Above average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Josephine Caring Community during CMS and state inspections, most recent first.
The facility failed to honor resident bathing preferences and schedules for three residents whose care plans specified twice-weekly showers. One resident with post-stroke hemiplegia and moderate cognitive impairment had documented gaps of up to ten days between showers, with no record of re-offering a shower after a refusal and repeated observations of disheveled appearance. Another cognitively intact resident dependent on staff for showers reported preferring two showers per week but stated they barely received one weekly, with documentation showing extended intervals between showers. A third resident who required substantial assistance for bathing reported going eight days without a shower and being told by family they smelled of urine, despite a care plan for twice-weekly showers. Staff interviews confirmed that bathing preferences were obtained and documented, and that NACs were expected to chart showers and refusals in the EMR, but actual practice did not consistently follow these preferences.
Two residents did not receive appropriate care related to skin treatment, positioning, and meal assistance. One resident with Parkinson’s disease, ataxia, and dermatitis had a painful rash on the feet and toes; staff applied Triamcinolone ointment for months without cleaning the feet beforehand, and the order lacked a defined application site and end date, with no documented monitoring of the skin condition on the MAR or TAR. Another resident with stroke-related hemiplegia, existing PIs on the ankle and heel, and documented need for substantial/maximal assistance and heel-floating was repeatedly observed in bed with heels and an injured ankle resting directly on the mattress and in poor alignment. The same resident, who required supervision or touching assistance with meals, was observed multiple times with an untouched lunch tray and no staff present to assist, despite staff stating they rely on Kardex and nurse communication to guide individualized care.
A facility failed to store controlled meds in accordance with state and federal requirements in 1 of 2 med storage rooms in the Rehab Unit. During an observation, an RN/Case Manager removed a locked metal box from the refrigerator in the med room and opened it with a key; the box contained 2 unopened bottles of Lorazepam oral liquid and 1 unopened injectable vial of Lorazepam. The RN/Case Manager stated the controlled meds were kept in the box and was not aware the Schedule substances had to be stored in a permanently affixed compartment.
The facility failed to keep resident records complete and accurately organized when outside-provider notes, dialysis records, and advance directive documentation were missing from the EHR. A resident on dialysis had no nephrology notes, labs, or communication packets in the chart, a resident with dementia had a physician letter about decision-making capacity filed only in paper records, and other residents had missing neurology or provider progress notes, including a physician visit note that was not documented in the EHR.
Failure to Complete Required PASARR Level II Evaluation: A resident with Parkinson's disease, depression, and dementia with psychotic features required a PASARR Level II evaluation after screening, but it was not completed. Social Services later stated there was a miscommunication, and the Level II invalidation noted the resident was not in the facility when the evaluation could not be completed.
A facility failed to update a resident’s care plan for dental needs and another resident’s comprehensive care plan for Hospice services. One resident had ongoing denture problems, gum irritation, oral pain, and an ulcer, and dental notes recommended a denturist referral and assessment for possible thrush, but the care plan was not revised to reflect these needs. Another resident elected Hospice, had a Hospice POC in the chart, but the comprehensive care plan did not incorporate the Hospice interventions and only mentioned Hospice in the smoking problem.
A resident with COPD and respiratory failure was ordered continuous oxygen at 2 L/min, but staff repeatedly observed the concentrator set at 1 L/min and an LPN admitted the order was not verified and the old setting was followed. Separately, a resident with diabetes who was receiving oral meds and daily sliding scale insulin had no documented A1c monitoring since admission, and staff confirmed the A1c level should have been completed.
A resident with dementia, osteoporosis, and muscle weakness developed severe left lower back pain that persisted despite PRN Tylenol, ibuprofen, and later a lidocaine patch order. Staff documented grimacing, rubbing the area, rocking, teary behavior, and complaints that the back hurt, while the care plan was not updated to address the new pain for 15 days after onset. Interviews showed staff awareness of the pain and that care plan updates were the responsibility of case management, but the unresolved pain was not reflected in the plan of care.
