Above average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fircrest Nursing Facility during CMS and state inspections, most recent first.
A facility failed to provide written bed hold notices for three residents transferred to the hospital, and for one resident also failed to provide a written transfer/discharge notice and notify the Ombudsman. Records showed hospital transfers for changes in condition, but the EHR and hard chart lacked documentation that the residents or their representatives were notified of the bed hold policy or that the required transfer notice was completed.
MDS assessments were not accurately completed for multiple residents. One resident with a Stage 3 pressure ulcer had treatment documented in the record, but the MDS did not code ulcer/injury care. Another resident on clozapine had an inaccurate antipsychotic/GDR entry, while a resident observed wearing hand mittens had no restraint coding despite the mittens being used to prevent face scratching. A fourth resident’s MDS failed to code an active Alzheimer’s dx documented in the chart.
Food items in the kitchen walk-in refrigerator were observed uncovered and unlabeled, including prepared casserole, noodles, and multiple trays of broccoli, cauliflower, and cheese. In addition, two ACs assisted residents with meals and moved residents to the day room without performing hand hygiene before or after resident care, despite staff stating hand hygiene was expected before and after meal assistance and between resident care.
Hand hygiene and glove use were not followed for two staff members during laundry and suction equipment handling, with gloves removed and replaced without hand hygiene between dirty and clean tasks. Enhanced Barrier Precautions were also not followed for two staff members caring for residents with feeding tubes: one AC transferred a resident without a gown, and an LPN administered medication via feeding tube wearing gloves but not a gown. Staff interviews confirmed the expected use of hand hygiene, gloves, and gowns during these activities.
A resident admitted with insomnia was prescribed Trazodone, an antidepressant used as a psychotropic medication, and received it daily. Review of the clinical record showed no documentation that the resident or representative was informed of the risks and benefits before the first dose, and RNs stated informed consent was expected prior to use.
Failure to implement care plans for two residents was cited after staff did not follow a tube-feeding plan requiring HOB elevation to 30 degrees and did not document or carry out an indwelling urinary catheter care plan. Observations showed a resident receiving enteral feeds with the HOB below the ordered level, and records for another resident with a catheter and recent bladder infection showed no TAR or ADL documentation of catheter care. Staff stated they expected the care plans to be followed, but the required interventions were not reflected in the record.
Failure to change an AIRVO 2 chamber kit as ordered for a resident with tracheostomy status. Staff observed the chamber remained dated beyond the ordered 2-month change interval, and RN/LPN staff were unsure why the task was not completed or what the MAR notation meant, despite the resident using the AIRVO 2 nightly for humidification.
A resident with profound intellectual disabilities, severe cognitive impairment, self-injurious behavior, and pica was left unsupervised when the assigned CNA, responsible for 1:1 protective supervision, was found asleep while on duty. The lapse was discovered after the resident missed a meal, and staff confirmed that the CNA failed to follow the care plan and facility policy requiring constant, alert supervision.
A resident's baseline care plan was found to contain another individual's name and included care instructions for colostomy care that did not apply to the resident. Both the RN who created the care plan and the DON confirmed these inaccuracies during record review and interviews, acknowledging that the care plan did not accurately reflect the resident's clinical status.
A resident was observed with bruising and discoloration on their left foot, later confirmed as a fracture of the fifth metatarsal. Despite facility policy requiring immediate reporting of injuries of unknown origin, staff delayed notifying the State Agency until several days after the injury was first identified and confirmed, resulting in a failure to ensure timely reporting.
A resident with a known fall risk and behavioral concerns was left briefly unattended in a shower room by a CNA, contrary to their care plan requiring constant supervision. The resident, seated in a wheelchair on a sloped floor, fell when the staff member turned away to place lotion on the counter. Staff interviews confirmed the care plan was not followed and that the environmental hazard contributed to the incident.
The facility failed to inform the representatives of two residents with profound intellectual disabilities about their positive RSV test results and treatments. Despite the facility's policy, there was no documentation to show that the representatives were notified, leading to a lack of informed decision-making regarding the residents' medical conditions.
The facility failed to post nurse staffing information daily in prominent locations accessible to residents and visitors across five units. Observations revealed that the information was placed in file holders or on clipboards, making it difficult for residents and visitors to access. Staff responsible for completing the forms were unaware of the requirement to post the information prominently, and some shifts' information was left blank.
The facility failed to accurately assess six residents using the MDS tool, leading to potential risks for unmet care needs. A resident's MDS was completed while they were absent, another's MDS incorrectly coded aspirin as an anticoagulant, and a third resident's tracheostomy care was omitted. Additionally, two residents had MDS sections completed prematurely, and another's discharge was inaccurately recorded. These errors reflect a failure to follow RAI Manual guidelines.
The facility failed to develop and implement comprehensive care plans for several residents, including those with pressure ulcers, on antidepressant and antibiotic medications, and exhibiting care refusal behaviors. This oversight led to unmet care needs and potential risks to residents' quality of life.
The facility failed to dispose of expired medications and properly account for controlled substances. An LPN found an expired antacid in a medication cart, and a discrepancy was noted in the controlled substance inventory for lacosamide tablets, which were not recorded as administered to a resident. Staff acknowledged the need for timely disposal and accurate recording.
