Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 Gig Harbor Health And Rehabilitation during CMS and state inspections, most recent first.
The facility failed to prevent physical abuse between cognitively impaired residents when, in one incident, a resident with dementia and agitation grabbed and pulled another resident’s arm after offering a marker, and in another incident, a resident with dementia hit another resident on the head in the dining area after the second resident self-propelled to the same table. Staff, including a CNA, an LPN, and a restorative aide, reported these events and described separating the residents and assessing for injury, but the incidents still resulted in residents being subjected to physical abuse despite an existing abuse policy intended to protect them.
The facility failed to accurately document two significant resident incidents in the medical record. In one case, a resident was struck in the head by another resident in the dining room, but no progress note entry was made for the resident who was hit. In another case, a cognitively intact resident choked during lunch, became unresponsive, and staff performed the Heimlich maneuver, initiated CPR, called 911, and the resident was transported to the hospital; however, the progress note omitted documentation of provider notification and the subsequent emergency interventions and transfer. These omissions did not meet accepted professional standards for medical record documentation.
A resident with multiple cardiac conditions, muscle weakness, unsteadiness, and a recent AICD placement reported that an RN told them to transfer and clean themself in the bathroom and stated they would have to do it themself or stay there forever. A CNA later found the resident in the bathroom, was told about the RN’s statements, and learned the resident had transferred and cleaned themself despite pain and left arm restrictions, but the CNA only informed the oncoming CNA and did not notify a supervisor because the resident asked them not to. Another CNA subsequently learned of the allegation and reported it to a nurse, but by then the facility’s policy and regulatory requirements for immediate reporting of abuse allegations to management and state authorities had already been violated.
A resident with dementia and moderate cognitive impairment, who ambulated independently on a locked unit, was taken by the hand into another resident’s room and had their breasts touched inappropriately by a severely cognitively impaired resident with dementia, aphasia, and a history of sexually inappropriate behaviors toward staff. Despite multiple documented incidents of this behavior, the facility did not timely add specific interventions to the behavior care plan, and when 1:1 supervision was later ordered, CNAs did not consistently maintain line-of-sight observation, allowing the resident to move out of visual range and into their room with the door closed. Staff interviews showed awareness of the sexually inappropriate behaviors but a lack of clear, pre-existing care plan guidance on how to manage them.
Staff failed to immediately report a witnessed incident of resident-to-resident sexual abuse involving two cognitively impaired residents, one with dementia and anxiety and the other with dementia, aphasia, and a cognitive communication deficit. A CNA discovered one resident in another’s room being touched on the breasts and notified an LPN, who documented an alert report but did not promptly notify the administrator, state agency, or police as required by facility policy and state guidelines. The incident was not reported to the state agency until the following day, well beyond the required two-hour reporting timeframe, despite staff interviews indicating they understood abuse should be reported immediately to supervisors and the DSHS hotline.
QAPI Program Failed to Sustain Compliance: The facility failed to maintain an effective QAPI program to correct repeated noncompliance and keep changes in place for ongoing compliance. The CASPER history showed recurring deficiencies across multiple areas, including resident rights, abuse/neglect investigation, assessments, PASARR, care planning, quality of care, nutrition/hydration, pharmacy, sanitation, QAPI, and infection prevention. The Administrator stated QAPI met quarterly, used corporate audit tools, and tracked problem areas until improvement was achieved, but also acknowledged the facility remained aware of several ongoing issues.
Failure to Obtain Informed Consent for Psychotropic Medications: The facility did not obtain proper informed consent for psychotropic meds for multiple residents. One resident with bipolar disorder, schizoaffective disorder, and anxiety had clonazepam orders with no consent on file; another resident with depression had an incomplete consent for bupropion; a third resident with bipolar disorder, borderline personality, anxiety, and PTSD had clonazepam ordered without consent; and a fourth resident with dementia and anxiety had a buspirone consent form that listed the wrong side effects and left the consent statement blank. The DON and RCM stated the records did not meet expectations.
Resident Council Grievances Not Addressed: The facility did not address resident council concerns about call light response times, staff entering rooms without knocking, and other resident care and dietary issues raised over multiple council meetings. The grievance log showed no matching grievances, and interviews with a resident, the Activities Director, and the Administrator confirmed that concerns discussed in council were not being followed up on timely.
The facility failed to accurately code MDS assessments for four residents. One resident had documented right ankle ROM impairment, but the MDS marked ROM limitation as No. Three residents had mental health diagnoses and level II PASRR information in the record, but their MDS assessments did not reflect PTSD or current PASRR status. The DON and MDS nurse acknowledged the coding inaccuracies.
A facility failed to initiate baseline care plans for two residents after admission. One resident with dysphagia, malnutrition, no teeth, and limited denture use reported not getting showers often enough and having itchy skin, while the care plan for denture/dental care and bathing was added later. Another resident admitted with pressure and non-pressure ulcers had a skin impairment care plan entered days after admission. Staff stated baseline care plans should be started on admission and include ADLs.
The facility failed to hold timely care conferences for 3 sampled residents. One resident with COPD, depression, and unsteadiness on feet could not recall the last care conference, another resident with Alzheimer’s disease, anxiety, bipolar disorder, and unsteadiness on feet had no recent conference in the record, and a third resident with a toe amputation, chronic heel/midfoot ulcer, and pressure ulcer had care conferences that did not align with the MDS schedule. The SSD said the conferences were late because of a staffing issue, and the ADM said the expectation was admission and quarterly care conferences.
The facility failed to keep hospice visit notes in the EHR for three residents receiving hospice services, and two residents’ care plans did not show an integrated hospice plan of care identifying who from hospice would visit or how hospice would assist. The facility also failed to follow the bowel protocol for a resident with a history of constipation, with no documented BM for several days and bowel medications given without the required supporting documentation.
Failure to follow fluid restriction orders for two residents with ESRD. One resident’s fluid intake was documented inconsistently in the MAR, and staff did not identify the resident as being on a restriction by the door symbol. For another resident, the ordered fluid restriction was not documented as a daily total in the MAR, a CNA poured drinks without checking diet slips, and multiple staff members stated they were unaware the resident was on a fluid restriction.
Unsafe Food Storage and Improper Microwave Reheating: The facility failed to keep resident refrigerator foods properly labeled and stored, with expired items, unlabeled food, mold growth, and food labeled for a discharged resident found in multiple unit refrigerators. The facility also failed to ensure microwave-reheated foods reached 165 F, as most temperatures on the log were below the required level. The DON and Administrator stated the findings did not meet expectations.
The facility failed to track and analyze infection control data for two months and did not include a resident’s UTI in the October infection log. A resident with an indwelling catheter and abdominal drain was observed with drainage bags on the floor and leaking onto the floor, while staff stated the bags should be secured to the bed and not left open or on the floor.
Failure to Offer and Document Flu and Pneumococcal Vaccinations: The facility did not document assessment, education, offer, or consent for influenza and pneumococcal vaccines for 3 sampled residents. One resident with adult failure to thrive had a consent form requesting due vaccines, but there was no record of vaccine assessment or administration. Another resident with stroke had vaccine information showing eligibility and no receipt of flu or pneumococcal vaccines, but no documentation of education or offer. A third resident with pneumonia, adult failure to thrive, and a history of falls had no documentation of assessment, education, or consent for pneumococcal vaccination.
Failure to Educate, Offer, and Document COVID-19 Vaccination: The facility failed to educate, offer, and document COVID-19 vaccination status for three sampled residents. One resident with adult failure to thrive had a consent form requesting due vaccines, but the EHR lacked documentation of assessment, education, or vaccine administration. Two other residents, including one with stroke and one with pneumonia, adult failure to thrive, and a hx of falls, were eligible for the COVID-19 vaccine, but records showed no documentation that they were educated, offered the vaccine, or consented.
Mechanical lifts used for resident transfers were found with missing safety clips on 2 of 2 lifts, including one lift used to transfer a resident from bed to wheelchair. The Maintenance Director said the clips had been replaced but later disappeared, and the DON stated the lifts should have had the clips and should have been taken out of service when the clips were missing.
Housekeeping services were not provided consistently in resident rooms on multiple halls. A resident reported the bathroom had not been cleaned in a week, with stained toilet surfaces observed, and another resident reported the bathroom had not been cleaned since Tuesday, with dried red matter observed on the floor. Resident council minutes also showed repeated complaints that rooms were not being cleaned often enough, while housekeeping staff and the supervisor stated the dept was short staffed and aides could only clean as many rooms as possible each day.
A resident with spondylolisthesis, AFib, bipolar disorder, and HF was found to have a wheelchair that was too small and constricting. Staff observed the resident leaning to one side and being squished in the chair, and the resident said the wheelchair caused pain and prevented participation in activities. The care plan called for assessing wheelchair size, but staff could not provide evidence of a therapy evaluation for the resident's wheelchair.
A resident with dementia, anxiety, and diabetes repeatedly requested ice water with meals and in the room, but staff did not consistently provide it. During dining room observation, the resident asked the RCM for ice water, yet only plain water was later given and the resident finished the meal without receiving the requested ice water. The resident’s care plan included honoring preferences as able within diet parameters, and the Administrator stated the resident should have been provided ice water when requested.
Failure to Review Advance Directive at Quarterly Care Conferences: A resident with ESRD, dementia, and palliative care needs was unable to make needs known, and the AD review field was left blank at two care conferences. The DSS and Administrator confirmed the resident did not receive the expected quarterly AD review.
A resident with dementia, mood disorder, BPH, incontinence, and hospice services had multiple falls and floor incidents that were not thoroughly investigated. Documentation was missing or incomplete for witness statements, hospice notification, provider/RP notification, progress notes, therapy screening, and timely care plan interventions, and staff stated several investigations did not meet expectations.