Failure to assess PTSD history and triggers for a resident with dementia, depression, anxiety, and PTSD. The resident had severe cognitive impairment, and the care plan addressed impaired cognition, refusals of personal care, and mood/behavior issues, but the record contained no trauma screening, PTSD details, or trigger information. Social Services had not gathered this information from the representative, and the family reported the resident had been sexually abused as a child.
Missed Required Physician Visits: The facility failed to ensure timely physician visits for several residents. A resident with chronic respiratory failure, diabetes, and chronic pain, another with hypertensive kidney disease and diabetes, a resident with COPD and MDD, and a resident with dementia were not seen within required intervals. Staff interviews showed chart audits and notifications occurred, but missed visit documentation and overdue provider visits remained unresolved.
Timely lab services were not provided for a resident with acute and chronic wounds and a bone infection. Weekly labs were ordered, but the resident record showed the labs as completed without any results filed in the chart or EHR. An LPN confirmed the results were missing, said the facility was not receiving them from the lab, and noted there was no process to track pending labs; later review found one set only partially available in the lab portal and the other still in the system.
Failure to Follow Contact Enteric Precautions: Staff entered a resident’s room under Contact Enteric Precautions without gown or gloves, did not perform hand hygiene after leaving the room, and returned with a blanket without PPE. The resident had sepsis and C. diff enterocolitis, and interviews showed staff misunderstood when PPE was required despite the posted sign and facility policy.
A resident experienced a significant weight loss due to the facility's failure to accurately obtain and monitor weights, recognize weight loss, and provide necessary assistance during meals. The resident, with a history of malnutrition and advanced dementia, was often left without support during meals, leading to inadequate nutritional intake. Staff inconsistencies in recording and reviewing weights contributed to the oversight of the resident's declining health.
The facility was observed serving uncovered cold foods, including fruit cups and desserts, across multiple units, leading to unsanitary food service practices. The Dietary Manager confirmed that dessert bowls and small cups of condiments were not covered, contributing to the deficiency.
The facility failed to maintain complete and accurate medical records for several residents, including missing weights, shower documentation, and consents for restraints. Additionally, consultant provider notes for wound care and podiatry were not included in the records. Staff interviews revealed issues with documentation processes, leading to delays and omissions in the residents' medical records.
The facility failed to create comprehensive care plans for residents with specific medical needs, including congestive heart failure, hypertension, stroke-related conditions, dementia, dysphagia, and chronic diarrhea. Care plans lacked necessary interventions and guidelines, such as wheelchair positioning and monitoring for weight loss. Staff responsible for updating care plans acknowledged these omissions.
Two residents in an LTC facility did not receive adequate assistance with ADLs. One resident, dependent on staff for bathing, was not offered showers as per their care plan due to staffing shortages. Another resident, requiring assistance with meals, was left unattended, resulting in poor meal consumption. Staff interviews revealed issues with staffing and adherence to care plans.
A resident with severe cognitive impairment and multiple health issues was discharged from physical therapy with a recommendation for restorative nursing services, which were not provided due to a communication breakdown among staff. Despite the resident's willingness to participate in exercises, there was no documentation of restorative care being offered, placing the resident at risk of losing the progress made during therapy.
A resident with severe cognitive impairment was prescribed Quetiapine Fumarate as needed for agitation, but the facility failed to conduct the required 14-day reviews to assess the necessity and rationale for its continued use. Interviews with staff confirmed the absence of documentation for necessary assessments, placing the resident at risk for unnecessary medication use.