The facility failed to follow professional standards of food safety, with expired and unlabeled food items found in storage, and staff not adhering to hand hygiene protocols. Observations showed improper handling of kitchen equipment, with a meal tray placed on the floor and returned to clean storage without washing. These actions were against the facility's policies, posing risks of foodborne illnesses and cross-contamination.
The facility failed to ensure timely fit testing and correct usage of N95 masks for two staff members, and did not adhere to proper hand hygiene and glove use protocols among several staff. Additionally, medical equipment was not disinfected between uses, and sharp containers were improperly stored with medication supplies, increasing the risk of contamination.
A resident with moderately impaired cognition was assisted with their meal by staff standing over them, contrary to the care plan directive to sit at eye level. The staff acknowledged the training to assist while seated but cited broken highchairs as a reason for standing. The care plan was not updated to reflect the situation, and the importance of following the care plan was emphasized by nursing staff.
The facility failed to obtain informed consent for the use of physical restraints for two residents. One resident with impaired cognition used a wheelchair seatbelt without updated consent, while another with cerebral palsy used a tilt-in-space wheelchair with a seatbelt and shoulder harness without documented consent. Staff interviews revealed a lack of clarity and adherence to the facility's informed consent policy.
A facility failed to complete an annual MDS assessment for a resident within the required timeframe, as per the RAI 3.0 User's Manual. The assessment, due 14 days after the ARD, was completed six days late, placing the resident at risk for delayed care. Staff acknowledged the delay, and the facility's policy assigns responsibility for timely completion to the Health Care Coordinator.
A resident experienced significant weight loss and developed pressure ulcers, leading to a decline in condition and placement on comfort care. Despite these changes, the facility failed to complete a Significant Change in Status Assessment (SCSA) MDS, as required by the RAI manual. Interviews with staff revealed uncertainty about the necessity of the assessment, highlighting a deficiency in care planning and assessment processes.
The facility failed to consistently provide ROM therapy for two residents, risking a decline in their ROM and unmet care needs. One resident did not consistently receive a right-hand soft splint as prescribed, while another did not receive bilateral upper extremity passive ROM therapy as scheduled. Staff shortages contributed to these lapses in care.
The facility failed to properly store medical supplies used for medication administration in two medication rooms, leading to potential exposure to cleaning chemicals. In the Cherry and Hickory Buildings, supplies like tongue depressors and pill cups were stored under sinks with Lysol and Clorox products. Staff acknowledged the improper storage and the risk of exposing residents to toxic chemicals.
A facility failed to ensure proper G-tube management for a resident, as an LPN did not check the G-tube placement by aspiration before administering water flushes and medications. The resident, diagnosed with gastrostomy status, required this procedure to ensure safe medication administration. Despite facility policy and expectations from RNs, the LPN proceeded without verifying tube placement, leading to a deficiency.
The facility failed to properly label and store oxygen tubing for two residents, leading to potential risks for unmet care needs. A resident's nasal cannula tubing was found on the floor, while another resident's tubing was undated, contrary to facility policy. Staff acknowledged these oversights, indicating a lapse in adherence to oxygen administration guidelines.
A facility failed to maintain accurate clinical records for a resident, leading to a discrepancy between the POLST form indicating DNAR status and the EHR showing full code. Staff interviews revealed inconsistencies in documentation and communication regarding the resident's code status, which should have matched across records.
A resident with Diabetes Mellitus was not offered the pneumococcal vaccine upon admission, despite being eligible and having received the PPSV23 vaccine in the past. A registered nurse confirmed that the facility follows CDC guidelines but could not find documentation that the resident was offered the PCV15 or PCV20 vaccine, indicating a lapse in immunization protocol adherence.
A resident accused staff of inappropriate touching, but the incident was not reported to the State Agency until two days later, contrary to the facility's policy requiring immediate reporting. The delay in reporting was identified as a deficiency in the facility's handling of abuse allegations.
Missing Bed Hold and Transfer Notifications
Penalty
Summary
The facility failed to provide a written bed hold notice at the time of hospital transfer for Resident 1, Resident 2, and Resident 86. Review of the facility policy titled, Nursing Facility Bed Hold Policy, dated 04/11/2023, showed that in an emergency transfer to the hospital or hospital admission, the guardian was to be provided prompt notification of the policy and the Ombudsman was to be notified using the Notification of Transfer or Discharge Notice form for additional notification. The policy also stated that notices would be sent for all hospitalizations in excess of 24 hours. Resident 1 was transferred to the hospital for a change in condition, and the discharge MDS showed an unplanned discharge to a short-term general hospital, but the EHR had no documentation that a bed hold notice was provided to the resident or representative. Resident 2 was transferred to the emergency room for a change in condition, and the EHR did not show documentation of a bed hold notice, a written transfer/discharge notice, or notification to the Ombudsman; staff also stated they could not find the transfer/discharge notice form. Resident 86 was transferred to the hospital, and the EHR and hard chart showed no documentation that the guardian was notified of the facility's bed hold policy.