A resident with anxiety and depression was screened for PASRR and determined to need a level 2 review for mood disorders, but no level 2 PASRR was found in the EHR. The Social Services Director said the resident had transferred from another SNF and they were told the review had been sent, but later learned it had never been submitted, and staff acknowledged they should have followed up sooner.
Incomplete Comprehensive Care Plans: Two residents had incomplete care plans. One resident admitted with epilepsy had no care plan entry for that diagnosis, and another resident receiving antidepressant and antianxiety medications had an outdated antipsychotic-focused care plan and a delayed psychoactive care plan that did not include target behaviors or side effects for staff to monitor.
A resident with cerebral palsy, bipolar disorder, schizoaffective disorder, and GAD had a provider order for monthly orthostatic BP monitoring, but no readings were documented in the EHR. The RN/RCM and DON both confirmed the order existed and that the required monitoring was not documented, stating this did not meet expectations.
A resident with hemiplegia, anxiety, and cognitive deficit was taken to a doctor’s appointment without an escort. The driver dropped the resident off and left, the resident could not navigate the office, missed the appointment, had a BM in the wheelchair, and had to return to the facility alone. Staff including the RCM, ADON, and DON stated the resident should have had an escort because the resident was dependent on staff for toileting and transferring.
A resident with COPD, unsteadiness on feet, and depression experienced a decline in mobility and ADLs, progressing from needing partial/moderate assistance for transfers and substantial/maximal assistance for ambulation to dependent transfers and inability to attempt ambulation or toilet transfers. Records noted a right ankle-foot deformity/contracture, but the care plan had no interventions for the contracture, the MDS did not identify ROM limitation, and staff interviews showed therapy, nursing, and the provider had discussed the issue without clear follow-through until an orthopedic referral was requested later.
Failure to Assist Resident With Vision Services: A resident with hx including HTN, stroke, and anemia reported declining vision and blurry reading, and said they had asked to see an eye doctor but no one followed up after the assigned SW left the facility. Records showed the resident was noted as having adequate vision on the MDS, had no focused vision care plan, and had been identified for optometry support in prior notes. The SSD and Administrator stated the resident should have been placed on the optometrist list and seen sooner.
A resident with Alzheimer’s disease, bipolar disorder, anxiety, unsteadiness on feet, BPH, and hospice services had repeated falls, but the facility did not clearly determine the root cause of the initial fall and did not timely complete or initiate new fall interventions or therapy screening/referrals after subsequent falls. Staff noted delayed care plan updates, an incomplete fall investigation, and use of a prior intervention instead of a new one after later incidents.
A resident with cerebral palsy, bipolar disorder, schizoaffective disorder, and GAD had clonazepam ordered PRN, then scheduled, then PRN again. Psych follow-up notes documented recommendations to increase the dose and later change the medication from PRN to scheduled because the resident had difficulty remembering to request it, but staff confirmed the changes were not implemented in a timely manner due to a communication issue between the behavioral health provider and the facility.
Failure to provide medically related social services for a resident with bipolar disorder and depression after the resident stated they felt like dying. The chart showed the statement was documented, but there was no follow-up, no documented social services interview, and no coordination with nursing or the provider; staff stated the resident should have been placed on alert and assessed for level of distress.
Medication administration was not completed as ordered for two residents. One resident with dementia, gout, and diabetes had a lidocaine patch left on past the prescribed 12-hour period, and the MAR did not provide a place to document removal. Another resident with diabetes, heart failure, and depression received docusate from an LPN even though the MAR order did not include a dosage, and staff noted the order should have been clarified before administration.
The facility failed to consistently document and provide NPI before PRN pain meds for two residents. One resident with cerebral palsy, bipolar disorder, schizoaffective disorder, and GAD received PRN tramadol multiple times without NPI being used first, despite an order requiring it. Another resident with dementia, anxiety disorder, and diabetes received PRN acetaminophen, but the MAR showed "NA" instead of an NPI code and there was no progress note showing NPI were provided before the dose.
Medication storage and labeling were not maintained in 1 medication cart and 1 medication room. Surveyors found missing refrigerator temp logs in the med room, along with expired tablets and an opened insulin pen on a med cart without a date or name. The ADON and DON confirmed the temp documentation and medication dating expectations were not met.
Failure to provide dental services for a resident with missing upper teeth and a need for a denture. The resident, who had diagnoses including spondylolisthesis, AFib, bipolar disorder, and HF, was seen by a dental hygienist who recommended a dentist, but the EHR had no referral or follow-up documentation. The DON stated the process was to obtain an order and have social services arrange the appointment, and that the resident's dental services did not meet expectations.
The facility did not provide timely emergency care or complete required post-fall monitoring for three residents who experienced falls, including a resident on anticoagulants who suffered a head injury and was not promptly sent for medical evaluation, resulting in serious harm. Documentation of alert charting was also incomplete or missing for multiple falls, despite staff and policy expectations.
Two residents with cognitive impairment did not consistently receive the correct size of briefs due to supply shortages, resulting in discomfort and inadequate containment of urine. Staff confirmed that brief shortages led to the use of incorrect sizes or delays in obtaining supplies, and the administrator was unaware of the need for daily supply order approvals.
A resident with a positive TB screening and inconclusive chest x-rays was not managed according to infection control standards, as the care plan was not updated, the local health jurisdiction was not promptly notified, and appropriate precautions were not clearly implemented or documented. Staff were uncertain about the correct type of precautions, and there was no systematic monitoring or intervention for possible TB exposure among staff or other residents.
The facility did not provide enough nursing staff to meet residents' needs, leading to missed showers, delayed call light responses, and a high number of falls. A resident dependent on staff for transfers was left in bed for several days without basic hygiene care, while another went weeks without a shower or hair wash. Staff reported caring for up to 15 residents at a time and struggling to complete care tasks, especially on weekends.
A resident with moderate cognitive impairment received an antibiotic that was not ordered, after a nurse failed to enter a verbal order into the electronic system, did not administer the medication as prescribed, and used another resident's discontinued medication. Required documentation for a change in condition was also not completed, and the medication was not pulled from the automated dispensing system as expected.
A resident with severe cognitive impairment and a recent hip surgery experienced a fall that was not reported or investigated at the time of the incident. The responsible nurse failed to notify management or implement risk management procedures, and the event was only discovered after the resident developed acute hip pain, leading to a delayed investigation that identified a dislocated hip arthroplasty.
A resident with anemia, who was cognitively intact, was physically harmed when a CNA abruptly pushed their wheelchair, causing knee injury and pain. The CNA, already suspended due to multiple abuse allegations, acted after expressing frustration at the resident's pace. The incident was reported about a week later, and the facility's investigation confirmed the CNA's involvement.
A resident with chronic pain was left without a fentanyl patch for 59 hours due to the facility's failure to ensure medication availability and obtain an alternative prescription. Despite severe pain reports, staff did not utilize available resources or contact the provider for a substitute, leading to significant discomfort for the resident.
Two residents experienced falls due to inadequate supervision and failure to follow care plans requiring two-person assistance during bed mobility. One resident sustained injuries requiring hospital evaluation, while the other had an assisted fall with no injuries. The root cause was identified as staff not adhering to the care plans.
The facility failed to implement effective infection control measures, leading to a widespread outbreak of respiratory illness among residents. Despite recommendations, the medical director did not fully follow CDC guidelines, resulting in delayed testing and treatment. Staff frequently neglected PPE protocols, and shared equipment was not sanitized properly, further contributing to the spread of infection.
The facility's QAPI program failed to self-identify and sustain corrections for deficiencies, leading to repeated and widespread issues. The DNS and Administrator acknowledged the need for improvement in the QAPI process. Deficiencies included infection control, residents' rights, and care planning.
Two residents in an LTC facility experienced unaddressed grievances, one involving a disruptive roommate and the other missing personal property. Despite expressing concerns to staff, no grievance forms were filed, and the facility's grievance logs showed no records of these issues.
The facility failed to provide written notification of transfer reasons to two residents hospitalized, as required by regulations. One resident with a history of stroke and atrial fibrillation was transferred without written notice, and another with a below-knee amputation and diabetes was also sent to the hospital without written notification. Staff confirmed that while verbal notifications were made, written documentation was not provided.
The facility failed to properly screen residents with mental health disorders for additional supports using the PASRR process. Four residents with diagnoses such as depression, anxiety disorder, and bipolar disorder were not referred for necessary PASRR level two evaluations, despite indications. Interviews with staff confirmed these oversights did not meet expectations.
Failure to Prevent Resident-to-Resident Physical Abuse Among Cognitively Impaired Residents
Penalty
Summary
The facility failed to protect residents’ right to be free from physical abuse when it did not prevent or adequately manage resident-to-resident altercations involving cognitively impaired residents. One incident involved a resident with severe cognitive impairment and dementia who was offered a marker by another severely cognitively impaired resident with dementia and agitation. When the first resident attempted to take the marker, the second resident grabbed the first resident’s arm and pulled on it. Staff later reported that the second resident had been self-propelling in a wheelchair in the hallway and, as they passed the first resident, they grabbed the resident’s arm. These events occurred despite the facility’s abuse policy, dated 10/20/2022, which recognized each resident’s right to be free from abuse. In a separate incident, another severely cognitively impaired resident with dementia was observed being hit in the head by a different severely cognitively impaired resident with dementia. A restorative aide reported that the resident who was struck had self-propelled to the table where the other resident was sitting, and the seated resident then hit the approaching resident on the head. The LPN on duty stated that the incident was reported to them after the residents were returned to the unit during mealtime, and they assessed the resident who had been hit after the residents were separated. These incidents demonstrate that residents experienced physical contact amounting to abuse from other residents, contrary to the facility’s stated policy and regulatory requirements to prevent abuse.