Failure to Honor Resident Bathing Preferences and Schedules
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ stated bathing preferences and schedules, as required for resident choice and self-determination. For Resident 2, who had a history of stroke with right-sided hemiplegia and hemiparesis, the quarterly MDS documented moderate cognitive impairment and dependence on staff for bathing and shower transfers. The resident’s preference care plan indicated a desire for showers twice a week before breakfast. However, v2 documentation showed inconsistent intervals between showers, including gaps of seven, eight, nine, and ten days between showers, and there was no documentation that a shower was re-offered after a refusal on one date. Observations over two days showed the resident repeatedly lying in bed in a hospital gown with disheveled hair. Resident 3, a long-term care resident with no cognitive impairment and dependent on staff for showers, had a care plan preference for two showers per week. Documentation for November and December showed some weeks where the interval between showers extended to six or seven days. In late December, showers were documented on two dates only. In January, the v2 report showed showers on three dates with seven and eight days between some showers. During an interview and observation, the resident, seated in a wheelchair and dressed, stated a preference for twice-weekly showers and reported they “barely get one a week.” Resident 4, also a long-term care resident, had an annual MDS indicating they could make their needs known and required substantial assistance for bathing. Their preference care plan documented a preference for two showers per week. In an interview, the resident reported they were bathed on Tuesdays and Fridays but stated it had been eight days since their last shower. The resident also reported that during a recent doctor’s appointment, a family member told them they smelled like urine, which the resident described as embarrassing, noting their limitations from using a wheelchair. Staff interviews confirmed that resident bathing preferences were obtained on admission and placed on care plans, and that NACs and shower aides were expected to document showers and refusals in the EMR and notify licensed nurses of refusals, but the documented shower frequencies did not consistently align with the residents’ stated preferences.
Failure to Provide Ordered Skin Care, Positioning, and Meal Assistance for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate skin care and treatment according to physician orders and resident needs for a resident with Parkinson’s disease, cerebellar ataxia, dementia, and muscle weakness. The resident, who had no documented cognitive impairment on a recent MDS, reported to a collateral contact that a rash on their toes and feet had worsened and was painful, and that staff did not clean their feet before applying prescribed ointment. The collateral contact observed the resident’s toes and feet as red, discolored, and with skin breakdown. The resident’s care plan documented chronic dermatitis to the lower extremities and later a fungal rash to both toes, and there was a long-standing order for Triamcinolone 0.1% ointment to be applied twice daily for rash, but the order lacked a specific application site and end date. Review of the MAR and TAR over several months showed no documentation of monitoring the skin condition of the feet/toes or cleaning the skin prior to ointment application. Nursing staff confirmed the ointment was applied to both feet and that the feet had not been cleaned prior to application until a specific date, and the DON acknowledged the order lacked a specific site and end date and could not clearly describe expectations for documenting and monitoring skin issues. The deficiency also involves the facility’s failure to follow care plan interventions for positioning and pressure injury prevention for a resident with a history of stroke, right-sided hemiplegia/hemiparesis, and existing pressure injuries to the right outer ankle and left heel. The resident’s MDS documented moderate cognitive impairment, a need for substantial/maximal assistance with bed mobility, supervision or touching assistance with meals, and risk for pressure ulcers. The care plan directed staff to provide substantial/maximal assistance with two staff for bed mobility and to float the resident’s heels when in bed as they allowed. Multiple observations showed the resident in bed with heels and feet lying directly on the mattress surface, including times when the lower legs were uncovered and when a pillow under the calves still left one heel resting directly on the bed. At another time, the resident was positioned on their side with their torso leaning toward the edge of the bed, knees hanging over the mattress edge, and the right outer ankle lying directly on the mattress. In addition, the facility failed to ensure appropriate assistance with meals for this same resident, who required supervision or touching assistance and only occasional monitoring and cueing after setup. Surveyors observed an untouched lunch tray on the overbed table within reach of the resident on multiple occasions over several hours, with no staff present to assist or supervise. Later observations showed the resident in the same position with the lunch tray still untouched, and when asked, the resident inaccurately reported having eaten lunch. Nursing assistants interviewed described relying on Kardex information in the closet or EMR and communication from licensed nurses or nurse managers for care directions, but the observed lack of meal assistance and positioning did not align with the resident’s documented needs and care plan requirements.