MDS Assessments Were Not Accurately Completed for Multiple Residents
Penalty
Summary
The facility failed to accurately complete MDS assessments for 4 of 18 residents reviewed, involving pressure ulcer coding, antipsychotic medication review, restraint coding, and diagnosis coding. The report states that the RAI 3.0 User’s Manual requires accurate assessment using multiple sources, including the resident, direct care staff, and the medical record, and that the facility policy required the RAI assessment to accurately reflect the resident’s status. For Resident 4, the quarterly MDS showed a Stage 3 pressure ulcer in Section M, but Section M1200 for skin and ulcer/injury treatments was not marked. Records showed a wound clinic note identifying a Stage 3 coccyx pressure ulcer and a nursing progress note documenting treatment applied to the coccyx. Staff interviewed stated they used the RAI manual, but were unsure whether pressure ulcer treatment should be coded, and the MDS was confirmed as not marked for pressure ulcer/injury care. For Resident 12, the quarterly MDS listed the last attempted GDR for clozapine as 07/20/2022 and indicated no physician-documented clinical contraindication, while the MRR and physician note showed the last GDR was on 09/17/2025 and that dose reduction was clinically contraindicated. For Resident 9, the quarterly MDS indicated physical restraints were not used, yet observations showed black hand mittens on both hands on multiple days, and the care plan directed mittens to be applied at all times to prevent face rubbing and scratching. For Resident 5, the quarterly MDS did not mark Alzheimer’s disease in Section I4200 even though the face sheet, active diagnosis list, and psychiatry consultation identified an active diagnosis of Alzheimer’s disease.
Uncovered Food in Walk-In Refrigerator and Missed Hand Hygiene During Meal Assistance
Penalty
Summary
The facility failed to ensure food was stored and handled in accordance with professional food safety standards in the Kitchen Main Preparation Walk-In Refrigerator. During a joint observation with the Food Service Manager, one uncovered and unlabeled tuna casserole in a metal pan, one uncovered and unlabeled pan of noodles with chopped onions, and three uncovered and unlabeled trays containing 40 individual pie pans filled with broccoli, cauliflower, and cheese were observed on an uncovered metal cart in the walk-in refrigerator. The Food Service Manager stated that the food items should have been covered and labeled with the food item and the date it was prepared. The facility also failed to ensure hand hygiene was performed when staff assisted residents with meals. Staff M assisted one resident with lunch, wiped food from the resident’s mouth with an orange washcloth, placed the resident’s plate and washcloth on the return counter, then assisted another resident with a meal using the same washcloth and moved that resident to the day room without performing hand hygiene before or after either resident interaction. Staff M stated that hand hygiene should have been performed before and after assisting the residents and when touching the residents and their wheelchairs. Staff N was observed assisting another resident with a meal, wiping the resident’s mouth multiple times with an orange washcloth, and then wiping the resident’s hands and wheeling the resident to the day room without performing hand hygiene after meal assistance and before touching the wheelchair. Staff N stated hand hygiene should have been performed before assisting the resident out of the dining room. Other staff interviewed, including the Attendant Counselor Manager and RNs, stated that hand hygiene was expected before and after meal assistance and between resident care.
Hand Hygiene, Glove Use, and EBP Not Followed
Penalty
Summary
The facility failed to ensure hand hygiene and proper glove use were followed for 2 staff members during laundry and resident care activities. One attendant counselor was observed wearing gloves while handling trash and laundry items, removing and replacing gloves without performing hand hygiene, and continuing tasks after disposing of trash outside the building. The same staff member was later observed handling trash, linens, and laundry carts, removing gloves and putting on new gloves without hand hygiene between tasks. In interview, the staff member stated hand hygiene should have been performed between glove use and after throwing trash in the dumpster, and an RN stated staff were expected to perform hand hygiene when hands were soiled and before and after resident care and glove use. An RN was also observed in a resident room wearing a gown, gloves, and face shield while handling a suction canister and tubing for a resident. The RN removed gloves and applied new gloves without hand hygiene, washed the suction equipment while wearing gloves, wiped it with a clean towel using the same gloves, then removed gloves and later returned with new gloves to place the equipment back on the resident’s table. The RN stated hand hygiene should have been performed between glove use and that dirty gloves should have been removed before drying the equipment with a clean towel. Another RN stated staff were expected to perform hand hygiene between glove use and between dirty and clean tasks. The facility also failed to ensure Enhanced Barrier Precautions were followed for 2 staff members during care of residents with feeding tubes. One attendant counselor transferred a resident with a feeding tube using a mechanical lift while not wearing a gown, although the other staff member assisting was wearing a gown and gloves. The attendant counselor stated a gown and gloves were required for the transfer. In a separate observation, an LPN administered medication via feeding tube to another resident while wearing gloves but not a gown. The LPN stated a gown should have been worn, and other staff interviewed stated gowns and gloves were expected for transfers and medication administration involving residents with feeding tubes.
Missing informed consent for psychotropic medication
Penalty
Summary
The facility failed to ensure informed consent explaining the risks and benefits of psychotropic medication was completed before administration of Trazodone for one resident. The resident was admitted with a diagnosis of insomnia, and physician orders showed Trazodone, an antidepressant, was prescribed on 07/03/2025 for insomnia. The October 2025 MAR showed the resident received Trazodone daily. Review of the resident’s clinical records, including the electronic health record and hard chart, showed no documentation that the resident and/or representative were informed of the risks and benefits of Trazodone use. During a joint record review, an RN stated that informed consent explaining the risks and benefits for psychotropic drug use was expected to be in the clinical record and should have been obtained before the resident received the first dose. Another RN stated that informed consent for any psychotropic medication, including Trazodone, was expected to be completed with the resident or representative prior to use.
