet care needs and negative outcomes for residents. Interviews with residents and family members revealed consistent concerns about long wait times for call light responses, with some residents waiting over an hour for assistance. Residents reported feeling frustrated and vulnerable due to the delays, and some were forced to perform activities of daily living independently despite needing assistance. Family members echoed these concerns, noting that weekends were particularly problematic, with staff being slow to respond and residents being left in soiled conditions for extended periods. The facility's grievance log and Quality Assurance Performance Improvement (QAPI) documents further highlighted the ongoing staffing issues. Multiple grievances were filed regarding call light response times, and the facility had implemented in-service training to address these concerns. Despite these efforts, the facility continued to struggle with staffing shortages, high employee turnover, and a population with high dependency needs, contributing to the repeated citation for insufficient staffing.
Inadequate Investigations and Documentation in Resident Care
Penalty
Summary
The facility failed to conduct thorough investigations for several residents, leading to potential risks for repeat incidents and unmet care needs. For Resident 71, the investigations into multiple falls were incomplete, lacking details such as medication information, predisposing situational factors, and witness statements. Additionally, there were allegations of abuse and neglect, including rough handling by staff, delayed incontinent care, and call lights being placed out of reach. These concerns were not thoroughly investigated, and the facility's response to grievances was inadequate. Resident 78 experienced a fall after a shower, but the investigation did not include statements from the staff who provided care shortly before the incident, nor did it address the removal of safety equipment like the helmet and neck brace. The investigation also failed to clarify the time of the fall or whether the resident's leg brace was on, leaving gaps in understanding the circumstances leading to the fall. For Resident 58, the investigation into new pressure injuries was insufficient, as it did not collect evidence to demonstrate that the wounds were unavoidable or rule out neglect. Similarly, the investigation into a skin tear for Resident 73 did not determine the cause or implement interventions to prevent future occurrences. These deficiencies highlight a pattern of inadequate investigation and documentation, potentially compromising resident safety and care quality.
Deficiency in Timely and Comprehensive Resident Assessments
Penalty
Summary
The facility failed to complete the Resident Assessment Instrument (RAI) within the required timeframes and did not provide comprehensive summaries of the Care Area Assessments (CAAs) for nine residents. This deficiency was identified through interviews and record reviews, revealing that the CAAs lacked necessary information such as current goals, preferences, strengths, or needs for specific care areas. The absence of this information hindered the development of individualized care plans for the residents. For Resident 71, the CAAs were incomplete, missing comprehensive summaries or analyses necessary for updating the care plan. Similarly, Resident 78's CAAs were blank except for auto-populated information, lacking the required analysis. Resident 58's CAAs for pressure ulcers, feeding tube, and nutrition were also incomplete, with no documentation of complications or risk factors. Resident 66's CAAs did not include input from the resident or family, nor did they document risk factors or necessary interventions. Resident 73's pressure ulcer CAA was similarly incomplete, lacking documentation of complications or risk factors. Additionally, the facility failed to complete comprehensive admission MDS assessments within the required 14-day timeframe for Residents 67, 80, and 334. Resident 13's annual comprehensive assessment was incomplete and overdue. Interviews with staff revealed a lack of awareness regarding the deadlines for MDS assessments and a failure to document risk factors or analyses in the CAAs. The Director of Nursing acknowledged the expectation for timely completion of MDS assessments.
Failure to Develop and Communicate Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement baseline care plans that included the minimum necessary healthcare information within 48 hours of admission for five residents. Specifically, the baseline care plans did not address critical aspects such as communication needs, dietary requirements, and did not ensure that residents or their representatives were informed of the initial plan for care and services. For example, one resident with aphasia and dysphagia used pen and paper to communicate and required nectar thick liquids, but these needs were not documented in the care plan or Kardex. Staff relied on observation and verbal handoff rather than documented guidance, leading to gaps in care delivery. Additionally, the facility did not provide documentation that residents or their representatives were informed of the baseline care plan within the required 48-hour timeframe. In several cases, care conferences and discussions about goals of care occurred several days after admission, with some meetings delayed up to fourteen days. There was also no evidence that written copies of the baseline care plan were provided to residents or their representatives, and staff interviews confirmed that this was not standard practice. The lack of timely and comprehensive baseline care plans, as well as the failure to communicate these plans to residents and their representatives, was observed across multiple cases. Staff interviews revealed inconsistent processes for obtaining and sharing information about new admissions, and documentation in the electronic health record was incomplete or missing regarding communication of care plans. These deficiencies were found to be in violation of facility policy and regulatory requirements.