Improper Storage of Controlled Medications in Medication Room
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored in accordance with state and federal requirements for 1 of 2 medication storage rooms in the Rehab Unit. During an observation and interview on 09/10/2025 at 9:50 AM, a Registered Nurse/Case Manager opened the refrigerator in the Medication Room and removed a locked metal box that was inside the refrigerator but not permanently affixed to it. The RN/Case Manager opened the box with a key, and inside were 2 unopened bottles of Lorazepam oral liquid and 1 unopened injectable vial of Lorazepam. The RN/Case Manager stated that controlled medications were stored in the locked box and was not aware that Schedule substances were required to be stored in a permanently affixed compartment in the refrigerator.
Incomplete and Missing Resident Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete, accurate, accessible, and systematically organized medical records for 5 of 11 residents reviewed. The record review and interviews showed that the facility’s hybrid electronic and paper chart system did not consistently capture outside-provider documentation, including physician visit notes, dialysis-related records, and advance directive information. Facility policies stated that medical records were to be maintained as complete and accurately documented, and that physicians should write or dictate a progress note for each visit. For Resident 74, the care plan documented dialysis services, weekly labs, and communication packets to and from the dialysis center, but the electronic medical record contained no nephrologist visit notes, lab results, or communication packets. Staff stated the nephrologist saw the resident at the dialysis center, that weekly labs were requested but not uploaded into the EHR, and that dialysis communication forms had not been placed in the EHR. Staff also stated the facility used a hybrid system of electronic records and paper charts, and that records from appointments were uploaded when staff became aware an appointment had occurred. For Resident 8, the record contained a POA document stating the POA became effective when the primary physicians determined the resident could not make health decisions, and staff described the resident as having severe dementia and relying on the son/POA for decision-making. A physician letter dated 1/13/2025 stating the resident was unable to make healthcare decisions was found in the paper chart, but staff stated it should have been in the EHR. For Resident 100, the EHR did not contain documentation for a neurology appointment that was listed in the order summary, and staff could not locate the visit note for the rescheduled virtual appointment. For Resident 78, the EHR lacked provider progress notes after admission, and staff could not provide the note for the provider visit on 08/11/2025. For Resident 5, the EHR showed physician visits on 11/25/2024, 01/27/2025, and 06/23/2025, but did not include dictation from the 09/08/2025 physician visit.
Failure to Complete Required PASARR Level II Evaluation
Penalty
Summary
The facility failed to coordinate with the PASARR program for 1 of 5 residents reviewed, Resident 8, who required a Level II evaluation for a serious mental disorder that was not completed. Resident 8 was admitted to the facility, later discharged to the hospital, and then readmitted. Their diagnoses included Parkinson's disease, depression, and dementia with psychotic features, including hallucinations or delusions. A PASARR Level I screening dated 01/10/2025 documented that a Level II evaluation was required. A PASARR Level II invalidation statement dated 03/06/2025 documented that a Level II evaluation could not be completed because the resident was not in the facility. Progress notes dated 04/28/2025 documented that the invalidation was received, and in an interview on 09/15/2025, Social Services staff stated there was a miscommunication and the Level II evaluation was not completed for Resident 8.
Care plans not updated for dental needs and Hospice services
Penalty
Summary
The facility failed to update the comprehensive care plan for a resident receiving dental services. The resident’s care plan, dated 07/09/2024, documented that the resident had no natural teeth and included goals and interventions related to denture fit and cleaning. However, progress notes showed the resident later reported bottom dentures that did not fit properly, gum irritation and pain, an ulcer to the lower gum, and sore spots in the mouth. Dental hygienist notes documented that the resident was seen for dental care and a referral was recommended for a denturist because of ill-fitting dentures and for primary care to assess tissue under the upper denture for possible thrush. During interview, the LPN/Resident Care Manager stated the resident had seen a denturist and that the care plan should have been updated to reflect the resident’s dental needs. The facility also failed to incorporate Hospice plan of care elements into the comprehensive care plan for a resident who elected Hospice services effective 08/15/2025 after readmission following hospitalization. The resident’s Hospice plan of care was filed in the hard chart, but the comprehensive care plan reviewed on 09/10/2025 only mentioned Hospice in the smoking problem and did not include the Hospice interventions. The DON stated nursing received the Hospice plan of care and was supposed to review it and incorporate the interventions into the comprehensive care plan.