Failure to Implement Tube Feeding and Catheter Care Plans
Penalty
Summary
The facility failed to implement the care plans for 2 residents reviewed for comprehensive care plans, involving tube feeding for one resident and an indwelling urinary catheter for another resident. The report states that the facility failed to implement a care plan for 2 of 18 residents, placing them at risk for unmet care needs and a diminished quality of life. The cited requirement referenced the facility’s Individual Plan of Care Process Requirements, which described care plan implementation as putting the course of action into motion by staff knowledgeable about the resident’s care goals and approaches. For the resident with tube feeding, the care plan reviewed on 10/04/2025 directed staff to always elevate the head of bed to 30 degrees when the resident was in bed, except during personal care and transfers, to prevent aspiration. Observations on 11/05/2025 and 11/06/2025 showed the resident lying in bed with the feeding pump running while the head of bed was at 11 degrees and then 21 degrees. During joint observation, an AC stated it was okay, while an LPN stated the head of bed should be at 30 degrees and adjusted it to 30 degrees. An RN later stated staff were expected to follow the care plan and that the head of bed had to be 30 degrees with feeds on. For the resident with an indwelling urinary catheter, the care plan last reviewed on 09/07/2025 instructed AC staff to perform peri care and catheter care every two hours and as needed. Observations on 11/03/2025, 11/04/2025, and 11/05/2025 confirmed the resident had an indwelling urinary catheter. The record showed the resident was diagnosed with a bladder infection on 10/20/2025 and was prescribed an antibiotic. The TAR for September, October, and November 2025 did not show catheter care implementation, and the November 2025 ADL verification sheet also did not document catheter care. Staff stated catheter care would be provided with incontinent care, but there was no area to document it, while an RN stated catheter care should be documented in the TAR and that the care plan should include step-by-step instructions.
Failure to Change AIRVO 2 Chamber as Ordered
Penalty
Summary
The facility failed to provide respiratory care in accordance with accepted professional standards of practice for Resident 83, who was admitted with tracheostomy status. The resident had an order on the Treatment Administration Record to change the AIRVO 2 chamber kit, tubing, and water chamber every 2 months on the night shift Sunday, with the order dated 05/07/2025. Observations on 10/30/2025, 10/31/2025, 11/03/2025, and 11/04/2025 showed an AIRVO 2 machine at the resident’s bedside, and the chamber was dated 07/21/2025. During interview and joint observation on 11/04/2025, Staff L stated the resident used the AIRVO 2 every night to humidify the tracheostomy and that the chamber was changed every two months on night shift, but Staff L was not sure why the chamber was still dated 07/21/2025. Review of the September 2025 MAR showed the AIRVO 2 chamber kit, tubing, and water chamber was scheduled to be changed on 09/21/2025, but it was marked with an equal sign indicating it was previously scheduled and not signed as completed. Staff D and Staff B stated they did not know what the equal sign meant, and Staff B stated staff should have changed the AIRVO 2 chamber as ordered.
Failure to Provide Required 1:1 Supervision for High-Risk Resident
Penalty
Summary
A deficiency occurred when a staff member assigned to provide 1:1 protective supervision for a resident with profound intellectual disabilities, severe cognitive impairment, self-injurious behavior, and pica was found asleep while on duty. The resident required total care with activities of daily living and had a care plan specifying the need for constant supervision in both the morning and evening. The facility's policy emphasized maintaining resident safety and well-being, and the care plan clearly outlined the need for vigilant monitoring due to the resident's high-risk behaviors. The incident was discovered when the resident was absent from the dining room during lunch, prompting a staff member to check on them. Upon entering the resident's room, the staff member found both the resident and the assigned CNA asleep, with the CNA failing to provide the required supervision. Interviews with facility staff, including the DON and a registered nurse, confirmed that staff assigned to 1:1 supervision are expected to remain alert and attentive at all times, and that sleeping while on duty constitutes a failure to follow the care plan and facility policy.
Inaccurate Baseline Care Plan Documentation
Penalty
Summary
The facility failed to ensure that the baseline care plan for one resident was accurate and reflected the resident's actual care needs. Upon review, the baseline care plan for a resident admitted for respite care contained another individual's name in the recreation (activity) care plan section. Additionally, the self-care deficit care plan included information about colostomy care, which was not applicable to the resident in question, as confirmed by the physician's progress note and staff interviews. During joint record reviews and interviews, both the registered nurse responsible for formulating the baseline care plan and the Director of Nursing acknowledged that the care plan contained inaccurate information, including references to another person and care needs not relevant to the resident. Both staff members confirmed that the care plan is part of the resident's medical record and must accurately reflect the resident's clinical status, which was not the case in this instance.
Delayed Reporting of Injury of Unknown Source
Penalty
Summary
The facility failed to ensure timely reporting of an injury of unknown source for one resident. Clinical notes indicated that the resident was first observed with discoloration and bruising on their left toe, which later was found to be a fracture of the fifth metatarsal bone in the left foot. The cause of the injury was unknown, and the facility's own investigation confirmed there was no probable cause for the injury. Despite policies requiring immediate reporting of such incidents, the injury was not reported to the State Agency until several days after initial observation and confirmation of the fracture. Staff interviews revealed that both nursing and administrative staff were aware of the requirement to report injuries of unknown origin immediately or within 24 hours. However, the report to the State Agency was delayed until staff connected the bruising and discoloration to the confirmed fracture. The delay in reporting was inconsistent with both facility policy and regulatory requirements, as staff did not act promptly upon first awareness of the injury.