Failure to Accurately Document Resident Incidents and Emergency Response
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly and accurately document resident incidents in accordance with accepted professional standards. For one resident involved in a resident-to-resident altercation, progress notes for the resident who was struck in the head did not contain any documentation of the incident, despite interviews confirming that the resident was hit by another resident in the dining room. Staff, including the Administrator and the RN/Director of Nursing Services, acknowledged that documentation for this resident should have been completed in the progress notes regarding the altercation. For another resident, who was cognitively intact per the annual MDS, the facility’s progress note documented that the resident began choking during lunch, that the CNA called the LPN, that the resident was pulled forward in bed, that another nurse performed the Heimlich maneuver twice, and that the resident reported something had moved down their throat before becoming unresponsive. However, the progress note did not include documentation of provider notification or what occurred after the resident became unresponsive. Interviews with involved staff revealed that additional actions were taken, including contacting another nurse for assistance, obtaining the crash cart, applying oxygen, calling the family, initiating CPR, calling 911, and the resident’s transfer to the hospital, none of which were reflected in the written progress note. The Administrator and RN/DNS stated that the progress note should have included information about provider notification, initiation of CPR, and transfer to the hospital.
Failure to Timely Report Resident’s Abuse Allegation Involving Required Assistance With Toileting
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of verbal and potential physical abuse involving one resident. The facility’s abuse policy, revised 10/20/2022, required all alleged violations involving abuse to be reported immediately, but not later than two hours after the allegation was made, to the administrator or designee and to state officials, including the state survey agency and adult protective services. The Nursing Home Guidelines (Purple Book) also required staff-to-resident allegations to be reported to the DSHS Hotline, logged within five days, and reported to police or 911. Resident 1, who had diagnoses including myocardial infarction, sepsis, unsteadiness on feet, muscle weakness, cardiomyopathy, and a recently placed AICD with instructions not to use the left arm, was moderately cognitively impaired per the 5-day MDS. On 03/07/2026, a facility incident investigation documented that an RN (Staff F) assisted the resident to the bathroom and told the resident they needed to transfer themself to and from the toilet, and when the resident asked if Staff F would return to help them off the toilet, Staff F stated the resident would have to transfer themself or stay there forever. Later that evening, a CNA (Staff E) answered the resident’s call light and found the resident in the bathroom; the resident reported they had already transferred and cleaned themself because Staff F had told them to do it themself or stay there forever. Staff E reported this concern only to the oncoming CNA at shift change and did not notify a supervisor, stating they did not report the allegation because the resident asked them not to. The next day, another CNA (Staff G) documented that the resident reported significant left arm pain and disclosed the prior day’s allegation, which Staff G then reported to their supervisor. Interviews confirmed that Staff E had recently received abuse training, including instruction to report all allegations of abuse and to report them within two hours to the abuse coordinator and/or supervisor, and that abuse should be reported even if a resident requests that it not be. The facility failed to follow its own policy and regulatory requirements for immediate reporting of an abuse allegation when Staff E did not escalate the resident’s report beyond informing the oncoming CNA.
Failure to Prevent Sexual Abuse and Timely Address Escalating Sexually Inappropriate Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident from sexual abuse and to timely implement appropriate interventions for a resident with escalating sexually inappropriate behaviors. Facility policy on abuse required immediate assessment and protection of residents following any allegation or observation of abuse, as well as prompt revision of the care plan with interventions to minimize recurrence. Despite this, the facility did not act in accordance with its policy when confronted with repeated sexually inappropriate behaviors by one resident toward staff, which preceded an incident of sexual contact with another resident. Resident 1 was admitted with dementia and anxiety disorder, was moderately cognitively impaired per the MDS, and resided on a locked unit due to wandering and exit seeking. Resident 1 was able to ambulate independently without assistive devices. On the date of the incident, Resident 1 was found in another resident’s room and reported that the other resident had taken them by the hand into the room and touched their breasts inappropriately. Resident 1 later stated they did not want to be touched and could not understand why the other resident had touched them. Staff interviews confirmed that Resident 1 had been led into the other resident’s room and touched on the breasts. Resident 2, who had dementia, aphasia, and a cognitive communication deficit and was severely cognitively impaired per the MDS, had documented sexually inappropriate behaviors toward staff on multiple days, including touching a CNA inappropriately, motioning a CNA to get into bed, rubbing a social worker’s arm and directing them toward the bed, and exposing their genitals to a CNA. Despite these documented behaviors, Resident 2’s behavior care plan did not include interventions for sexually inappropriate behaviors until after the incident involving Resident 1. One-to-one supervision was initiated the following day, and observations showed that even after this was ordered, staff did not consistently maintain line-of-sight supervision, allowing Resident 2 to move out of visual range and into their room with the door closed. Staff interviews indicated that some staff were aware of Resident 2’s sexually inappropriate behaviors but did not have clear guidance or care plan interventions to manage these behaviors prior to the substantiated incident of sexual abuse involving Resident 1.
Failure to Timely Report Witnessed Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to immediately report a witnessed incident of sexual abuse between residents to the state agency and other required authorities. Facility policy on abuse required that all alleged violations involving abuse be reported immediately, but no later than two hours after the allegation was made, to the administrator or designee and to officials including the state survey agency and adult protective services. The Nursing Home Guidelines (Purple Book) further specified that resident-to-resident sexual abuse/assault incidents must be reported to the DSHS hotline, logged within five days, and that police or 911 be called. Resident 1, who had dementia and anxiety disorder and was assessed as moderately cognitively impaired, was admitted on a specified date. Resident 2, who had dementia, aphasia, and a cognitive communication deficit and was assessed as severely cognitively impaired, was also admitted on a specified date. On 02/02/2026 at 11:45 AM, an incident report documented that Resident 1 was touched inappropriately by Resident 2. A progress note at 12:45 PM the same day showed that a CNA found Resident 1 in Resident 2’s room being touched on the breasts by Resident 2 and notified the nurse, who then wrote an alert report to inform managers of the incident. However, the state agency report showed the incident was not reported until 02/03/2026 at 10:42 AM, outside the required two-hour timeframe. Incident investigation documentation showed the nurse did not immediately report the inappropriate touching to the administrator, state agency, or police, despite being a mandated reporter. During interviews, multiple CNAs, LPNs, and an RN described that abuse should be reported promptly to supervisors and the DSHS hotline, and the Administrator and DNS later stated they only became aware of the incident the following morning while reviewing progress notes and that the incident should have been reported immediately to leadership, DSHS, and the police within two hours.
QAPI Program Failed to Sustain Compliance
Penalty
Summary
The facility failed to maintain an effective QAPI program to correct identified noncompliance and ensure changes were maintained for ongoing compliance. Review of the CASPER Provider History Profile dated 11/25/2025 showed repeated noncompliance on prior LTC surveys and complaint investigations that continued on the current 12/02/2025 survey, including F552 Right to be Informed/Make Treatment Decisions, F610 Investigate/Prevent/Correct Alleged Violation, F641 Accuracy of Assessments, F645 PASARR Screening for MD & ID, F656 Develop/Implement Comprehensive Care Plan, F657 Care Plan Timing and Revision, F684 Quality of Care, F685 Treatment/Devices to Maintain Hearing/Vision, F688 Increase/Prevent Decrease in ROM/Mobility, F692 Nutrition/Hydration Status Maintenance, F745 Provision of Medically Related Social Service, F757 Drug Regimen is Free from Unnecessary Drugs, F761 Label/Store Drugs and Biologicals, F812 Food Procurement, Store/Prepare/Serve-Sanitary, F865 QAPI Program/Plan, Disclosure/Good Faith Attempt, and F880 Infection Prevention & Control. During interview, the Administrator stated the QAPI program met quarterly and used an agenda to review issues. The Administrator stated the facility used corporate audit tools to identify problem areas and that QAPI would use the data to develop protocols to track and trend those areas until improvement was achieved. The Administrator also stated that once compliance was achieved, it was expected to become part of the standard, and acknowledged the facility was aware of the issues identified at F552, F610, F685, F692, F757, and F880 and was continuing to develop methods to ensure compliance.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for psychotropic medications for 4 of 5 sampled residents reviewed for unnecessary medications. Resident 5, who was admitted with cerebral palsy, bipolar disorder, schizoaffective disorder, and generalized anxiety disorder and was able to make needs known, had orders for clonazepam dated 11/07/2025 and 11/28/2025, but the EHR showed no consent was obtained for its use. During interviews, the RN/Resident Care Manager and the DNS stated that risks and benefits should be explained and resident consent obtained for psychotropic medications, and both stated Resident 5 did not provide consent and that this did not meet expectations. Resident 3, who was admitted with sleep disorder, depression, atrial fibrillation, and chronic kidney disease and was able to communicate needs, had an order for bupropion HCI ER dated 11/01/2025, but the EHR showed an incomplete informed consent form. Resident 7, admitted with bipolar disorder, borderline personality, anxiety, and PTSD and able to communicate needs, had a clonazepam order dated 08/14/2025 but no informed consent in the record. Resident 78, who was readmitted and able to make needs known, had diagnoses including dementia, anxiety disorder, and diabetes; the MAR showed buspirone was administered, but the informed consent form listed buspirone while checking anti-psychotic side effects instead of anti-anxiety side effects, and the consent statement was left blank. The DNS and RCM stated these records did not meet expectations.
Resident Council Grievances Not Addressed
Penalty
Summary
The facility failed to address grievances brought by the resident council related to resident care, staff concerns, and dietary issues during resident council meetings reviewed for July, August, September, October, and November 2025. The resident council minutes and notes showed repeated concerns about call light wait times, staff not knocking before entering resident rooms, staff entering rooms without knocking, and call lights not being answered timely on night shift. In September and October 2025, residents also reported that when staff answered call lights, they said they would return but did not come back, and the concerns were documented as ongoing with no improvement. Review of the grievance log from 06/2025 through 11/2025 showed no grievances that matched the concerns voiced at resident council meetings. During interview, a resident stated that management did not follow up with grievances discussed in resident council meetings. The Activities Director stated that resident concerns were supposed to be documented on a grievance form and given to department managers, who had until the next resident council meeting to respond, but kitchen and nursing staff did not regularly return documentation related to the conclusion of the grievance. The Administrator stated they were unaware that resident council grievances were not being appropriately addressed and that it did not meet their expectation that specific concerns raised in resident council had not been followed up on timely.