Delayed Implementation of Pharmacist Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to act on the consultant pharmacist's monthly medication regimen review (MRR) recommendations in a timely manner, as required by their own policies and procedures. Specifically, for one resident with schizoaffective disorder, major depression, and panic disorder, the pharmacist recommended completion of an Abnormal Involuntary Movement Scale (AIMS) assessment due to ongoing antipsychotic medication use. Although the provider agreed to the recommendation, the assessment was not completed within the required timeframe, with the last documented AIMS assessment occurring more than six months prior to the recommendation. Staff interviews revealed a lack of awareness and follow-up regarding the overdue assessment. Additionally, a review of the November MRR revealed that out of 93 provider recommendations, the majority were not addressed until 47 to 64 days after the initial report, well beyond the facility's policy of acting within 30 days. Several residents had recommendations related to the clarification or discontinuation of injectable anticoagulant medications, such as heparin and enoxaparin, which were not implemented until 51 to 60 days after the recommendations were made. Documentation showed that providers agreed to the recommendations, but the actual changes in medication orders were delayed. Interviews with facility leadership, including the Director of Nursing Services and the Administrator, indicated that they were unaware of the delays in implementing the MRR recommendations for the month in question. The facility's policy required that MRR reports be available within 48 hours and that recommendations be acted upon within 30 days, but this standard was not met for multiple residents and recommendations during the review period.
Expired Medications, Improper Storage, and Unassessed Self-Administration
Penalty
Summary
The facility failed to ensure proper management and storage of drugs and biologicals, as evidenced by multiple expired medications found in three out of five medication carts. During observations and interviews, staff discovered expired bottles of Iron, Omeprazole, Saline Nasal Spray, and Naloxone HCl in various medication carts. Staff members acknowledged that nurses were responsible for checking for expired medications, but some believed the pharmacist was primarily responsible for these checks. The facility policy required immediate removal and disposal of outdated or discontinued medications, which was not consistently followed. Temperature monitoring for medication refrigerators was also deficient. In two out of three refrigerators storing medications, daily temperature logs were incomplete or missing for several days, and in one case, temperature checks were only performed once daily instead of the required twice daily when vaccines were present. Staff interviews confirmed that the responsibility for temperature checks was not consistently executed according to policy, and there was confusion regarding the proper storage location for certain vaccines. Controlled substances were not stored in compliance with facility policy or regulatory requirements. In both medication rooms, controlled medications such as Lorazepam were found in containers that were not permanently affixed inside the refrigerators, and in one case, a plastic container was secured only with a zip tie, which staff considered a lock. Staff were unaware that controlled substances required a separately locked, permanently affixed compartment. Additionally, a resident was found to have medications at bedside without being assessed for a self-medication program, lacking both a physician order and care plan, despite facility policy requiring evaluation and documentation for self-administration. The resident had no cognitive impairment and was observed using the medications independently, but no assessment or care plan was present in the clinical record.
Incomplete and Inaccurate Medical Record Documentation for Multiple Residents
Penalty
Summary
The facility failed to ensure that residents' medical records were complete, accurate, accessible, and systematically organized for four out of five residents reviewed for unnecessary medication. This included incomplete assessments, missing documentation of restorative care, and incomplete records related to resident incidents. For example, documentation for anticoagulant monitoring was inconsistent, with several instances where required follow-up notes were missing after staff indicated a potential issue by marking 'N' on monitoring forms. Additionally, blood pressure and heart rate measurements were not consistently recorded before administering certain medications, as required. For one resident, there were multiple falls documented, but the facility did not complete or document assessments every shift for 72 hours following each fall, as expected. Progress notes were missing or incomplete for several shifts after these incidents, and there was a lack of documentation related to the monitoring of side effects for anticoagulant medications, even when monitoring forms indicated a need for further assessment. Another resident's records showed similar gaps in documentation after a fall, with missing shift assessments and unclear or incomplete progress notes regarding the incident and the resident's condition. In another case, a resident's allegation against a staff member was not promptly or thoroughly documented in the electronic health record. The alert charting system was not used consistently, and late entries were made without clear indication of the dates they referred to. Additionally, for a resident on a restorative program, there was no documentation of evaluations or progress notes in the electronic health record, despite weekly meetings to discuss the resident's needs. Staff interviews confirmed that documentation practices did not align with facility policy or expectations.