Failure to Follow Fall Prevention Care Plan and Provide Adequate Supervision
Penalty
Summary
The facility failed to follow the established plan of care and provide adequate supervision for a resident identified as being at risk for falls and accident hazards. According to the resident's care plan, staff were required to always remain in front of the resident during showers and maintain line-of-sight supervision at all times, without leaving the resident unattended. On the day of the incident, a CNA briefly turned away from the resident in the shower room to place lotion on the counter, leaving the resident in their wheelchair on a sloped section of the floor. During this short interval, the resident, who was known to exhibit rocking and agitated behaviors, tipped over and fell to the floor. The investigation revealed that the wheelchair's placement on the curved, sloped floor contributed to the fall, and staff did not adhere to the care plan's supervision requirements. Further review showed that after the fall, the resident was found back in their wheelchair and appeared stable upon initial RN assessment. Interviews with staff confirmed that the expectation was for staff to remain with the resident at all times, especially for those on one-on-one supervision due to behavioral risks and mobility. The facility's fall protocol also required that a nurse assess any resident who had fallen before they were moved, which was not followed in this case. Staff and administrative interviews acknowledged that the care plan was not followed and that the environmental hazard of the sloped shower room floor was a contributing factor to the incident.
Failure to Inform Representatives of Positive RSV Tests and Treatments
Penalty
Summary
The facility failed to inform the representatives of two residents about their positive Respiratory Syncytial Virus (RSV) test results and the treatments provided. Resident 1, who has a profound intellectual disability, exhibited symptoms such as a dry cough, wheezing, and a mild runny nose. A nasal swab confirmed RSV, and the resident was treated with Guaifenesin and DuoNeb. However, Resident 1's representative was not informed about the change in condition, the positive test result, or the treatment administered. Staff C claimed to have notified the representative but could not provide documentation to support this claim. Similarly, Resident 2, also diagnosed with a profound intellectual disability, showed symptoms of a dry cough, tiredness, and lethargy. A nasal swab confirmed RSV, and the resident was treated with Guaifenesin. Resident 2's representative only became aware of the condition and treatment upon visiting the facility. Staff C again claimed to have notified the representative but lacked documentation to verify this. Staff D and Staff B confirmed that no notifications were made to the representatives of either resident, despite the facility's policy requiring such communication.
Failure to Post Nurse Staffing Information in Accessible Locations
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted daily at the beginning of each shift in prominent locations accessible to residents and visitors across five units: [NAME], Hickory, Elm, Cherry, and Birch. Observations on multiple dates revealed that the nurse staffing information was not displayed in a manner that was easily accessible or visible to residents and visitors. Instead, the information was placed on clipboards or in file folders within wall file holders, mixed with other files, making it difficult for residents and visitors to access. On the [NAME] Unit, observations showed that the nurse staffing information was not posted prominently and was placed on a clipboard within a wall file holder. Additionally, the staffing information for the evening shift on 10/30/2024 was not completed, leaving the form blank. Staff W, responsible for completing the form, confirmed that the information used to be posted on the wall but was now placed in the file holder. Similar issues were observed in the Hickory Unit, where the staffing information was consistently placed in a wall file holder, as confirmed by Staff S, the AC Manager. In the Elm Unit, the nurse staffing information was placed in a blue file folder within a wall file holder, and the information for the night shift on 11/04/2024 was not completed. Staff U, responsible for the form, was unaware that the posting was intended for residents and visitors. The Cherry Unit had similar issues, with the staffing information placed in a green file folder labeled as Census. Staff T confirmed this practice. In the Birch Unit, the staffing information was placed on a clipboard labeled as Census, and Staff V believed the information was for facility staff, not residents or visitors. Staff A, the Nursing Facility Program Area Team Director, stated that the expectation was for the information to be posted daily in a prominent area accessible to residents and visitors.
Inaccurate MDS Assessments in LTC Facility
Penalty
Summary
The facility failed to accurately assess six residents using the Minimum Data Set (MDS) assessment tool, leading to potential risks for unidentified and unmet care needs. Resident 348's annual MDS was completed inaccurately as the resident was not present in the facility during the observation period. Despite this, the MDS was submitted, which was acknowledged as incorrect by the staff involved. Similarly, Resident 82's MDS inaccurately coded aspirin as an anticoagulant, contrary to the guidelines in the RAI Manual, which specifies that aspirin should not be coded as such. Resident 45's quarterly MDS failed to include tracheostomy care and suctioning, despite records indicating that these procedures were performed. This oversight was identified during a joint record review, where staff confirmed that the care should have been coded. Additionally, Resident 35's annual MDS had sections completed before the start of the look-back period, which is against the RAI Manual's instructions. Staff acknowledged that these sections should not have been completed prematurely. Resident 97's discharge MDS was inaccurately marked as discharged to an acute hospital, while records showed the resident was discharged to their home. Lastly, Resident 12's annual MDS was completed before the observation period, with multiple sections signed off prematurely. Staff confirmed that the MDS should have been completed after the observation period, as per the RAI Manual. These inaccuracies in MDS assessments highlight a failure to adhere to the required guidelines, potentially impacting the quality of care provided to the residents.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for five residents, leading to unmet care needs and potential risks to their quality of life. Resident 44 had unhealed pressure ulcers, but no care plan was initiated for pressure ulcer care. Despite being aware of the condition, staff did not include it in the comprehensive care plan, relying instead on an alert care plan, which was deemed insufficient by other staff members. Resident 88 was prescribed antidepressant medication, yet there was no care plan for its use. Staff initially believed a separate care plan was unnecessary, but other staff members, including a psychologist, indicated that a care plan should have been in place. Similarly, Resident 45 was on multiple antibiotics, but there was no comprehensive care plan addressing the long-term use of these medications, which staff acknowledged should have been documented. Resident 24 exhibited behaviors and refusal of care, such as resisting shaving, but there was no care plan for these behaviors. Staff noted the difficulty in providing care and the lack of documentation for refusals. Lastly, Resident 77 was on antipsychotic medication and required regular assessments for side effects, but the assessments were not conducted within the required timeframe, indicating a failure to follow the care plan. Staff recognized the oversight and the need for timely assessments.