Inaccurate MDS Coding for ROM and PASRR Status
Penalty
Summary
The facility failed to ensure minimum data set (MDS) assessments accurately reflected resident status for 4 of 22 sampled residents. For Resident 45, the electronic health record showed diagnoses including COPD, unsteadiness on feet, and major depressive disorder, and a progress note documented a deformity/contracture of the right ankle-foot; however, the quarterly MDS marked functional limitation in range of motion as No. Staff J, Director of Rehabilitation, stated Resident 45 had limited range of motion in the right ankle, and a PT evaluation later documented impaired right lower extremity range of motion. Staff L, the MDS nurse, stated the coding was believed to be accurate, while the Administrator stated the expectation was that residents be assessed according to the RAI manual and coded accurately. For Resident 7, the record showed diagnoses including bipolar disorder, borderline personality, anxiety, and PTSD, and the resident had an initial psychiatric evaluation summary identifying a level two PASRR with requirements and recommendations for care and treatment; however, the annual MDS did not mark PTSD or level 2 PASRR. For Residents 5 and 83, both had diagnoses including serious mental health conditions, and each had a level II PASRR completed in the record, but their annual MDS assessments marked A1500 as No for current level II PASRR status. Staff L stated the A1500 coding for Residents 5 and 83 was inaccurate, and the DON stated the expectation was for the MDS to be accurate.
Delayed Baseline Care Plans for Resident Needs
Penalty
Summary
The facility failed to initiate a baseline care plan for 2 of 19 sampled residents, Resident 8 and Resident 6, when reviewed for baseline care plans. Resident 8 was admitted with diagnoses of dysphagia and malnutrition and was able to make needs known. On observation and interview, Resident 8 was lying in bed, had no teeth, stated they had dentures but did not wear them often, and said staff did not assist with putting them in regularly. Resident 8 also stated they did not get showers often enough and had itchy skin because of it. The record showed a dietitian note documenting that the resident reported not always putting dentures in for meals and was agreeable to nursing assistance with denture placement before meals. The care plan included a denture/dental care entry dated months after admission and a showers/bathing care plan initiated three months after admission. Resident 6 was admitted with diagnoses of pressure ulcer and non-pressure ulcer and was able to make needs known. During interview, Resident 6 stated they had a pressure injury on their heel and bottom, that the heel wound had resolved, and that it came back when they started walking on it. The care plan showed a skin impairment entry with interventions dated eight days after admission. Staff stated that all ADLs should be initiated on admission in the baseline care plan, and the DNS stated the baseline care plan should be initiated on admission and include all ADLs. Staff also stated Resident 8 and Resident 6's baseline care plans did not meet expectations.
Late Care Conferences for Multiple Residents
Penalty
Summary
The facility failed to conduct timely care conferences with the resident or responsible party for 3 of 22 sampled residents, including Residents 45, 11, and 6. Resident 45 was admitted with chronic obstructive pulmonary disease, unsteadiness on feet, and major depressive disorder, and was able to make needs known. Resident 45 stated during interview that they could not recall when they last attended a care conference, and the record showed care conferences were conducted on 03/26/2025 and 09/19/2025. Resident 11 was readmitted with diagnoses including unsteadiness on feet, Alzheimer's disease, anxiety disorder, and bipolar disorder, and the most recent care conference in the record was 03/10/2025. Resident 6 was admitted with amputation of the right toe, chronic ulcer of the heel and midfoot, and pressure ulcer of the lower back, and was able to make needs known. The record showed care conferences on 04/03/2025 and 09/29/2025, while MDS assessments occurred on 03/29/2025, 06/26/2025, 09/25/2025, and 11/15/2025. Staff F, SSD, stated care conferences were offered on admission and quarterly, but were late due to a staffing issue and did not meet expectations. Staff A, ADM, stated the expectation was for residents to be offered care conferences on admission and then quarterly, and stated the lack of a care conference for Resident 6 between 04/03/2025 and 09/29/2025 did not meet expectations.
Missing Hospice Documentation, Incomplete Hospice Care Planning, and Bowel Protocol Failure
Penalty
Summary
The facility failed to provide hospice visit notes in the electronic health record for Residents 96, 24, and 11. Resident 96 had diagnoses including kidney failure, depression, and dementia and had an order for do not resuscitate/comfort measure/hospice, but recent hospice visit notes from January through May 2025 were not available in the EHR. Resident 24 had diagnoses including dementia, high blood pressure, and diabetes and was admitted to hospice for advanced dementia, yet no hospice services visit notes were documented in the EHR. Resident 11 had diagnoses including unsteadiness on feet, Alzheimer’s disease, anxiety disorder, and bipolar disorder, received hospice care services, and was observed receiving care from a hospice aide, but no hospice visit notes were found in the EHR. The facility also failed to develop integrated comprehensive care plans involving hospice services for Residents 24 and 11. Both residents had focused hospice care plans that identified hospice admission for terminal progressive disease, but the plans did not document who from hospice would be visiting or how hospice would be helping with each resident’s plan of care. Staff interviews confirmed that hospice was only mentioned in focused care plans and that the documentation did not reflect an integrated care plan with hospice services. For Resident 14, the facility failed to follow the bowel management protocol. Resident 14 had diagnoses including hemiplegia, diabetes, and kidney failure, reported problems with bowel movements, and had no documented bowel movements for five days. The resident received loperamide on two dates without documentation of loose stools, and later received MiraLAX and a bisacodyl suppository after the period without bowel movements. The resident’s plan of care identified a history of constipation and directed staff to follow the bowel protocol, and the facility policy required specific actions for diarrhea and constipation.
Failure to Follow Fluid Restriction Orders
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for 2 of 2 sampled residents when reviewed for fluid restrictions. One resident with end stage renal disease, renal dialysis, anxiety, depression, and hypertension stated they were allowed 1200 ml of fluids per day, but the MAR showed documentation of 240 ml for daytime and 240 ml for nighttime for the first four days of December 2025, with similar documentation in November 2025. During interview, a CNA stated residents on fluid restrictions were identified by a symbol on the door, but the resident did not have a symbol on the door. The DON stated staff were expected to follow orders and document correctly in the MARs, and that the resident’s fluid restriction documentation did not meet expectations. Another resident with diabetes and end stage renal disease had a provider order for an 1800 ml fluid restriction, with 720 ml from dietary and 1080 ml from nursing. The MAR showed an average of 794 ml daily in November 2025, but the daily total was not documented in the MAR. During observation, a CNA poured liquids onto trays without looking at diet slips and stated they were not aware of any residents on fluid restriction. The resident stated they were not on a fluid restriction because they got constipated, and a full glass of clear liquids was observed on the bedside table. Staff interviews showed inconsistent understanding of the restriction process, with one LPN stating CNAs recorded amounts each meal and nurses totaled them at the end of the shift, while other CNAs stated they were not aware of any residents on fluid restriction. The RCM and DON stated staff were expected to review meal tickets, know who was on fluid restriction, and document totals at the end of shifts and daily.
Unsafe Food Storage and Improper Microwave Reheating
Penalty
Summary
The facility failed to maintain safe food storage in 3 of 3 resident refrigerators and failed to ensure safe food reheating for 1 of 2 reheating microwaves. Observations in the Serenity Unit Refrigerator showed a gallon jug of milk with a best by date of 11/27, a plastic container with an unidentifiable yellow food item with white growth on top, and a pitcher of facility-made juice without a date label. The 300 Hall Refrigerator contained an unopened bottle of brewed tea labeled as placed in the refrigerator on 11/15 with a use by date of 11/04/2025. The 100 Hall Refrigerator contained a jar of salsa with a worn-off use by date and labeled with a resident's name, even though the resident had been discharged from the facility on 10/21/2025. The same refrigerator area also had a piece of cheesecake labeled as placed in the refrigerator on 11/29/2025. A later observation of the Serenity Unit Refrigerator found a bowl of clam chowder dated as placed in the refrigerator on 12/03/2025. Review of the facility's Microwave Reheating policy dated 10/01/2021 stated that after reheating foods in the microwave, standing time should be allowed and then a clean food thermometer should be used to check that the food reached 165 F. Observation of the 100 Hall resident refrigerator area showed a microwave and a temperature log for December 2025 used to record reheated food temperatures. Review of the log showed six of seven temperatures were more than 15 degrees below 165 F. The Dietary Manager stated food in resident refrigerators should be labeled with the date placed into the refrigerator and thrown away after three days, and stated the refrigerator observations and microwave temperature log did not meet expectations. The Administrator also stated the observations and low temperatures did not meet expectations.
Infection Control Surveillance and Drain/Catheter Bag Management
Penalty
Summary
The facility failed to implement an infection control program to monitor for and manage infections for 2 of 3 months, September and October 2025, and for 2 of 22 residents reviewed. The facility policy titled Infection Control Surveillance stated the infection preventionist would collect and analyze infection control data to identify trends by comparing rates to previous months and previous years and to implement interventions to improve those rates. However, the infection control log for September 2025 showed no documentation that the collected data was analyzed for trends or that interventions were implemented to address trends. Resident 73 was admitted with diagnoses of brain cancer and seizures and was able to make needs known. The provider ordered cephalexin for a UTI starting 10/30/2025, but the October 2025 infection control log did not include this infection. Resident 12 was admitted with diagnoses including infection and inflammatory reaction due to an indwelling urethral catheter, anemia, and malnutrition, and was able to communicate needs. Observations showed the resident’s abdominal drain bag draining dark red fluid onto the floor, later with blood stains on the floor under the bag and the table leg on top of the drain bag, and then the catheter bag laying on the floor and draining urine onto the floor. Staff stated the drain bag should be pinned to the bed and not touching the floor, the catheter bag should be closed and not drain on the floor, and the catheter and drainage bags were to be attached securely to the bed and not on the floor.