Failure to Assist Residents with ADLs in LTC Facility
Penalty
Summary
The facility failed to assist three residents, identified as Residents 52, 67, and 28, with routine activities of daily living (ADLs), specifically in repositioning and transferring them out of bed. Resident 52, who was in a persistent vegetative state and dependent on a ventilator, was observed not being transferred to a wheelchair as required by their care plan. Despite the care plan and medication administration record indicating the need for daily mobilization, documentation showed multiple days where Resident 52 was not transferred. Interviews with staff revealed inconsistencies in following the care plan, with some staff admitting to not transferring the resident due to time constraints or only doing so on specific days like Bingo Day. Resident 67, also in a persistent vegetative state and dependent on a ventilator, was observed lying on their back for extended periods without being repositioned as required by their care plan. The care plan directed staff to reposition the resident every one to two hours, but observations and interviews indicated that this was not consistently done. Staff interviews confirmed that the resident was dependent on two staff members for bed mobility, yet the required repositioning was not documented or observed during the survey period. Similarly, Resident 28, with a diagnosis of a persistent vegetative state and ventilator dependency, was observed lying on their back with elevated heels for extended periods without repositioning. The care plan and Kardex directed repositioning every two to three hours, but observations showed that staff did not enter the resident's room for significant periods. The Director of Nursing confirmed the facility's standard practice of repositioning every two to three hours, yet this was not adhered to, as evidenced by the observations and lack of documentation.
Failure to Ensure Resident Dignity Due to Exposure to Explicit Content
Penalty
Summary
The facility failed to maintain a dignified environment for a resident who was in a vegetative state and fully dependent on staff for care. The resident was placed in a shared room with another resident who frequently watched and listened to pornography at a high volume on their laptop. The sexually explicit audio was loud enough to be heard from the hallway, and several staff members were observed to notice the noise but did not intervene or address the situation. Staff interviews revealed that the roommate regularly watched pornography loudly due to being hard of hearing and had previously refused to use headphones. Staff also indicated that the roommate could become aggressive if interrupted, leading them to avoid intervening directly and instead notify a nurse. Despite being aware of the situation, staff did not document any interventions or care plan updates for either resident regarding this issue. The care plans for both residents lacked documentation about the exposure to pornography or any measures to address it. Leadership, including the Resident Care Manager, DON, and Administrator, were not aware of the ongoing situation until it was brought to their attention during the survey. Staff acknowledged that a reasonable person would not want to be exposed to such content in their living environment. The facility's failure to address the situation resulted in a violation of the resident's right to dignity and a respectful environment, as outlined in facility policy and CMS guidance.
Failure to Ensure Call Lights Within Reach for Multiple Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for three residents, as required by its own policy and regulatory standards. Multiple observations and interviews revealed that call lights were repeatedly left out of reach for residents with significant medical needs, including one resident with hemiplegia, depression, anxiety, and PTSD, another with a traumatic brain injury and multiple fractures, and a third with glaucoma, dementia, and limited English proficiency. In several instances, call lights were found clipped to the mattress, hanging on the wall, or wrapped under the bed, making them inaccessible to the residents. Interviews with residents and their family members indicated that staff sometimes purposefully moved call lights out of reach, particularly for residents who frequently used them. One resident and their spouse expressed concern about possible retribution for reporting this issue. Family members reported consistently finding the call light out of reach during visits, and one resident reportedly crawled out of bed to seek help, resulting in a fall, when the call light was not accessible. Staff interviews confirmed that the expectation was for call lights to always be within reach, and staff were observed entering and leaving rooms without correcting the placement of call lights. Despite these expectations, staff and administration were unaware of the ongoing issue until it was brought to their attention. The facility's failure to ensure call lights were accessible placed residents at risk for delayed care and other negative outcomes.