Medication Management Deficiencies
Penalty
Summary
The facility failed to ensure the timely disposal of expired medications and proper handling and accounting of controlled substances. During an observation and interview, a Licensed Practical Nurse (LPN) identified an expired bottle of over-the-counter liquid antacid with a manufacturer's expiration date of September 2024 in a medication cart. The LPN acknowledged the medication was expired and needed to be removed from the cart. A Registered Nurse (RN) later confirmed the expectation that expired medications should be disposed of promptly. Additionally, a discrepancy was found in the controlled substance inventory for lacosamide 200 mg tablets, a medication used to control seizures. The total count of tablets in a blister pack did not match the recorded count in the controlled substance inventory ledger for a resident. The LPNs involved stated that the 8:00 AM dose for the resident was not recorded in the ledger as expected. Another RN confirmed that the inventory ledger should accurately reflect the medications administered to residents and that nurses are expected to record medications immediately after they are given.
Deficiencies in Food Safety and Hygiene Practices
Penalty
Summary
The facility failed to adhere to professional standards of food safety, as evidenced by improper handling and storage of food items in two refrigerators and a dry storage room. Observations revealed expired food items, such as a chef salad and shredded cabbage, that were not discarded as per the facility's policy. Additionally, there were unlabeled food items, including roast beef and raisin bread, which should have been labeled with preparation and discard dates. Staff interviews confirmed that these practices were against the facility's policy, which mandates the removal of expired food and proper labeling. The report also highlighted deficiencies in hand hygiene practices among staff members. Staff NN was observed using the same gloves for multiple tasks without performing hand hygiene in between, despite being aware of the requirement to wash hands between glove use. Similarly, Staff OO failed to perform hand hygiene between tasks and glove changes while handling food items. These actions were contrary to the facility's policy, which requires hand hygiene between tasks and glove use to prevent cross-contamination. Furthermore, the handling of kitchen equipment was found to be inadequate. Staff PP placed a meal tray on the floor and then returned it to a stack of clean trays without washing it, which was against the facility's procedures. Staff interviews confirmed that any equipment that touched the floor should be considered dirty and placed in the dish room for cleaning. The facility's failure to follow its own policies and procedures in food handling, hand hygiene, and equipment sanitation placed residents at risk for foodborne illnesses and cross-contamination.
Infection Control Deficiencies in Mask Fit Testing, Hand Hygiene, and Equipment Disinfection
Penalty
Summary
The facility failed to ensure timely fit testing and correct usage of N95 masks for two staff members, Staff EE and Staff FF. Staff EE was observed wearing an N95 mask with a surgical mask underneath, which compromised the mask's seal, while working in a quarantine unit. Staff EE had previously failed a fit test for the N95 model they were using. Staff FF had not undergone fit testing in 2024, despite being required to do so annually. The facility's Safety Officer confirmed the oversight in fit testing and acknowledged that Staff EE should not have been using the 3M 1870+ mask. The facility also failed to adhere to proper hand hygiene and glove use protocols among several staff members. Staff Z, L, JJ, Q, and R were observed not performing hand hygiene between glove changes or after providing resident care. For instance, Staff Z did not perform hand hygiene between glove changes during a dressing change for a resident's pressure ulcer. Similarly, Staff L and Staff JJ failed to perform hand hygiene after removing gloves and before donning new ones, despite handling potentially contaminated materials. Additionally, the facility did not ensure the disinfection of medical equipment between uses. Staff II used an oximeter on a resident without disinfecting it afterward, and Staff U and Y did not disinfect a Hoyer lift between resident transfers. Furthermore, the storage of sharp containers in medication rooms was not managed according to infection control practices, with biohazardous materials stored alongside medication administration supplies, increasing the risk of contamination.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to maintain and promote the dignity of a resident during meal assistance. Resident 29, who had moderately impaired cognition, was observed being assisted with their meal by Staff O while standing over them, contrary to the care plan directive that staff should sit at the resident's eye level. Staff O acknowledged that they were trained to assist residents while seated but did not follow this protocol due to the resident dropping food. The care plan for Resident 29, printed on 11/04/2024, clearly instructed staff to sit down at the resident's eye level during meal assistance. Staff P, the Attendant Counselor Manager, initially stated that the care plan specified not to sit while assisting Resident 29 due to the high wheelchair, but later acknowledged that the care plan should be updated. Staff P also mentioned that highchairs were broken and unavailable, leading to staff assisting while standing. Staff B, a Registered Nurse, emphasized the importance of following the care plan and communicating any shortage of chairs. Staff A, the Nursing Facility Program Area Team Director, reiterated the expectation for staff to be seated at eye level with the resident during meal assistance.
