Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lake Ridge Center during CMS and state inspections, most recent first.
Staff failed to implement effective interventions to prevent resident-to-resident altercations involving cognitively impaired residents. In one case, a resident with dementia and prior aggressive behavior pushed another cognitively impaired resident into a wall while both were in a hallway. In another case, a resident with dementia, agitation, poor impulse control, and a history of entering others’ spaces and wheeling other residents pushed a dependent resident’s tilt-in-space wheelchair from behind, causing the seated resident to slide to the floor. Care plans called for redirection and close oversight of the resident with poor impulse control, but resident-to-resident contact still occurred and was acknowledged by the DON as meeting the definition of abuse in at least one incident.
Surveyors found that the facility failed to identify and assess residents at risk for hot beverage spills and did not implement individualized care plans to address this hazard. Written guidelines acknowledged that hot beverages between 120°F and 150°F and residents with dementia, tremors, weakness, or who moved about with hot drinks were at increased risk for scald injuries, yet there was no formal process to flag such residents. One resident with severe dementia, stroke, behavioral disturbances, and wheelchair dependence repeatedly self-propelled with hot tea, had a documented incident of spilling 146°F tea into their lap with redness and peeling skin, and had a known history of prior spills, but no care plan interventions were in place. Another resident with stroke, Alzheimer’s disease, and a cognitive communication deficit spilled hot coffee on their thigh during an activity, with discoloration noted, yet this event was not investigated and did not result in care plan changes. Staff interviews confirmed that many cognitively impaired residents were at higher risk for spills, that hot beverages were routinely delivered at 150°F, and that no residents had care plans addressing hot beverage spill risks.
Representative Signed Arbitration Agreement Without Authority: A resident with moderate dementia and severely impaired cognition had a POA for health care that authorized only health care decisions, but not agreement to a binding arbitration contract. Facility staff accepted the resident representative’s signature on the arbitration agreement anyway, and interviews showed staff believed the POA could sign for the resident despite the limits in the advance directive.
PASARR Level I assessments were not accurately completed for 3 residents with documented behavioral and psychiatric concerns. Records showed dementia with agitation, severe cognitive impairment, and dependence for ADLs, along with notes describing aggression, paranoia, and hallucinations, yet the Level I forms did not identify mental illness indicators and no PASARR Level II referrals were requested.
The facility failed to complete OBRA registry verification for 2 NAs before they worked in the facility. Their personnel records had no OBRA documentation, and HR and the Administrator confirmed the required verification process was not followed despite the facility abuse prohibition policy and state guidance requiring active registry status.
A resident with dementia and severe cognitive impairment received an influenza vaccine, but the record lacked documentation that the resident’s representative was educated on the risks and benefits or signed consent for the vaccine. The IP/LPN stated the paperwork could not be found in the resident’s chart.
A resident with multiple comorbidities experienced a change in urinary condition and had orders for urinalysis with culture and sensitivity, but the facility failed to ensure timely review and follow-up of the lab results. The results, which showed multi-drug resistant bacteria, were not reviewed for 14 days, during which the resident's condition deteriorated, leading to hospitalization for septic shock due to urosepsis. Communication lapses among LNs, the medical provider, and the DON contributed to the delay and harm.
A resident with dementia, heart failure, and diabetes repeatedly refused prescribed diabetes medications, including insulin, over an extended period. Facility staff did not notify the resident's representative or physician of these refusals, as required, and there was no documentation of such notifications. The resident was later hospitalized for hyperglycemia and altered mental status, and the representative was unaware of the medication refusals.
The facility failed to properly monitor and respond to significant changes in a resident's respiratory status, resulting in an opioid overdose and aspiration pneumonia, and did not promptly assess or notify providers about a worsening pressure injury in another resident, causing severe pain. Additionally, two residents did not receive required specialized services due to missed referrals and lack of care plan communication, placing them at risk for health decline.