Failure to Complete and Update PASRR Assessments for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that Pre-Admission Screening and Resident Review (PASRR) assessments were accurately completed and updated for two residents with mental health diagnoses. For one resident with major depressive disorder, anxiety disorder, and PTSD, the Level 1 PASRR was marked as an exempted hospital discharge, indicating no Level II evaluation was needed unless the resident stayed beyond 30 days. Despite the resident remaining in the facility for 48 days and receiving multiple psychotropic medications, there was no evidence of a Level II PASRR referral or evaluation as required. Another resident with mild cognitive impairment and bipolar disorder also had a Level 1 PASRR marked as an exempted hospital discharge, but key sections were left blank and the form was not signed by a physician as required. The resident remained in the facility for 38 days without a Level II PASRR referral, despite the requirement to complete one if the resident's stay exceeded 30 days. The responsible staff member acknowledged that the PASRR should have been completed but had not yet contacted the PASRR coordinator. The facility's policy assigns responsibility for PASRR coordination and updates to Social Services, including prompt notification to state authorities after significant changes in a resident's mental or physical condition. However, the records and staff interviews confirmed that these procedures were not followed for the two residents, resulting in incomplete or missing PASRR evaluations beyond the allowed exemption period.
Failure to Review and Revise Care Plans for Resident Needs
Penalty
Summary
The facility failed to review and revise care plans for three residents, resulting in care plans that did not accurately reflect the residents' current conditions and needs. For one resident with a swallowing disorder, major depressive disorder, anxiety disorder, and PTSD, the care plan was not updated to include the resident's preferences regarding medication administration and handling of their feeding tube, despite the resident expressing concerns about being given medications while not awake and not being informed about the medications being administered. The resident's preferences were not reflected in the care plan, even after the issue was brought to the attention of nursing staff and the Director of Nursing Services. Another resident, who was severely cognitively impaired, experienced a fall from their wheelchair after sliding forward due to a Hoyer sling being left under them following a transfer. Staff interviews revealed inconsistent practices regarding the removal of the sling, and the care plan did not include instructions for removing the Hoyer sling after transfers. The omission was confirmed during record review and staff interviews, and the care plan was only revised to include this instruction after the incident. These failures to review and revise care plans as required placed residents at risk for unmet care needs.
Failure to Follow Professional Standards in Medication Administration and Monitoring
Penalty
Summary
A deficiency was identified when a registered nurse (RN) prepared a resident's morning medications, including controlled substances and other prescribed drugs, and attempted to administer them. The resident, who had moderate cognitive impairment and diagnoses including diabetes, osteoarthritis, and Alzheimer's disease, refused the medications and asked the nurse to leave the room. The nurse placed the unlabelled and uncovered medicine cup containing the medications on top of the medication cart. Later, the RN handed the same cup to another nurse, who attempted to administer the medications to the resident without the original nurse present to observe the administration or confirm ingestion. Facility staff interviews revealed inconsistent understanding and application of the facility's medication administration policy, which requires the nurse who prepares the medication to administer it and mandates disposal of refused medications. Another deficiency was found regarding the administration of antihypertensive medications to a resident with hypertension. The resident's medication orders specified that blood pressure should be checked and medications held if systolic blood pressure was less than 100. However, review of the medication administration record (MAR) and vital signs documentation showed that blood pressures were not recorded at multiple required times before medication administration. Interviews with nursing staff confirmed that blood pressures should have been checked and documented prior to giving antihypertensive medications, but no records could be found for the specified dates and times. The facility's failure to follow professional standards of medication administration, including proper documentation, preparation, and administration procedures, as well as failure to adhere to physician orders for monitoring blood pressure prior to antihypertensive medication administration, resulted in deficiencies. These actions did not meet the facility's own policies or regulatory requirements, as confirmed by staff interviews and record reviews.
Failure to Assist Resident with Activities as Outlined in Care Plan
Penalty
Summary
The facility failed to ensure that a resident with severe cognitive impairment received assistance with activities as outlined in their care plan. The resident's care plan specified that they should be assisted to activities, helped to sit at the nurse station, and provided with sensory items, as well as opportunities to watch TV and listen to music. Despite these directives, multiple observations over several days showed the resident repeatedly left alone in their room, often with the TV turned off, and not engaged in any activities. During times when group activities such as BINGO and painting were occurring in the dining room, the resident remained in their room and was not assisted to participate. Interviews and record reviews confirmed that the resident enjoyed being around people and exploring their environment, and that staff were aware of these preferences. However, the Activities Director acknowledged that the resident had not been taken to any activities or received room visits during the week in question, citing being too busy and organizational lapses. This lack of engagement and failure to follow the care plan resulted in the resident being isolated and not provided with meaningful activities as required by facility policy.