Failure to Obtain Informed Consent for Restraints
Penalty
Summary
The facility failed to inform residents and/or their representatives of the risks and benefits before applying physical restraints, specifically for two residents. Resident 41, who had severely impaired cognition, was observed using a wheelchair seatbelt without updated informed consent. The consent on file was signed by the resident's representative over a year ago, and staff acknowledged that it should have been updated annually. This oversight meant that the resident's representative was not fully informed of the continued use of the restraint. Resident 12, diagnosed with athetoid cerebral palsy, used a tilt-in-space wheelchair with a seatbelt and shoulder harness for support. However, there was no documentation indicating that the resident or their representative had been informed or had consented to the use of these devices. Staff interviews revealed a lack of clarity regarding the need for consent for the tilt-in-space wheelchair, although it was acknowledged that consent was necessary for the seatbelt and shoulder harness. The facility's policy on informed consent requires that consent be obtained for treatments and services that involve restraints or support devices that limit voluntary or involuntary movement. Despite this policy, the facility did not ensure that informed consent was obtained and documented for the use of these devices, placing residents at risk of not being fully informed about their care options.
Failure to Timely Complete Annual MDS Assessment
Penalty
Summary
The facility failed to complete the annual Minimum Data Set (MDS) assessment for a resident within the required timeframe, as outlined in the Resident Assessment Instrument (RAI) 3.0 User's Manual. The manual specifies that the annual assessment must be completed no later than 14 days from the Assessment Reference Date (ARD). For Resident 24, the ARD was set on January 25, 2024, but the MDS was not completed until February 14, 2024, which was six days late. This delay in completing the assessment placed the resident at risk for delayed and/or unmet care needs, potentially affecting their quality of life. During interviews, staff members acknowledged the delay. Staff E, a Registered Nurse, confirmed that the MDS was completed late and should have been finalized within the 14-day period following the ARD. Staff B, another Registered Nurse, emphasized the importance of timely and accurate MDS completion. The facility's policy assigns the Health Care Coordinator the responsibility for ensuring the MDS is completed by the due date, but this was not adhered to in this instance.
Failure to Complete SCSA MDS for Resident with Multiple Declines
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) for a resident who experienced multiple areas of decline. According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, an SCSA is required when a resident undergoes a significant change in condition, impacting more than one area of their health status. The resident in question, identified as Resident 35, had a pressure ulcer/injury on their left shoulder and right scapula, and experienced unintentional significant weight loss of 6.8 pounds, which constituted a 6.1 percent loss of body weight in the last month. Additionally, the resident was placed on comfort-focused treatment due to a decline in condition, yet no SCSA MDS was completed to address these changes. Interviews with facility staff revealed a lack of clarity and understanding regarding the necessity of completing an SCSA MDS for Resident 35. Staff E, a Registered Nurse, acknowledged the resident's significant weight loss and placement on comfort care but was unsure if a significant change assessment was needed. Another staff member, RN 4, confirmed that an SCSA MDS should have been completed due to the resident's multiple areas of decline. The absence of this assessment placed the resident at risk for delayed care planning, unmet care needs, and a diminished quality of life.
Inconsistent ROM Therapy for Two Residents
Penalty
Summary
The facility failed to consistently provide services to maintain or improve the range of motion (ROM) for two residents, leading to a risk of decline in ROM and unmet care needs. Resident 12, who had limited ROM in both upper and lower extremities, was supposed to have a right-hand soft splint applied five times a week as part of their therapy program. However, documentation showed that the splint was not applied consistently throughout October 2024, with several days missed each week. Observations confirmed that Resident 12 was not wearing the splint on multiple occasions, and staff interviews revealed that the therapy team was short-staffed, leading to lapses in care. Similarly, Resident 81, who also had limited ROM, was on a therapy program for bilateral upper extremity passive ROM three times a week. Documentation indicated that the program was not provided consistently, with several days missed in the last two weeks of October 2024. Observations showed Resident 81 with arms crossed and hands in a fist, suggesting a lack of therapy intervention. Staff interviews confirmed that the therapy aide program was not carried out as expected, and there was a lack of coverage when therapy aides or therapists were unavailable.
Improper Storage of Medical Supplies with Chemicals
Penalty
Summary
The facility failed to ensure that medical supplies used for medication administration were stored properly in two of the three medication rooms reviewed, specifically in the Cherry and Hickory Buildings. During observations and interviews, it was found that in the Cherry Building medication room, an open box of tongue depressors and plastic pill cups were stored under the hand washing sink alongside a spray canister of Lysol and a portable heater. Staff L, an RN, acknowledged that these supplies should not have been stored with the Lysol spray and should have been kept in the nurse supply room instead. Similarly, in the Hickory Building medication room, an open box of plastic spoons and pill cups were found stored together with a Clorox spray bottle under the hand washing sink. Staff D, an LPN, confirmed that these supplies should be stored separately from chemicals in the medical supply room. Interviews with other staff members, including RNs, revealed a consensus that medication administration supplies should not be stored with cleaning chemicals due to the potential risk of exposing residents to toxic chemicals. Staff B, an RN, stated that these supplies should be stored in wall cabinets above the hand washing sink, not with chemical cleaning supplies.