Failure to Offer and Document Flu and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to offer, educate, and obtain consent for influenza and pneumococcal vaccinations for 3 of 5 sampled residents. Review of the facility policies showed that residents were to be assessed for pneumococcal vaccine eligibility prior to or upon admission and offered the vaccine series within 30 days when indicated, and that residents were to be educated, offered, and consented for influenza vaccination upon initial admission. The deficiency was identified during review of immunization records and interviews related to Residents 6, 15, and 23. Resident 6 was admitted with a diagnosis of adult failure to thrive and was able to make needs known; the EHR showed a Vaccine Consent Form stating the resident had requested any vaccine that was due, but there was no documentation that the facility assessed the resident for appropriate vaccines or administered influenza or pneumococcal vaccines. Resident 15 was admitted with a diagnosis of stroke and was able to make needs known; the vaccine information sheet showed the resident was eligible and had not received influenza or pneumococcal vaccines, but the Vaccine Consent Form contained no documentation that the resident was educated and offered those vaccines. Resident 23 was admitted with diagnoses of pneumonia, adult failure to thrive, and history of falls and was able to make needs known; the vaccine information sheet showed the resident was eligible and due for pneumococcal vaccine, but the EHR had no documentation that the resident was assessed for the need for, educated on, and consented to the pneumococcal vaccine.
Failure to Educate, Offer, and Document COVID-19 Vaccination
Penalty
Summary
The facility failed to educate residents and staff on COVID-19 vaccination, offer the vaccine to eligible residents after education, and document vaccination status for 3 of 5 sampled residents: Residents 6, 15, and 23. The report states that this failure denied residents the opportunity to make an informed decision regarding immunizations and/or placed them at risk for communicable diseases, complications of other medical conditions, hospitalization, and death. Review of the facility’s Clinical Protocol for SARS COV-2 showed that all residents were to be offered resources and counseled about receiving the COVID-19 vaccine. Resident 6 was admitted with adult failure to thrive and was able to make needs known; although a Vaccine Consent Form dated 03/25/2025 showed the resident had requested any vaccine that was due, the EHR on 12/08/2025 contained no documentation that the facility assessed the resident for need, educated the resident, or administered the COVID-19 vaccine. Resident 15 was admitted with stroke and was able to make needs known; the vaccines information sheet showed the resident was eligible, due on 08/22/2025, and had not received the COVID-19 vaccine, and the Vaccine Consent Form dated 01/02/2025 had no documentation that the resident was educated and offered the vaccine. Resident 23 was admitted with pneumonia, adult failure to thrive, and a history of falls, was able to make needs known, and had a vaccines information sheet showing eligibility and that the COVID-19 vaccine had not been received, but the EHR had no documentation that the resident was assessed, educated, or consented for the vaccine.
Mechanical Lifts Missing Safety Clips
Penalty
Summary
The facility failed to ensure mechanical lifts were in safe working order for 2 of 2 lifts, identified as Free Spirit and Tenor, during activities of daily living. On 12/04/2025, Resident 1 was observed being transferred from bed to wheelchair using a mechanical lift, and the lift had no safety pins on the prongs where the resident's sling was attached. On 12/05/2025, both Free Spirit and Tenor were observed with missing safety clips. The Maintenance Director stated the clips had been replaced on 11/18/2025 but disappeared about one week later, and that monthly maintenance inspections were being done while staff were looking to order replacement clips. Review of the November and December 2025 inspection reports showed no safety clips on the two mechanical lifts. The DON stated the lifts were supposed to have safety clips, were monitored monthly by maintenance, and should be taken out of service if the safety clips were missing.
Housekeeping Services Not Provided Consistently in Resident Rooms
Penalty
Summary
The facility failed to provide necessary housekeeping in resident rooms on 3 of 4 halls reviewed, including Halls 100, 200, and 300, for a safe, clean, functional, and comfortable environment. On 12/04/2025, Resident 95 asked a housekeeping aide if the bathroom could be cleaned, and the aide stated they had three other rooms to clean and would try to get to it on the next scheduled shift, three days later. On 12/05/2025, Resident 95 stated the bathroom had not been cleaned in a week, and observation of the toilet bowl showed brown and orange stains on the toilet seat and in the bowl. Also on 12/05/2025, Resident 83 stated the bathroom had not been cleaned since Tuesday, and observation showed dried red matter on the bathroom floor. Resident council minutes from July, August, and September 2025 documented repeated concerns and complaints that rooms were not being cleaned often enough, including reports of housekeeping being seen only once in a month and two residents reporting no housekeeping services for approximately two weeks. Housekeeping aides and the housekeeping supervisor stated the department was short staffed and that aides were responsible for cleaning multiple areas and could only clean as many rooms as possible each day.
Inadequate Wheelchair Sizing and Assessment
Penalty
Summary
The facility failed to assess and provide an appropriately sized wheelchair for Resident 1, who was admitted with diagnoses including spondylolisthesis of the lumbar region, atrial fibrillation, bipolar disorder, and heart failure. Resident 1 was able to communicate needs and was observed in bed on 12/02/2025 stating they were getting out of bed less often and that the mechanical lift staff used to transfer them caused pain. On 12/03/2025, Resident 1 was again observed in bed and said they hoped to get out of bed and attend their restorative program. On 12/04/2025, Resident 1 was transferred by mechanical lift from bed to wheelchair and was placed into a wheelchair that was constricting and tight. Two nursing assistants then tried to lift Resident 1 manually to reposition them in the seat, and stated the wheelchair was small, leaving Resident 1 leaning to the left side and squished into it. On 12/05/2025, Resident 1 stated they did not participate in activities the previous day because they were hurting in the wheelchair and could not tolerate sitting up. The care plan included an intervention dated 04/01/2025 to assess that the wheelchair is of appropriate size, and staff interviews indicated the wheelchair issue had been reported but not passed on to therapy. The DON stated residents were assessed for wheelchairs by therapy, but could not provide information regarding an assessment and therapy evaluation for Resident 1's wheelchair.
Failure to Honor Resident Preference for Ice Water
Penalty
Summary
The facility failed to honor Resident 78’s choice for ice water when requested. Resident 78 was readmitted to the facility and was able to make needs known. The annual MDS dated 11/12/2025 listed diagnoses of dementia, anxiety disorder, and diabetes. During interviews, Resident 78 stated they preferred ice water with lunch, said they would ask for it but would only receive a glass of water, and reported that when they requested ice water at lunch they did not get it. The resident also stated they would like a water pitcher with ice in their room but were provided a water bottle instead, and no ice water pitcher was observed in the room. Observation in the dining room on 12/03/2025 showed Resident 78 asked the RCM for ice water at lunch. The RCM said they would provide it in a minute and left the dining room, but ice water was not provided while the resident continued eating. Another staff member later gave the resident a cup of water without ice, and the resident finished the meal without ever receiving ice water. The resident’s diet order included a carbohydrate-controlled regular texture diet with thin liquids, and the nutritional status care plan included honoring preferences as able within diet parameters. Staff E stated Resident 78 often asked for ice water during lunch and that they would ensure it was provided, while the Administrator stated they were not aware the resident was not consistently being provided ice water when requested and agreed the resident should have been provided ice water when requested.
Failure to Review Advance Directive at Quarterly Care Conferences
Penalty
Summary
The facility failed to periodically review one resident’s advance directive for Resident 96, who was admitted with end stage renal disease, dementia, and an encounter for palliative care and was unable to make needs known. Review of the Multidisciplinary Care Conference assessments dated 07/28/2025 and 10/16/2025 showed the Advanced Directives Reviewed/Offered field was blank. During interviews, the Director of Social Services stated advance directives were reviewed on admission and quarterly with care conferences, then later stated Resident 96 did not have an advance directive review at the two prior care conferences and that this did not meet expectations. The Administrator also stated advance directives should be reviewed quarterly and that the resident’s lack of review at the two most recent care conferences did not meet expectations.
Incomplete fall investigations and delayed documentation for a resident on hospice
Penalty
Summary
The facility failed to complete and/or implement thorough investigations to rule out abuse or neglect related to multiple falls for one resident. The resident was readmitted with diagnoses including unsteadiness on feet, Alzheimer’s disease, anxiety disorder, bipolar disorder, and benign prostatic hyperplasia, and the quarterly MDS showed the resident had two or more falls since admission or the prior assessment, received hospice services, and was able to make needs known. The record also showed the resident was frequently incontinent of bowel and bladder and was unable to use a call light because of cognitive deficits. For the fall found on 09/13/2025, the resident was discovered lying on their belly just outside the bathroom door and said they wanted to use the bathroom. The investigation did not show hospice was informed, and the root cause of the fall was not clear. During interview, the DNS stated the resident was on urine retention medication and should have been checked for urinary retention with a PVR, and also stated hospice should have been informed. For the fall on 09/14/2025, the resident was found on the floor crawling toward outside of the room and said they were getting out of bed. The incident report referenced another witness, but no additional witness statement was attached. The intervention to wake the resident before breakfast and offer assistance to get up was not initiated until 09/22/2025, eight days later. The DNS and RCM stated the investigation was not thorough because the intervention was late and the witness statement was missing. For the fall on 10/05/2025, the resident was observed crawling on the floor from the bed and said they were hungry. The incident report had a blank witness form and no statements found, and it did not show the provider or responsible party were notified. New interventions such as keeping the wheelchair close and locked, nighttime snack, pain and anxiety monitoring, PRN pain medication review, and therapy screening were documented, but the therapy referral was dated 10/16/2025 and completed on 10/20/2025. The progress notes did not show a note on the date of the fall, and staff could not locate documentation that hospice was informed or that PRN pain medications were reviewed. The resident was also found sitting on the floor on 10/13/2025, stating they crawled out of bed, but this fall was not logged in the October incident report log and no investigation was conducted. On 10/21/2025, the resident was witnessed standing from the wheelchair, walking, and slipping to the buttocks after bingo; the incident report included a therapy referral dated 10/22/2025 and signed on 10/26/2025, but therapy determined the resident was on hospice and not appropriate for skilled PT. The intervention to assist the resident back to the nursing station for an opportunity to lie down or use the bathroom was not initiated until 10/27/2025. For the fall on 11/07/2025, the resident was found sitting on the floor outside the room and stated they had slid out of bed. CNAs reported the resident had been putting themselves on the floor for the past week, but the witness form was incomplete and did not show the last time the resident was toileted or when they were changed or assisted to the bathroom. The therapy referral indicated the resident would be screened, but the screen was not attached to the incident report. Staff stated each time the resident was found scooting on the floor should have been investigated and reported, and the fall investigation did not meet expectations.