Failure to Maintain and Discontinue Midline IV as Ordered
Penalty
Summary
A deficiency occurred when a resident with a persistent vegetative state and ventilator dependence did not receive appropriate care for a midline IV catheter. The resident's midline IV, placed in the right arm, was observed with a discolored dressing, curled edges exposing the insertion site, and visible discoloration (purple and red) around the site. The dressing was dated nearly a month prior, and the catheter tubing and connector contained a brown substance. Staff interviews revealed that the dressing had not been changed as required, and there were no orders or documentation for IV flushes or dressing changes. The IV had not been flushed, and the dressing was not intact, contrary to facility policy and professional standards. Further review of the resident's records showed that there was a physician's order to discontinue the midline IV over two weeks prior to the observation, but the IV remained in place. Staff were unaware of when the dressing was last changed and confirmed that the IV should have been removed according to the order. The facility's policies required sterile dressings to be maintained and vascular access devices to be flushed routinely, but these were not followed. This deficiency was also noted as a repeat from a previous statement of deficiencies.
Failure to Provide Timely Social Services and Care Conference
Penalty
Summary
The facility failed to provide medically related social services to help a resident achieve the highest practicable physical, mental, and psychosocial well-being. A resident with aphasia, dysphagia, and a history of stroke was admitted and was cognitively intact but had unclear speech. Upon review, there was no documentation in the resident's chart regarding advance directives, nor evidence that the resident had been asked about them. The initial social work assessment was completed nine days after admission, and the care conference was not scheduled within the required 72 hours, but instead was set for 14 days after admission. Interviews with staff revealed that the social worker was on extended leave at the time of the resident's admission, and no effective plan was implemented to ensure continuous social service coverage. Other staff members, such as the business office manager, MDS nurse, and receptionist, attempted to cover social work duties, but there was no documentation of efforts to set up the care conference or follow up on advance directives. The resident reported not knowing their plan of care and not having had a care conference prior to the scheduled date.
Failure to Replace Full Sharps Containers in Multiple Facility Locations
Penalty
Summary
Surveyors observed that sharps containers in multiple locations, including a medication cart, a shower room, and a resident room at Station 2, were filled above the designated full line. Specific observations noted that insulin pens, lancets, and blue disposable razors were present above the full line in these containers. These conditions persisted over several days, as evidenced by repeated observations, with the contents remaining above the full line and, in one case, the container not being properly affixed to its stand. Interviews with staff revealed confusion regarding responsibility for replacing full sharps containers. A registered nurse was unsure who was responsible and initially believed it was the Infection Preventionist (IP) nurse, while the IP nurse stated that floor nurses were responsible for replacement. The Resident Care Manager and Director of Nursing Services both indicated that nurses were responsible for replacing full containers, with the IP nurse tasked with monitoring them. Despite these stated responsibilities, the containers remained overfilled during the survey period.
Failure to Complete PASRR Evaluations for Residents with Mental Disorders
Penalty
Summary
The facility failed to adhere to the Preadmission Screening and Resident Review (PASRR) process for three residents, which is a federal requirement to ensure individuals with mental disorders or intellectual disabilities receive appropriate care and services. Resident 15, who was readmitted with severe major depressive disorder, anxiety disorder, and panic disorder, had an updated Level I PASRR indicating a need for a Level II evaluation. However, no Level II evaluation was completed, and there was a lack of documented follow-up communication with the PASRR evaluator. Staff F, the Social Services Director, acknowledged the absence of documentation and stated that communication with the PASRR Coordinator had occurred but was not recorded. Resident 13, diagnosed with bipolar disorder, also required a Level II evaluation as indicated by a Level I PASRR. However, the clinical record lacked this evaluation and any follow-up documentation. Staff F believed a PASRR invalidation existed due to a past Level II evaluation but could not find it in the record. Similarly, Resident 5, with diagnoses including anxiety and depression, required a Level II evaluation as per their PASRR, but there was no documentation of validation or communication with the PASRR validator. Staff F confirmed that a new PASRR was submitted in June, but no further follow-up was conducted.