Failure to Verify G-Tube Placement Before Medication Administration
Penalty
Summary
The facility failed to ensure appropriate treatment and services related to gastrostomy tube (G-tube) management for one resident. Specifically, the deficiency involved the failure to check for G-tube placement by visual inspection of aspirated stomach content prior to medication administration. This oversight was observed during an interaction where a Licensed Practical Nurse (LPN) dissolved crushed medications into a cup of water and proceeded to flush the resident's G-tube with water without first checking the tube's placement by aspiration. This action was contrary to the facility's policy, which mandates checking the enteral tube for correct placement by aspiration before administering water flushes and medications. The resident involved had a diagnosis of gastrostomy status, requiring nutrition and medication through a G-tube due to an inability to eat or swallow normally. The facility's policy, revised in March 2024, clearly outlines the procedure for checking G-tube placement, which was not followed in this instance. Interviews with registered nurses confirmed the expectation that nurses should aspirate to check for G-tube placement before administering water flushes and medications, highlighting a lapse in adherence to established protocols by the staff involved.
Failure to Properly Label and Store Oxygen Tubing
Penalty
Summary
The facility failed to ensure proper labeling and storage of oxygen tubing for two residents, leading to potential risks for unmet care needs. For Resident 4, the nasal cannula tubing was observed on the floor beside the oxygen concentrator, with the nasal prongs directly touching the floor. Staff members acknowledged that the tubing should not have been on the floor and should have been stored in a resealable plastic bag attached to the concentrator. It was also noted that once the tubing touched the floor, it should not be used again and should be replaced immediately. For Resident 80, the nasal cannula tubing was found to be undated during multiple observations, despite the facility's policy requiring weekly changes and dating of the tubing. Staff interviews confirmed that the tubing should have been dated, as per the facility's guidelines. The lack of proper labeling and storage of oxygen supplies for both residents indicates a failure to adhere to the facility's oxygen administration and safety guidelines, potentially compromising the residents' respiratory care.
Inconsistent Code Status Documentation for a Resident
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurate for a resident, identified as Resident 18, which placed the resident at risk for unmet care needs and medical complications. The deficiency was identified through observation, interview, and record review. The facility's policy on supporting end-of-life decisions required that all direct care staff be shown and trained to implement the Physician Orders for Life-Sustaining Treatment (POLST). However, discrepancies were found between Resident 18's POLST form, which indicated a Do Not Attempt Resuscitation (DNAR) status, and the Electronic Health Record (EHR), which showed the resident as full code. Interviews with various staff members, including an Attendant Counselor, a Licensed Practical Nurse (LPN), and a Registered Nurse (RN), revealed inconsistencies in the documentation of the resident's code status. Staff members were unable to find consistent information regarding the resident's code status in the 24-hour communication log, paper medication administration record, or the EHR. The RN confirmed that the POLST form and the EHR should match, but they did not. This inconsistency in documentation and communication among staff members led to the deficiency identified by the surveyors.
Failure to Offer Pneumococcal Vaccine to Resident with Diabetes
Penalty
Summary
The facility failed to ensure that the pneumococcal vaccine was offered to a resident, identified as Resident 80, who was reviewed for immunizations and infection control. Resident 80, who was admitted to the facility with a diagnosis of Diabetes Mellitus, had previously received the PPSV23 vaccine in 2001 and 2017. However, there was no documentation indicating that the resident was offered the newer PCV15 or PCV20 vaccines upon admission in July 2023, despite being eligible due to her age and medical condition. During an interview and joint record review, a registered nurse confirmed that the facility follows CDC recommendations for offering immunizations to residents. The nurse acknowledged that Resident 80, who was in her 40s and had Diabetes Mellitus, should have been offered the PCV15 or PCV20 vaccine at the time of admission. The absence of documentation showing that these vaccines were offered highlights a deficiency in the facility's adherence to immunization protocols, potentially placing residents at risk of acquiring or transmitting pneumococcal disease.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to ensure the timely reporting of an abuse allegation to the State Agency for a resident, which placed the resident at risk for potential unidentified and ongoing abuse. The facility's policy required immediate reporting of suspected abuse, with no delay between awareness of the incident and making the report. However, an incident involving a resident who accused staff of inappropriate touching occurred on 08/25/2024, but was not reported to the Department's 24-hour Hotline until 08/27/2024. This delay in reporting was contrary to the facility's policy and the expectations set by the Nursing Facility Director. The incident involved a resident who was admitted to the facility and later accused staff of inappropriate touching during care. The allegation was initially communicated via email by a Certified Nursing Assistant to facility staff, rather than being reported immediately to the State Agency. Interviews with facility staff, including Registered Nurses and the Nursing Facility Director, confirmed that the incident should have been reported immediately, as per the facility's policy and state law. The delay in reporting was identified as a deficiency in the facility's handling of abuse allegations.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 1,109 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Seattle
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Shoreline Health And Rehabilitation | 2.1 mi | ★★★★★ | 55 | 0 |
| Avamere Rehabilitation Of Shoreline | 2.2 mi | ★★★★★ | 12 | 0 |
| Bridges To Home | 2.3 mi | ★★★★★ | 9 | 0 |
| Bothell Health Care | 3 mi | ★★★★★ | 2 | 0 |
| Edmonds Post Acute | 3.4 mi | ★★★★★ | 60 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.