Failure to Follow Up on PASRR Level 2 Review
Penalty
Summary
The facility failed to follow up on a PASRR for one resident who had been screened on 04/17/2025 and determined to require a level 2 PASRR for mood disorders. The resident had been admitted to the facility on 05/30/2025 with diagnoses of anxiety and depression and was able to make needs known. Review of the EHR found no level 2 PASRR on file. During interview, the Social Services Director stated the resident had transferred from another skilled nursing facility and they were told the PASRR had been sent for review, but on 12/02/2025 they contacted the PASRR review team and learned it had never been sent or received. Staff also stated they should have followed up sooner.
Incomplete Comprehensive Care Plans
Penalty
Summary
The facility failed to initiate comprehensive care plans for 2 of 22 sampled residents. Resident 4 was admitted with diagnoses of diabetes and epilepsy, was able to make needs known, and the resident plan of care initiated on 05/30/2025 did not include any care plan entry with interventions for epilepsy. During interview, the RCM stated Resident 4's diagnosis of epilepsy should have been included in the plan of care, and the DNS stated it was their expectation that care plans be comprehensive and that epilepsy should have been addressed. Resident 78 was readmitted with diagnoses including dementia, anxiety disorder, and depression, was able to make needs known, and the MAR showed the resident received an antidepressant and an antianxiety medication but was not prescribed or receiving an antipsychotic medication. The focused care plan for antipsychotics initiated on 12/05/2024 stated the resident used an antipsychotic medication, and the focused care plan for psychoactive medications was not initiated until 11/16/2025, after antianxiety medications had been ordered. The psychoactive care plan did not list target behaviors or side effects for staff to monitor related to antidepressant and antianxiety medication use. The RCM and DNS stated the care plan should have been revised with changes in condition and should have included monitoring for behaviors and side effects for these medications.
Failure to Document Ordered Orthostatic Blood Pressure Monitoring
Penalty
Summary
The facility failed to follow a provider order for Resident 5 to have orthostatic blood pressure monitored monthly. Resident 5 was admitted with diagnoses including cerebral palsy, bipolar disorder, schizoaffective disorder, and generalized anxiety disorder, and was able to make needs known. Review of the electronic health record showed the order for orthostatic blood pressure monitoring dated 02/01/2025, but no orthostatic blood pressure readings were documented in the record. During interviews, the Registered Nurse/Resident Care Manager stated the facility monitored orthostatic blood pressure to ensure a resident was not at risk for falling due to medications, and acknowledged that Resident 5 had the order but no documented readings in the EHR. The Director of Nursing Services also stated that residents' orthostatic blood pressure was monitored for fall risk related to medications and confirmed that Resident 5 had the order but there was no documented monitoring. Both staff stated this did not meet expectations.
Dependent resident sent to appointment without escort
Penalty
Summary
The facility failed to provide the necessary care and services to maintain the physical and psychosocial well-being of Resident 14 when the resident was taken to a doctor’s appointment without an escort. Resident 14 was admitted with hemiplegia, anxiety, and cognitive deficit, and was able to make needs known. During the appointment trip on 12/02/2025, the resident stated the driver dropped them off and left them there, the resident was unable to navigate the doctor’s office, missed the appointment, had a bowel movement in the wheelchair, and then had to navigate back to the facility alone. The care plan initiated on 10/21/2025 identified the resident as dependent on staff for toileting and transferring. Staff D, the Resident Care Manager, stated the resident did not have an escort but should have; Staff C, the ADON, stated a resident dependent on staff and incontinent of bowel would need an escort for doctor appointments; and Staff B, the DON, stated the resident should have had an escort for the appointment.
Failure to Prevent Decline in ADLs Due to Untreated Ankle Contracture
Penalty
Summary
The facility failed to provide the necessary care and services to ensure that Resident 45’s ability to participate in activities of daily living did not diminish, as the resident experienced a decline in mobility involving sit-to-stand, toilet transfers, and ambulation. Resident 45 was admitted with diagnoses including COPD, unsteadiness on feet, and major depressive disorder, and was able to make needs known. During observation, the resident was lying in bed with the right ankle elevated on a pillow and turned inward, and stated the ankle was not inverted on admission and that they were no longer able to stand because of pain and the ankle position. Record review showed that on the initial PT evaluation, Resident 45 required partial/moderate assistance for sit-to-stand, chair/bed transfers, and toilet transfers, and substantial/maximal assistance to walk 10 feet. A later PT evaluation showed the resident had declined to dependent transfers and was unable to attempt toilet transfer due to medical condition or safety concerns, with ambulation refused. Progress notes documented a right ankle-foot deformity/contracture, and the quarterly MDS marked no functional limitation in range of motion. A later therapist note stated Resident 45 reported being unable to stand due to right foot contracture and that therapy could not address the contracture because it required surgical intervention. The care plan initiated for the resident contained no interventions related to a right ankle contracture. Staff interviews indicated therapy had ordered a brace that was not useful, a referral for orthopedic consultation had been discussed, and the provider was aware of the situation, while the nurse practitioner stated the facility requested an orthopedic referral only on the day of the interview and was unaware it had been previously discussed.
Failure to Assist Resident With Vision Services
Penalty
Summary
The facility failed to provide treatment and services to maintain vision for Resident 15. The resident was readmitted with diagnoses including high blood pressure, stroke, and anemia, and was able to make needs known. During interviews, Resident 15 stated they had asked to see an eye doctor because their vision had declined and their reading was blurry. The resident also stated they had told a social worker they wanted to see an eye doctor, but that social worker no longer worked at the facility and no one else had followed up. Record review showed the quarterly MDS dated 10/02/2025 indicated Resident 15 had adequate vision with no corrective lenses. The current care plan had no focused care plan for vision. A care conference progress note dated 04/05/2025 identified optometry as an ancillary need, and a provider/encounter note dated 04/07/2025 stated Resident 15 was working with the social worker to schedule an optometry appointment. During interview, the SSD stated another social worker had been responsible for the LTC caseload and was no longer employed as of 08/13/2025. The SSD stated Resident 15 should have been placed on the list to be seen by an optometrist and should have been seen prior to now, and the Administrator stated the social worker who should have followed up with the resident's vision concerns had been terminated due to a pattern of failure to follow up.
Failure to investigate falls and timely initiate interventions
Penalty
Summary
The facility failed to investigate the root cause of a resident’s falls, and failed to ensure new interventions and referrals or screenings were completed in a timely manner to minimize further falls. Resident 11 was readmitted with diagnoses including unsteadiness on feet, Alzheimer’s disease, anxiety disorder, bipolar disorder, and benign prostatic hyperplasia, and the quarterly MDS showed the resident had two or more falls since admission or the prior assessment, received hospice services, and was able to make needs known. After a fall on 09/13/2025, the resident was found lying on their belly just outside the bathroom door after telling staff they wanted to use the bathroom. The incident investigation did not clearly show the root cause of the fall. The DNS stated the resident was on urine retention medication and should have been checked for urinary retention with a PVR, but that this was not done and the investigation did not meet expectations for thoroughness. Following later falls, interventions and referrals were not initiated within the expected timeframe. After a fall on 09/14/2025, the intervention to wake the resident before breakfast and offer to get up in a wheelchair was not initiated until 09/22/2025. After a fall on 10/05/2025, new interventions included keeping the wheelchair close and locked, providing a nighttime snack, and therapy screening for bed height, but the therapy referral was dated 10/16/2025 and completed on 10/20/2025, and the resident fell again on 10/13/2025 before those actions were initiated. After a fall on 10/21/2025, the referral was for therapy rather than a screen, therapy later documented the resident was on hospice and not appropriate for skilled PT, and the intervention to assist the resident back to the nursing station for an opportunity to lie down or use the bathroom was not initiated until 10/27/2025. A later fall on 11/07/2025 showed the same wake-up-before-breakfast intervention had been reused, and staff stated a new intervention should have been revised rather than using one already used before.
Failure to Implement Behavioral Health Medication Recommendations
Penalty
Summary
The facility failed to ensure that a behavioral health provider’s recommendations for changes to mental health medications were considered and implemented for a resident with cerebral palsy, bipolar disorder, schizoaffective disorder, and generalized anxiety disorder. The resident was able to make needs known and was receiving clonazepam for mental health-related symptoms. The record showed clonazepam was ordered as needed, then later as scheduled, and then again as needed during the review period. Psych follow-up notes documented that the behavioral health provider recommended increasing clonazepam to three times daily as needed and later recommended changing clonazepam from PRN to scheduled twice daily because the resident reported difficulty remembering to request PRN doses and wanted the medication scheduled. The notes also showed that these recommendations had not been implemented at the time of later follow-up. Staff interviews confirmed that the provider’s medication change recommendations were not acted on in a timely manner and that there had been a communication issue between the behavioral health provider and the facility.