A resident with multiple health conditions, including malnutrition and skin breakdown, experienced significant unplanned weight loss due to the facility's failure to conduct ongoing nutritional assessments, monitor intake, and communicate changes to the interdisciplinary team. Staff did not consistently offer alternative food options or document refusals, and key team members were unaware of the resident's decline until hospitalization for complications related to poor nutrition.
A resident with severe cognitive impairment and a history of falls did not receive the required supervision and proper use of a fall prevention device when a nursing assistant failed to engage the drop seat in the resident's wheelchair. This omission led to the resident falling forward in the dining room and sustaining a forehead laceration that required hospital treatment.
Three residents were admitted with mental health diagnoses and received psychotropic medications, but their PASARR documentation did not accurately reflect these conditions or the need for Level II evaluation. Staff interviews revealed inconsistent verification of PASARRs against actual diagnoses and confusion about updated processes, leading to incomplete or incorrect PASARR records at admission.
The facility did not complete required OBRA registry verifications for several nurse aides before they began providing direct care, with some verifications delayed by months and others missing entirely. This failure meant the aides' eligibility and background were not confirmed as required by policy.
Multiple resident rooms and shower rooms were found with significant environmental deficiencies, including water on bathroom floors, cracked and stained flooring, exposed cement, mildew odors, damaged walls and trim, missing tiles, and unsanitary conditions such as soap scum and black substances. Maintenance staff were not consistently notified of these issues due to lapses in regular facility rounds and reporting procedures.
A resident with a urinary retention catheter experienced multiple UTIs and repeated antibiotic treatments after admission. Despite ongoing catheter use and recurrent infections, the facility did not refer the resident to a urologist to assess the need for continued catheterization or to address the cause of the UTIs.
Two residents requiring continuous oxygen therapy did not receive care according to physician orders, including failure to monitor oxygen saturation, replace and label oxygen tubing, maintain equipment cleanliness, and ensure humidification. One resident experienced skin irritation and used unlabeled, unchanged tubing without humidification, while another was left with an empty oxygen tank and low oxygen saturation, with staff unaware of the issue.
Two residents receiving high-risk medications, including a cytotoxic drug and an immunosuppressant, did not have appropriate care plans, monitoring, or administration protocols in place. Staff failed to use required precautions during medication administration, did not consistently administer medications at prescribed times, and did not monitor therapeutic drug levels as needed. Staff interviews revealed a lack of awareness regarding special handling and monitoring requirements for these medications.
Three residents received meals that were not appetizing or at safe temperatures due to delays in meal service. Although food was initially at the correct temperature, it became cold or lukewarm by the time it was served. Residents and staff reported dissatisfaction with the quality and temperature of the food, and staff acknowledged that delays in delivery contributed to the issue.
A resident with severe cognitive impairment and a history of falls sustained a laceration after falling in the dining room and was sent to the ER. The facility's investigation into the incident was incomplete, as required witness statements from staff were missing, despite established procedures for incident documentation.
A resident with Alzheimer's, depression, and anxiety was physically abused by a staff RN in response to the resident's aggressive behavior. The RN kicked the resident multiple times, which was witnessed by a Nursing Assistant. The facility's investigation substantiated the abuse, resulting in the RN's termination.
A resident with epilepsy and dementia experienced multiple falls and seizures after returning from a hospital stay, but the facility failed to ensure timely medical evaluation. Despite elevated Phenytoin levels, the resident was not seen by a medical provider until 13 days after readmission, leading to further health decline and repeated hospitalizations.
A resident with severe dementia and other conditions was injured during a mechanical lift transfer due to inadequate supervision. The facility's policy required two trained staff for such transfers, but only one staff member was actively involved, leading to the resident falling and sustaining a head injury. Interviews confirmed that the second staff member was merely observing, contrary to the policy.
A resident with dementia and severe cognitive impairment was physically abused by an RN who pushed them, causing a fall. The incident occurred after the RN's shift had ended, and the abuse was substantiated by the facility's investigation, leading to the RN's termination.