Failure to Follow Oxygen Orders and Monitor A1c Levels
Penalty
Summary
The facility failed to ensure professional standards of quality were met for a resident who required continuous oxygen. The resident had diagnoses including respiratory failure and COPD, was assessed as requiring oxygen, and had a care plan directing supplemental oxygen at 2 L/min continuously to keep oxygen saturation above 88%. The physician order also directed oxygen at 2 L/min continuously to the nasal passageway. However, during multiple observations, the resident’s oxygen concentrator was set at 1 L/min, and staff confirmed the resident had been receiving 1 L/min instead of the ordered 2 L/min. An LPN stated the resident had previously been on 1 L/min and that the order was not verified, later acknowledging the error and that the old order had been followed. The facility also failed to ensure appropriate diabetes monitoring for a resident with diabetes who was receiving two oral diabetes medications and a daily sliding scale insulin injection. The resident’s care plan called for blood glucose monitoring and lab work as needed, but the medical record contained no documented hemoglobin A1c lab work since admission. Staff stated the facility did not have a specific policy for when to monitor A1c levels and that they would notify the provider if they noticed one had not been done during quarterly review. Staff confirmed the resident had not had an A1c level checked since admission, and the DON confirmed the resident should have had an A1c lab level completed.
Failure to Assess and Manage Ongoing Back Pain
Penalty
Summary
The facility failed to assess and provide pain management to adequately control the pain of a resident with osteoporosis, dementia, and muscle weakness. The resident’s quarterly MDS documented severe cognitive impairment, supervision only for transfer and walking, no signs of pain, and no pain medications. After the resident complained of left lower back pain described as stabbing and spasms, the licensed nurse documented that the resident was hunched over holding the left side of the back, and the provider ordered a urinalysis and started an antibiotic for five days. The resident was also given PRN Tylenol for back pain. The resident continued to report severe left lower back pain after the urinalysis showed no infection and an x-ray of the lower back was negative. The provider started ibuprofen, and later added a stool softener and monitoring for pain. Progress notes documented ongoing severe left lower back pain from 09/02/2025 through 09/11/2025, with no relief from Tylenol or ibuprofen and trouble sleeping due to pain. Observations during this period showed the resident rubbing the lower back, grimacing, rocking back and forth, appearing teary, and telling staff the back was hurting. The care plan was not updated to address the new onset pain until 15 days after the severe left lower back pain began, and at that time there was no focus area for pain, no updated goal of care, and no interventions to treat the pain. Staff interviews showed the NACs observed the resident grimacing and rubbing the area, while the LPNs and case management staff stated they were responsible for care plan updates or were unaware of the unresolved pain. The DON stated the case managers were responsible for revising the plan of care and confirmed the problem should have been addressed on the care plan. The deficiency cited WAC 388-97-1060(1).
Failure to assess PTSD history and triggers
Penalty
Summary
The facility failed to identify, assess, and address potential signs and symptoms of PTSD for one sampled resident with diagnoses including dementia, depression, anxiety, and PTSD. The resident’s quarterly MDS dated 07/08/2025 showed a BIMS score of 3 out of 15, indicating severe cognitive impairment. The care plan dated 09/10/2025 documented impaired cognition related to PTSD and dementia, refusals of personal care related to dementia and depression, and ineffective mood and behavior regulation related to dementia, depression, anxiety, and PTSD, with interventions such as staff anticipating needs, limiting background noise, reapproaching after refusals, and encouraging out-of-room group activities. The resident’s clinical record from 01/25/2025 through 09/10/2025 contained no documentation of a trauma screening, details of the PTSD diagnosis, or information about experiences or triggers that could affect care or cause re-traumatization. During an attempted interview, the resident was sitting in a recliner in the unit hallway, responded slowly with a flat affect, and did not engage in conversation. Social Services stated they had not discussed or gathered information about the resident’s PTSD diagnosis or triggers with the resident’s representative, and the family member stated they had not been interviewed by facility staff until 09/10/2025 at 5:30 PM about the PTSD diagnosis and reported the resident had been sexually abused as a child.