Failure to Provide Follow-Up Social Services After Suicidal Statement
Penalty
Summary
Medically related social services were not provided for a resident with bipolar disorder, depression, and chronic pain after the resident stated they were so sad that their family did not come to visit that they felt like dying. The resident was admitted to the facility and was able to make needs known. A progress note documented the resident’s statement, and the mental health care plan, initiated earlier, included interventions to contact the 988 crisis hotline if the resident presented as a danger to self/suicidal and to contact local law enforcement if they presented as a danger to others. The medical record contained no documented follow up related to the resident’s comment. During interviews, the Social Services Director stated social services should have followed up with the resident after the statement about dying to conduct an interview, place the resident on alert, and contact the crisis line if necessary. The Resident Care Manager stated nursing staff should have coordinated with social services to ensure the resident was interviewed, the provider was contacted, and the care plan was updated. The DON stated the resident should have been placed on alert and social services should have conducted an interview to determine the level of distress, and that the lack of communication and intervention did not meet expectations.
Medication Administration Errors Involving Patch Removal and Missing Dosage
Penalty
Summary
Pharmaceutical services were not provided to meet the needs of two residents during medication administration review. One resident with diagnoses including dementia, gout, and diabetes had a lidocaine 4% external patch ordered for the left shoulder to be applied once daily for pain, left on for a maximum of 12 hours, and removed per schedule. On 12/05/2025, an LPN removed a patch dated 12/04/2025 from the resident’s left shoulder and stated it should have been removed the prior night as prescribed. The December 2025 MAR showed the patch order, but it did not provide a place to document when the patch was removed. The DON stated the MAR did not have a removal attached to the order and that this did not meet expectations, identifying it as a medication error. A second resident with diagnoses including diabetes, heart failure, and depression received docusate sodium 100 mg in a med cup from an LPN along with other prescribed medications. The December 2025 MAR showed an order for docusate sodium to be given twice daily for constipation and held for loose stools, but the order did not include a dosage. The LPN stated medication orders should include a dosage and that the order should have been clarified before administration, while the DON stated the order lacked a dosage and should have been verified or clarified with the provider. The resident was able to make needs known, and the medication was administered despite the incomplete order.
Failure to Document Non-Pharmacological Interventions Before PRN Pain Medications
Penalty
Summary
Ensure each resident’s drug regimen was free from unnecessary drugs was not met when the facility failed to consistently provide non-pharmacological interventions (NPI) before administering PRN medications for 2 of 5 sampled residents. Resident 5 was admitted with diagnoses including cerebral palsy, bipolar disorder, schizoaffective disorder, and generalized anxiety disorder, and was able to make needs known. Provider orders showed PRN tramadol with an instruction that NPI be used before administration. Review of the September, October, and November 2025 MARs showed tramadol was given without NPI on multiple occasions, including 6 of 14 opportunities in September, 6 of 11 in October, and 4 of 15 in November. Resident 78 was readmitted with diagnoses including dementia, anxiety disorder, and diabetes, and was able to make needs known. The November 2025 MAR showed an order for PRN acetaminophen with monitoring for pain and documentation of NPI using a code number. On 11/16/2025, acetaminophen was administered, but the MAR documented "NA" instead of an NPI code, and the progress notes contained no documentation that NPI were provided before the medication was given. Staff interviews confirmed the expectation that NPI be used and documented before PRN pain medication, and that the documentation for both residents did not meet expectations.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications in 1 of 3 medication carts and 1 of 2 medication rooms. In the Peak Medication Room refrigerator, temperature logs were missing for the evening shifts on 12/03/2025 and 12/04/2025, and Staff C, the ADON, stated Licensed Nurses were expected to document refrigerator temperatures twice daily but could not provide temperature logs for November 2025. In the Run Four Medication Cart, surveyors observed expired slow magnesium chloride with calcium tablets dated October 2025 and an insulin pen that had been opened and used without a date or name. Staff DD, RN, stated the insulin and tablets were expired, and Staff B, the DON, stated refrigerated medications were to have twice-daily temperature documentation and medications on carts were to be dated when opened and discarded when expired.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to provide dental services for 1 of 2 sampled residents reviewed for dental needs. Resident 1 was admitted with diagnoses including spondylolisthesis of the lumbar region, atrial fibrillation, bipolar disorder, and heart failure, and was able to communicate needs. During observation and interview, Resident 1 was found in bed with missing upper teeth and stated they had problems with their teeth and needed a denture. The electronic health record showed the resident was seen by a dental hygienist who recommended a dentist, but there was no referral or follow-up information about a dentist documented in the record. The Director of Nursing stated the process was to obtain an order and have social services set up the appointment, and that this should be documented in the record, and stated the resident's dental services did not meet expectations.
Failure to Provide Timely Emergency Care and Post-Fall Monitoring
Penalty
Summary
The facility failed to provide timely emergency services and thorough documentation for three residents who experienced falls, resulting in a deficiency related to quality of care. One resident, who was on a blood thinning medication, suffered an unwitnessed fall with a head injury. Despite having a laceration above the eye and being at high risk for intracranial bleeding, the resident was not sent for immediate medical evaluation. Instead, the resident was monitored in the facility, and only after a significant change in condition, including delayed response and unequal pupils, was the resident transferred to the emergency department. Hospital records confirmed a large subdural hematoma requiring emergency surgery, and the resident was later placed on comfort care. For two other residents who experienced falls, the facility's response was inconsistent. Both residents were not on blood thinners but were sent to the emergency department for evaluation after their falls, one with a head laceration and the other with head pain. However, the facility failed to complete required alert charting and post-fall monitoring every shift for 72 hours as outlined in facility policy. Documentation was missing or incomplete for multiple falls, and alert charting was not consistently performed as expected by facility leadership. Interviews with staff confirmed that the expectation was for alert charting to be completed every shift for 72 hours following a fall, but this was not consistently done. The deficiency was further supported by a review of facility policies and external clinical guidelines, which emphasize the need for rapid assessment and intervention for residents on anticoagulants who sustain head injuries. The lack of timely emergency response and incomplete documentation placed residents at risk for medical complications and delayed care.
Failure to Consistently Provide Appropriate Toileting Supplies
Penalty
Summary
The facility failed to consistently provide necessary toileting supplies, specifically briefs, for two residents with moderate cognitive impairment who required staff assistance for toileting hygiene. One resident reported that the facility had run out of their size of brief on three occasions since admission, resulting in the use of smaller briefs that were uncomfortable and did not adequately contain urine, leading to leakage. Another resident stated that staff sometimes used larger briefs when the correct size was unavailable, which did not always prevent wetness. Both residents were able to communicate their needs, and their experiences were corroborated by staff interviews. Staff, including a CNA and Central Supply personnel, confirmed that the facility occasionally ran out of briefs and would substitute with different sizes or obtain supplies from a sister facility, sometimes with delays of up to 12 hours. The administrator was unaware of the need for daily approval of supply orders and acknowledged that the facility should not have been running out of briefs. These actions and inactions resulted in residents not consistently receiving appropriate toileting supplies, as required.
Failure to Implement Proper Infection Control for Suspected Tuberculosis Case
Penalty
Summary
The facility failed to follow infection control standards in the management of a resident suspected of having tuberculosis (TB). According to the facility's own policy, residents with suspected or confirmed TB should be immediately placed on droplet precautions pending transfer, and only admitted if the facility is equipped with a private airborne infection isolation room. The resident in question had a positive PPD test and subsequent positive QuantiFERON gold test, with chest x-rays that could not rule out TB. Despite these findings, the care plan was not updated to reflect the suspicion of TB, the initiation of droplet precautions, or the treatment for pneumonia. The facility did not notify the local health jurisdiction (LHJ) promptly after the positive PPD test, waiting six days before making contact. Staff interviews revealed uncertainty about the correct type of precautions for TB, with the Director of Nursing Services (DNS) acknowledging that airborne precautions are typically required for TB, not droplet precautions as stated in the facility's policy. There was also a lack of documentation and timely communication with the LHJ regarding the resident's status and the facility's actions. Additionally, the facility did not implement interventions for possible TB exposure among staff or other residents, relying instead on verbal communication for monitoring signs and symptoms. The care plan was not reviewed or updated at key points when new information about the resident's condition became available. These lapses in infection control practices and communication placed residents, staff, and visitors at risk for contracting and spreading infections.
Insufficient Staffing Resulting in Unmet Resident Care Needs and Increased Falls
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents across three of four halls, resulting in unmet care needs and increased risk of falls. Review of facility records showed that a significant percentage of residents required assistance with activities of daily living, such as bathing, dressing, transferring, and toileting. Despite policies stating that staffing levels were reviewed daily and adjusted as needed, incident logs revealed a high number of resident falls over several months. Interviews with staff indicated that CNAs were often responsible for caring for up to 15 residents at a time, making it difficult to complete necessary care tasks, especially on weekends when staffing was lower. Staff also reported having to stay late to finish tasks and being frequently asked to cover open shifts. Observations and interviews with residents further highlighted the impact of insufficient staffing. One resident, who was dependent on two staff for transfers and had recently been diagnosed with pneumonia, reported not receiving scheduled showers, not being out of bed for six days, and not having their teeth brushed. Another resident stated they had not had a shower for at least two weeks and had not had their hair washed in about a month. Staff interviews confirmed that administrative nursing staff were counted in the nursing hours per patient day (PPD), but these staff were not always available on weekends. The deficiency was cited under WAC 388-97-1080 (1) and 1090 (1).