Deficiencies in ADL Assistance and Hygiene Care
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for five residents, leading to deficiencies in personal hygiene, grooming, and repositioning. Resident 3, who was comatose and dependent on staff for all care, was observed multiple times with unkempt hair and facial hair, indicating a lack of grooming. Despite the care plan directing staff to turn and reposition the resident every two hours, observations showed the resident remained on their back for extended periods, and family members reported insufficient attention from staff. Resident 15, who was cognitively intact and dependent on staff for personal hygiene, was observed repeatedly on their back, contrary to the care plan's directive for repositioning every two to three hours. The resident reported not being turned unless they specifically requested it, highlighting a failure in routine care. Similarly, Resident 122, who had a stage IV pressure ulcer and was dependent on staff for all care, was consistently observed on their back, despite care plan instructions for frequent repositioning. Residents 62 and 53 experienced deficiencies in oral care. Resident 62, who was cognitively intact and dependent on staff for ADLs, was observed with unclean teeth and reported not having their teeth brushed. No oral care supplies were found in their room. Resident 53 also reported not receiving assistance with oral care since admission, and no supplies were present in their room. Staff interviews confirmed that oral care was expected daily, yet it was not provided, indicating a systemic issue in meeting residents' hygiene needs.
Deficiencies in Medication Management and Lab Testing
Penalty
Summary
The facility failed to provide treatment and care according to professional standards for several residents, leading to potential adverse health events. Resident 60, who had a history of anemia and cardiac issues, was administered blood pressure medications despite a heart rate below the prescribed threshold. Additionally, there were lapses in laboratory testing and reporting, with missing results for critical tests that were supposed to be conducted, leading to a delay in identifying a gastrointestinal hemorrhage. Resident 15, admitted with hypotension, received Midodrine outside of the prescribed parameters, as the medication was administered even when the systolic blood pressure was above the threshold. This indicates a failure to adhere to medication administration guidelines, potentially compromising the resident's health. Resident 53, with chronic kidney disease and diabetes, missed an insulin dose while at dialysis, and there was no coordination with the dialysis center to ensure insulin administration. Furthermore, Resident 66, who experienced diarrhea after tube feedings, had a delayed referral to a gastrointestinal specialist, which was not scheduled until 47 days after the order was given. These deficiencies highlight significant lapses in medication management, lab testing, and specialist referrals.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a 15% error rate during medication administration by two licensed nurses. Specifically, Staff R, an RN, administered a liquid multivitamin to a resident through a gastrostomy tube instead of the prescribed tablet form, citing the unavailability of the tablet. Additionally, Staff R documented the administration of eye cleansing wipes, which were not used at the time, and left them in the resident's room for later use by a nursing assistant. This action was not in accordance with the resident's medication administration record, which specified a multivitamin in tablet form. Staff E, an LPN, dispensed medications to another resident, who stated they would take them later, and left the medications at the bedside. This was against the facility's policy, as confirmed by Staff C, the unit manager, and Staff B, the Director of Nursing Services, who stated that medications should not be left at the bedside unless the resident is on a self-medication program, which neither resident was. The facility's failure to adhere to proper medication administration protocols placed residents at risk for adverse events and decreased quality of care.
Medication Security and Administration Deficiencies
Penalty
Summary
The facility failed to ensure the security and proper administration of medications and biologicals on two units, leading to unauthorized access and potential medication errors. Observations revealed that Resident 54, who was not on a self-medication program, was found with pills on their pudding without a nurse present. Similarly, Resident 24 had OcuSoft eyelid cleansing pads left in their room by a nurse, and Resident 35 was observed with pills left on their bedside table. Resident 41 also had pills left unattended on their bedside table, despite not being on a self-medication program. None of these residents had assessments or care plans indicating they were capable of self-administering medications. Interviews with staff highlighted a lack of awareness and adherence to the facility's medication administration policies. Staff D, an LPN, was unaware of any self-medication programs on Unit 2 and speculated that nurses might have left medications for alert and oriented residents. Staff C, another LPN, confirmed that medications should not be left at the bedside, and the Director of Nursing Services (DNS) expressed concern over the recurring issue of medications being left unattended. Additionally, the facility's process for narcotic reconciliation was found to be disorganized and potentially inaccurate. During a shift change, Staff J and Staff S, both RNs, conducted a narcotic count using multiple books in a disorganized manner, leading to confusion and the potential for errors. The DNS acknowledged the issue, noting that the facility had switched pharmacies, resulting in some medications being recorded in old books, which contributed to the disorganized reconciliation process.