Missed Required Physician Visits
Penalty
Summary
The facility failed to ensure timely physician visits were completed for 4 of 7 residents reviewed for physician visits. CMS requires residents to be seen by a physician at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter, with a visit considered timely if it occurs no later than 10 days after the required date. The facility policy titled, Physician Visits, stated Health Information personnel should track due dates of physician visits and notify the resident when a physician visit was due, and that the resident must be seen at least once every 30 calendar days after admission and at least every 60 days thereafter. Resident 5, admitted with chronic respiratory failure, diabetes, and chronic pain, was seen by a physician on 11/25/2024, 01/27/2025, and 06/23/2025, but was not seen in March 2025 or August 2025. Resident 49, admitted with hypertensive kidney disease and diabetes, was last seen by a physician on 06/23/2025 and was not seen in August 2025. Resident 79, admitted with chronic obstructive pulmonary disorder and major depressive disorder, was last seen by a physician on 06/16/2025 and was not seen in August 2025. Resident 84, admitted with dementia, had no required provider visit in April 2025, and the provider visit due in August 2025 was not completed within the required 60 days plus the 10-day grace period. Staff interviews showed the Health Information Manager audited charts and notified Collateral Contact 1 of missed visits, the RN/Nurse Manager stated the residency doctor was supposed to complete dictations for the 09/08/2025 visits, and the Administrator, DON, and ADON were informed of the missed physician visits.
Delayed Laboratory Results and Missing Documentation
Penalty
Summary
Timely laboratory services were not provided for one resident who was readmitted with acute and chronic wounds with infection of the bone. The resident had physician orders dated 08/29/2025 for weekly laboratory testing every Tuesday, and the record showed the labs should have been completed on 09/02/2025 and 09/09/2025. The treatment administration record showed both sets of labs as completed, but the resident record contained no laboratory results or progress notes documenting any results. During interview, an LPN stated hard copy results should be in the resident's chart or scanned into the electronic record and confirmed the results were not present. The LPN also stated the facility was not receiving results from the lab and staff had to go into the system to print them, and there was no process or system to remind staff to follow up on pending labs. On later record review and interview, staff confirmed the resident's laboratory results were still not filed in the hard chart or electronic medical record, and one set showed only a partial result in the lab portal while the other was in the system.
Failure to Follow Contact Enteric Precautions
Penalty
Summary
The facility failed to ensure staff followed infection control practices for a resident who was on Contact Enteric Precautions. The resident was re-admitted with diagnoses including sepsis and enterocolitis due to Clostridium difficile. A sign posted outside the resident’s room directed staff to wash or gel hands before entry, wear a gown and gloves, and use soap and water upon leaving the room, and the facility policy stated that staff should don a gown and gloves prior to entry for all interactions that may involve contact with the resident or the resident’s environment. During observation, a Nursing Assistant entered the resident’s room to answer the call light without any PPE, left the room and went directly to the clean utility room without performing hand hygiene, then returned to the resident’s room with a blanket and again entered without PPE. The Nursing Assistant later used hand gel outside the room. In interviews, the Nursing Assistant stated PPE was only worn for contact care, another Nursing Assistant stated gowns and gloves were used only for high-contact care such as peri-care or handling soiled items, and an RN/Case Manager initially described the precaution as PPE only when touching the resident before later stating that anyone entering the room should wear PPE. The Infection Preventionist stated staff receive a lot of training on transmission-based precautions and that staff should follow the PPE instructions posted by the door.