Failure to Prevent Significant Medication Error Due to Improper Order Entry and Administration
Penalty
Summary
A significant medication error occurred when a nurse failed to enter a provider's verbal order for an antibiotic (Rocephin 1 gm IM) into the electronic medication administration system (Point Click Care) and did not administer the medication as ordered. Instead, the nurse administered Ceftriaxone 2 gm/Dextrose 50 ml via the clysis system, which was not ordered for the resident. Additionally, the nurse used medication that was prescribed for another resident, which had been discontinued and was awaiting return to the pharmacy. The nurse also failed to complete the required documentation for a change in condition and did not place the resident on alert charting as required by facility policy. The resident involved was moderately cognitively impaired and had multiple diagnoses. Review of the resident's medication administration records showed no antibiotic order was present at the time of administration. The facility's policies required that all medication orders, especially verbal orders, be immediately and accurately recorded in the resident's medical record, including all necessary details such as drug name, strength, dosage, route, and frequency. The nurse did not follow these procedures, resulting in the administration of an unprescribed medication and lack of proper documentation.
Failure to Promptly Investigate and Report Resident Fall
Penalty
Summary
The facility failed to conduct a prompt and thorough investigation following a fall experienced by a resident who was assessed as severely cognitively impaired and had recently undergone surgical repair for a right hip dislocation. The fall, which occurred on 04/06/2025, was not reported by the responsible licensed nurse at the time of the incident, and nurse management was not notified. Risk management procedures and immediate interventions were not implemented as required by facility policy. The incident only came to light when the resident developed new onset pain, prompting an investigation on 04/14/2025, which revealed a dislocation of the right hip arthroplasty without acute fracture. Record review and staff interviews confirmed that the facility's policy for investigating and reporting accidents and incidents was not followed. The nurse supervisor/charge nurse did not promptly report the accident to the administrator or initiate and document an investigation at the time of the fall. The lack of timely notification and intervention was acknowledged by the Director of Nursing Services, who stated that a thorough investigation should have been conducted and documented immediately after the fall.
Failure to Protect Resident from Physical Abuse by CNA
Penalty
Summary
A resident, assessed as cognitively intact and admitted with anemia, experienced physical harm when a Certified Nursing Assistant (CNA) abruptly moved the resident's wheelchair while the resident was self-propelling from the dining room to their room. The CNA reportedly told the resident they were moving too slowly and needed to be passed, then pushed the wheelchair, causing the resident's knee to hit the side of the chair. The resident experienced immediate pain and swelling in the knee, which was later evaluated by x-ray and determined to have no injury, with swelling expected to resolve on its own. The resident did not report the incident immediately, waiting about a week before informing facility staff. The facility's investigation documented that the CNA involved had been identified in three separate abuse allegations recently. At the time the incident was reported, the CNA was already suspended pending a decision from the corporate Human Resources department regarding termination. The facility's abuse policy defines abuse as the willful infliction of injury or punishment resulting in physical harm, pain, or mental anguish, and requires that residents be protected from such actions.
Failure to Provide Adequate Pain Management
Penalty
Summary
The facility failed to ensure the availability of pain medications and did not obtain a provider's order for an alternative pain medication of similar strength for a resident experiencing chronic pain. Resident 1, who was admitted with chronic pain due to lumbar spine stenosis and degenerative disc disease, was prescribed a fentanyl transdermal patch to be applied every 72 hours. However, the Medication Administration Record (MAR) indicated that the patch was not in place for three consecutive shifts, and a new patch was not applied until 59 hours later, leaving the resident without adequate pain management. During this period, Resident 1 reported severe pain, rating it as a 10 on the pain scale, and expressed discomfort due to the absence of the fentanyl patch. Nursing notes documented that the resident had a difficult night without the patch and that the pharmacy was delayed in sending a new one. Despite the availability of pain patches in the Cubex and the option to contact the provider for an alternative medication, the facility staff did not take appropriate actions to manage the resident's pain effectively. This oversight resulted in the resident experiencing significant pain and discomfort.
Inadequate Supervision Leads to Falls in Residents
Penalty
Summary
The facility failed to provide adequate supervision and assistance during bed mobility care for two residents, leading to falls and injuries. Resident 1, who was admitted with multiple diagnoses and required substantial assistance with activities of daily living, experienced a fall from bed when a single staff member attempted to provide care alone, despite the care plan requiring two caregivers. This incident resulted in Resident 1 sustaining injuries that required hospital evaluation. The root cause was identified as inadequate staffing during in-bed care. Similarly, Resident 2, who was receiving hospice services and required substantial assistance, also experienced a fall during care. The care plan for Resident 2 specified the need for two staff members during care due to the resident's fear of rolling off the bed. However, the staff failed to adhere to this plan, resulting in an assisted fall. Although no injuries were noted, the root cause was again identified as the failure to follow the care plan requiring two-person assistance.
Inadequate Infection Control and Outbreak Management
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, leading to the transmission of a communicable disease among residents. The facility did not implement transmission-based precautions (TBP) in a timely manner for residents exhibiting symptoms of respiratory illness. Specifically, residents were not tested for influenza or COVID-19, nor were they placed on droplet precautions or administered antiviral medications like Tamiflu as per the facility's outbreak protocols. This failure resulted in several residents being hospitalized with complications such as pneumonia, sepsis, and acute kidney injury. The facility's outbreak management was inadequate, as evidenced by the lack of timely communication and action from the infection preventionist and medical director. Despite recommendations from the local health jurisdiction to follow CDC guidelines for influenza outbreak management, the medical director chose not to implement these recommendations fully, opting instead to provide antiviral treatment only to symptomatic residents. This decision contributed to the spread of the illness, affecting a significant portion of the resident population. Additionally, the facility did not adhere to proper transmission-based precautions and enhanced barrier precautions. Observations revealed that staff frequently entered rooms without appropriate personal protective equipment (PPE), failed to sanitize shared equipment between uses, and did not follow hand hygiene protocols. The laundry process also lacked proper sanitation, with visible debris and grime on washing machine gaskets not being cleaned between loads. These lapses in infection control practices placed residents, staff, and visitors at increased risk of exposure to communicable diseases.
Failure in QAPI Program Leads to Repeated Deficiencies
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Performance Improvement (QAPI) program effectively self-identified deficiencies and developed or implemented effective plans of action to sustain corrections for previously identified deficiencies. This failure led to repeated deficiencies, a pattern of deficiencies, widespread deficiencies, and a pattern of actual harm that placed residents at repeated risk for unmet needs. During interviews, the Director of Nursing Services (DNS) acknowledged being informed of infection control issues upon taking over the position in July 2024, but expected these issues to have been resolved by then. The DNS admitted that improvements could be made in the QAPI process to reduce repeated deficiencies. The facility conducted QAPI meetings but failed to self-identify deficiencies, recognize unsustained corrections of previously identified deficiencies, or make timely revisions to action plans. The Administrator admitted to being aware of some improvements but not others and acknowledged the need for better engagement with the QAPI process. The report lists numerous deficiencies, including issues related to residents' rights, grievances, abuse and neglect, reporting of alleged violations, care planning, and infection control, among others. These deficiencies were not effectively addressed or sustained, leading to repeated citations and harm.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to properly address grievances for two residents, leading to a deficiency in honoring residents' rights to voice grievances without discrimination or reprisal. Resident 14, who has bipolar disorder and COPD, expressed increased anxiety and dissatisfaction due to a disruptive roommate. Despite multiple progress notes indicating Resident 14's distress and dissatisfaction with the offered solution of earplugs, no grievance was filed, and the Social Services Director was unaware of the situation. The Administrator acknowledged that a grievance should have been initiated, and the resident should have been offered a room change or the first available room. Similarly, Resident 66, who has a left below-knee amputation and diabetes, reported missing personal property, specifically two jackets, to various staff members, including a nurse aide, a nurse, and laundry staff. Despite these reports, no grievance form was completed, and the grievance logs showed no record of the missing items. The Administrator confirmed that the expectation was for staff to assist residents with grievance forms for missing items, but this was not done for Resident 66.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide written notification of the reason for transfer or discharge to the resident or responsible party for two residents who were hospitalized. Resident 38, who had a history of stroke, high blood pressure, and paroxysmal atrial fibrillation, was transferred to the hospital on 11/29/2024. The electronic health records showed no documentation of a written notice being provided to Resident 38 or their responsible party regarding the transfer. Staff interviews revealed that while verbal notifications were made, there was no written documentation provided. Similarly, Resident 66, who had diagnoses including a left below-knee amputation, infection, and diabetes, was sent to the hospital for evaluation on 08/22/2024. There was no documentation found indicating that the resident or their representative was notified in writing of the reason for the transfer. Staff interviews confirmed that written notices were not provided to residents or their representatives for hospital transfers, which is a requirement under the relevant regulations.
Failure in PASRR Screening for Mental Health Disorders
Penalty
Summary
The facility failed to ensure that residents with mental health disorders were properly screened for additional mental health supports using the Preadmission Screening and Resident Review (PASRR) process. Specifically, four residents with diagnoses of depression, anxiety disorder, and bipolar disorder were not referred for a PASRR level two evaluation despite indications that such referrals were necessary. For instance, Resident 53, who was admitted with a diagnosis of depression, had a PASRR level one indicating the need for a level two referral, which was not completed. Similarly, Resident 5, with diagnoses including anxiety disorder, depression, and bipolar disorder, had serious mental illness indicators on their PASRR level one but was not referred for a level two evaluation. Additionally, Resident 8, who was readmitted with anxiety disorder and depression, was not referred for a PASRR level two evaluation despite the presence of mood disorder indicators. Resident 66, admitted with a diagnosis of depression and receiving antidepressant medication, was not marked for serious mental illness on the PASRR level one, and no level two evaluation was conducted. Interviews with the Social Services Director and the Administrator confirmed that these oversights did not meet the facility's expectations for mental health screening and referral processes.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,298 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Gig Harbor
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cottesmore Of Life Care | 1.4 mi | ★★★★★ | 18 | 0 |
| Eliseo | 3.8 mi | ★★★★★ | 5 | 0 |
| Heron's Key | 4.2 mi | ★★★★★ | 10 | 0 |
| Avamere Transitional Care Of Puget Sound | 4.2 mi | ★★★★★ | 56 | 0 |
| Park Rose Care Center | 5.8 mi | ★★★★★ | 0 | 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.