Failure to Report Alleged Abuse and Neglect
Penalty
Summary
The facility failed to immediately report potential abuse and/or neglect to the state agency for three residents, which placed them at risk for unidentified mistreatment. Resident 19, who had cognitive impairment, had concerns raised by their responsible party regarding hydration, oral care, and positioning. These concerns were dismissed by the facility's administrator, and no grievance or investigation was initiated. The facility's grievance logs and state incident reporting log showed no entries related to Resident 19's potential neglect. Resident 61, with a traumatic brain injury, experienced bruising on their arm due to a blood pressure cuff being left on too tight. Despite the visible injury and the family being informed, the facility did not log the incident in the state reporting log or conduct an investigation to rule out abuse or neglect. The Director of Nursing Services was aware of the discoloration but had not been informed of the incident involving the blood pressure cuff until later. Resident 62, diagnosed with anxiety disorder, depression, and spinal stenosis, reported being verbally abused by their roommate, including the use of racial slurs. Although the incident was reported to the mental health provider and discussed with the Director of Nursing Services, no formal investigation was conducted, and the allegation was not reported to the state agency. The facility's social services director was aware of the situation but did not report it, and the resident declined an offer to move rooms.
Incomplete Investigations of Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse and neglect for two residents, which placed them at risk for unidentified abuse or neglect. Resident 41, who had a history of stroke, diabetes, and cognitive impairment, reported being handled roughly by a staff member, causing arm pain. The facility suspended the alleged staff member and initiated an investigation, but there were inconsistencies in the documentation. Staff M, a registered nurse, claimed not to have provided physical care to Resident 41, yet documented applying antifungal cream on the day of the alleged abuse. Additionally, an earlier fall incident involving Resident 41 lacked witness or staff statements and did not confirm if care plan interventions were in place. Resident 62, diagnosed with anxiety disorder, depression, and spinal stenosis, reported being called derogatory names and racial slurs by their roommate. Despite these serious allegations, the facility did not conduct a formal investigation. The incident report noted that Resident 62 had a history of bipolar disorder and schizophrenia and was sometimes confused. Although Resident 62 was offered a room change, which they declined, there was no written or verbal statement from the roommate included in the investigation. The facility's policy on abuse prevention mandates that investigations be initiated within 24 hours of an allegation, including interviews and documentation. However, the investigations for both residents were incomplete, lacking necessary documentation and statements. This failure to adhere to policy and thoroughly investigate the allegations compromised the residents' safety and quality of life.
Deficiency in Respiratory Care for Resident
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident by not maintaining, changing, or dating oxygen tubing and nasal cannula as per professional standards. Resident 11, who was admitted with diagnoses including high blood pressure, chronic pain, and muscle weakness, had a physician's order for supplemental oxygen as needed to maintain oxygen saturation above 90%. However, there was no documentation or indication of when the oxygen equipment should be changed or replaced. Observations revealed that Resident 11 was using undated oxygen equipment, and the care plan lacked focus or interventions related to oxygen use. Interviews with staff revealed inconsistencies in the monitoring and maintenance of Resident 11's oxygen therapy. Staff O, an LPN, stated that checking oxygen saturation was not required during the day shift and deferred the responsibility of changing oxygen tubing to respiratory therapy. However, the respiratory therapist, CC 5, was unsure about the tracking of equipment changes. Additionally, the Director of Nursing Services confirmed that Resident 11 used oxygen as needed, but there was no clear process in place to ensure compliance with the physician's orders. This lack of coordination and documentation led to the deficiency in providing appropriate respiratory care.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications, specifically an antidepressant, as required. The resident, who was admitted with diagnoses including metabolic encephalopathy and dementia, was prescribed Sertraline HCl for dementia with behavioral disturbance. However, there was no documented diagnosis of depression in the resident's medical record. Additionally, the facility did not have any orders for monitoring depressive behaviors, symptom management, interventions to prevent, or adverse side effects related to the antidepressant medication. Interviews with facility staff revealed that the care plan and physician orders, which are supposed to guide resident care, did not include necessary information for monitoring the resident's use of the antidepressant. Staff members, including an LPN and the Director of Nursing Services, acknowledged the lack of documentation and monitoring for the resident's psychotropic medication. The deficiency was identified as a failure to ensure appropriate indication for the medication and to monitor and document behaviors and symptoms, placing the resident at risk for adverse side effects and unnecessary medication use.
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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.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Everett
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bethany At Silver Lake | 2.8 mi | ★★★★★ | 10 | 0 |
| Madison Post Acute | 3.9 mi | ★★★★★ | 1 | 0 |
| View Ridge Care Center | 4 mi | ★★★★★ | 16 | 0 |
| Alderwood Post Acute & Rehabilitation | 4.8 mi | ★★★★★ | 61 | 0 |
| Lynnwood Post Acute Rehabilitation Center | 5.2 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.