Failure to Monitor and Address Resident's Nutritional Needs
Penalty
Summary
The facility failed to consistently and accurately obtain weights, recognize significant weight loss, and provide consistent assistance with eating and cueing for Resident 33, who was reviewed for nutrition. Resident 33 experienced a significant 14.6% weight loss over a period of approximately six weeks. The facility's policy required weekly weights for new admissions, but there was a discrepancy in the recorded weights, and the facility did not document or address this discrepancy. The initial weight recorded at the facility was 140 lbs., which was inconsistent with the hospital's weight of 114 lbs. prior to admission. This discrepancy was not reviewed or corrected until much later. Observations revealed that Resident 33 was not receiving adequate assistance during meals. On multiple occasions, the resident was left alone with their meal tray, and staff did not provide necessary cueing or encouragement to eat. The resident, who had a history of protein calorie malnutrition, fractured hip, fractured left arm, and advanced dementia, struggled to consume meals independently. The resident's meal intake records showed that they consumed 50% or more of their meals only 31 times out of 137 meals, indicating a lack of adequate nutritional intake. Interviews with staff revealed inconsistencies in the process of obtaining and recording weights. Weights were recorded on worksheets by shower aides, but these were not entered into the electronic medical record or reviewed by nurses. The facility's Director of Nursing and Assistant Director of Nursing were unaware of the weight loss and the inaccuracies in weight documentation. The facility's failure to accurately monitor and address Resident 33's nutritional needs and weight loss was a significant deficiency, as it placed the resident at risk for further decline in health and quality of life.
Unsanitary Food Service Practices
Penalty
Summary
The facility failed to transport and serve food in a sanitary manner across three units: East, West, and North. Observations revealed that trays with uncovered cold foods, such as mandarin oranges, fruit cups with melon, apricots, and desserts like cake with whipped cream, were served to residents. These incidents occurred on multiple occasions, with specific observations noted on July 8th, 9th, 10th, and 15th, 2024. During an interview, the Dietary Manager, identified as Staff T, admitted that dessert bowls and small cups of condiments were not covered, which contributed to the deficiency.
Incomplete and Inaccurate Medical Records in LTC Facility
Penalty
Summary
The facility failed to maintain complete, accurate, and accessible medical records for several residents, leading to potential risks for medical complications and unmet care needs. For Resident 33, the facility did not document weights consistently, with only one weight recorded in the clinical record over a period of time. Similarly, Resident 49's records showed only three showers documented over two months, despite additional showers being noted on handwritten worksheets that were not part of the official medical record. This lack of systematic organization and accessibility of records was acknowledged by the Assistant Director of Nursing, who admitted that the worksheets were not considered part of the medical record. Resident 92's records were incomplete regarding the use of a tilt n space wheelchair, classified as a restraint, as there was no documentation of a Physical Restraint Informed Consent form at the time of the survey. Additionally, there were multiple missing entries for meal tray monitoring, which were supposed to be documented by CNAs. The consent form was eventually found, but it was dated two weeks after the restraint was initiated, indicating a delay in obtaining necessary consents. Staff interviews revealed that the documentation process was not being followed correctly, leading to these omissions. For Residents 78 and 103, the facility failed to include consultant provider notes in their medical records. Resident 78's records lacked documentation from an outside wound clinic, despite the resident attending weekly appointments. Similarly, Resident 103's records did not contain podiatry notes, even though the resident had been seen by a podiatrist for an infection. Staff interviews indicated that documentation was not being scanned into the electronic medical record in a timely manner, with case managers holding onto documents before they were scanned, leading to significant delays in record updates.
Deficiencies in Resident Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for several residents, leading to deficiencies in meeting their specific needs and preferences. Resident 7, who was admitted with congestive heart failure and hypertension, did not have a care plan addressing these conditions. Staff F, an LPN/Case Manager, confirmed the absence of a care plan for these diagnoses. Similarly, Resident 87, who used a tilt n space wheelchair due to stroke-related conditions, lacked a care plan detailing proper wheelchair positioning. Staff M, responsible for updating the care plan, acknowledged this omission. Resident 92, diagnosed with dementia, dysphagia, and muscle weakness, also used a tilt n space wheelchair and was at risk for weight loss. However, their care plan did not include guidelines for wheelchair positioning or monitoring for weight loss. Staff M admitted that these interventions were missing from the care plan. Additionally, Resident 73, who had been experiencing chronic diarrhea for 17 weeks, did not have a care plan addressing this issue despite a diagnosis of functional diarrhea and a referral to a GI physician. Staff B, the Director of Nursing, indicated that case managers were responsible for care plan updates, yet these deficiencies persisted.
Deficiencies in ADL Assistance for Two Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for two residents, leading to deficiencies in care. Resident 10, who was dependent on staff for bathing due to dementia and weakness, did not receive the preferred number of showers per week. Despite having a care plan that required substantial assistance for bathing, the resident was only offered showers five times over a period of six weeks, with no refusals documented. Interviews with staff revealed that the shower aide was often reassigned to other duties due to staffing shortages, resulting in the resident not receiving the necessary care. Resident 33, who required supervision and setup assistance with eating due to advanced dementia and physical impairments, was not provided with the necessary assistance during meals. Documentation showed that the resident consumed less than 50% of their meals in most instances, with only eight meals documented as having received partial or extensive assistance. Observations confirmed that the resident was left unattended during meals, struggling to eat without staff intervention. Interviews with staff indicated a lack of awareness and adherence to the care plan, which required cueing and assistance during meals. The deficiencies in care for both residents were attributed to inadequate staffing and a lack of adherence to established care plans. Staff interviews highlighted issues with staffing call-offs and the reassignment of shower aides, which contributed to the failure to meet the residents' care needs. The facility's policies on providing assistance with ADLs were not consistently followed, resulting in unmet care needs and a diminished quality of life for the affected residents.
Failure to Provide Restorative Nursing Services
Penalty
Summary
The facility failed to provide appropriate services and assistance to maintain or improve mobility and range of motion for a resident, identified as Resident 107, who was reviewed for the restorative nursing program. The facility's policy on the Restorative Nursing Program, dated 12/27/2023, indicated that residents should receive maintenance and restorative services to maintain and improve their abilities to the highest practicable level. Resident 107, who was admitted with multiple facial fractures, iron deficiency anemia, and essential tremors, was discharged from physical therapy on 06/11/2024 with a recommendation for restorative nursing services to maintain the abilities gained during therapy. However, a review of the resident's clinical record from 06/10/2024 to 07/11/2024 showed no documentation of receiving or refusing such services. Interviews conducted with facility staff revealed a breakdown in communication regarding the recommendation for restorative nursing care. Staff R, a CNA, noted that Resident 107 required more care than appeared necessary, while Staff M, an LPN and Restorative Program Manager, stated they had not received a recommendation for restorative care for the resident. CC1, a Physical Therapy Assistant, confirmed they had recommended restorative services for Resident 107 but acknowledged that the resident was not currently receiving the program. Additionally, Resident 107 expressed willingness to engage in exercises and walking with staff, indicating a missed opportunity to maintain their mobility and range of motion.
Failure to Review PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications, specifically regarding the extended use of a PRN anti-psychotic medication without proper assessment and documentation. The resident, who had severe cognitive impairment due to Alzheimer's disease and dementia, was prescribed Quetiapine Fumarate 25 mg every four hours as needed for agitation. This medication was initially prescribed by hospice. However, the facility did not conduct the required 14-day reviews to assess the necessity and rationale for the continued use of this PRN medication, nor was there any documentation of a stop date or duration of use. Interviews with facility staff, including a Registered Nurse/Case Manager and the Director of Nursing Services, revealed that the PRN medication had not been reviewed as required. The staff confirmed the absence of documentation for the necessary assessments and rationale for the medication's continued use. This oversight placed the resident at risk for medication-related complications and receiving unnecessary psychotropic medication, as there was no documented justification for the extended use of the anti-psychotic medication.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 190 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Stanwood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arlington Health And Rehabilitation | 11.7 mi | ★★★★★ | 16 | 0 |
| Life Care Center Of Mount Vernon | 12.3 mi | ★★★★★ | 9 | 0 |
| Mira Vista Care Center | 12.4 mi | ★★★★★ | 26 | 0 |
| Regency Coupeville Rehab And Nursing Center | 14.4 mi | ★★★★★ | 6 | 0 |
| Marysville Care Center | 15.6 mi | ★★★★★ | 23 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Josephine Caring Community.
100% money-back within 48 hours.
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.