The facility failed to conduct annual performance reviews for five NAs, as required by WAC 388-97-1680. Personnel records showed missing or outdated reviews, placing residents at risk. Interviews revealed a flawed process where HR distributed forms that were not returned, and the Director of Nursing did not receive necessary forms. The Administrator acknowledged the broken process.
The facility failed to ensure proper hand hygiene and PPE use among staff, leading to potential exposure to MDROs. Staff members were observed not performing hand hygiene before and after resident contact and entering EBP rooms without PPE, despite facility policies and CDC guidelines.
A facility failed to honor a resident's right to make their own healthcare decisions by incorrectly designating a representative without consent. The resident, with chronic obstructive pulmonary disease and kidney disease, was able to make decisions but was overridden by their son-in-law, who was mistakenly treated as their representative. This led to a refusal of requested medication, violating the resident's rights.
The facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) and a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) as required for residents receiving Medicare-covered services. A resident with Alzheimer's did not receive the NOMNC within the required notice period, and another resident with a history of falls did not receive the SNFABN. Staff acknowledged the failure to provide timely notices.
The facility failed to ensure a sanitary and homelike environment in Hall C, the shower room, and several resident rooms. Observations revealed a strong urine odor in Hall C, damaged furniture, and a shower room in disrepair. Resident rooms had worn furniture and strong urine odors. Staff acknowledged the issues, noting that the furniture and room conditions were not up to standard.
The facility failed to notify the Ombudsman of transfers for two residents, one with Alzheimer's and dementia and another with a leg fracture and depression. Documentation of the required notices was missing, as confirmed by staff interviews, indicating non-compliance with the facility's notification process.
The facility failed to provide a complete Bed Hold Notice during hospital transfers for two residents, resulting in incomplete documentation and lack of information on bed hold charges. Interviews revealed that staff did not follow the expected procedure, risking residents' awareness of their rights and potential charges.
The facility failed to update the PASARR for two residents with new mental health diagnoses, including depression, anxiety, and dementia with behavioral disturbance. Despite the diagnoses being added to their records, the PASARRs were not updated, indicating a breakdown in the process. Staff interviews confirmed the oversight but did not provide an explanation for the failure.
A resident with severe cognitive impairment and multiple diagnoses, including dementia and dysphagia, did not receive consistent oral care as required by physician orders. Observations showed the resident's mouth was coated with a thick white film, and staff interviews revealed uncertainty about whether oral hygiene had been performed. The Director of Nursing acknowledged the system for assisting with oral care was ineffective.
The facility failed to implement resident preferences for outdoor activities, affecting multiple residents who expressed a desire to go outside. Despite care plans indicating the importance of outdoor activities, residents reported not being invited or given opportunities to go outdoors. Staff interviews revealed a lack of initiative in facilitating these activities, with some staff unaware of their role in assisting residents outside.
The facility failed to provide necessary restorative care to two residents, leading to a potential reduction in range of motion. One resident with hand contractures was not wearing prescribed splints, and another resident with severe dementia had no documented restorative therapy program. Staff interviews revealed confusion and miscommunication regarding the implementation of restorative programs, contributing to the deficiency.
A resident receiving enteral feeding through a PEG tube was at risk due to inappropriate connections between the tube and feeding spike set, leading to potential contamination and leakage. A nurse used a paper towel for traction on the slippery connection, a method not officially trained or sanctioned. The Director of Nursing and Administrator expected staff to report equipment issues, but this was not done, resulting in the deficiency.
A resident with COPD and heart failure did not receive continuous oxygen as prescribed while being transported within the facility. Observations showed the resident without oxygen on multiple occasions, and staff confirmed the lack of portable oxygen for in-facility use, relying on oxygen concentrators instead.
The facility failed to maintain complete and individualized clinical records for residents receiving foot care. Residents with significant medical conditions had identical podiatry notes, and there was a lack of communication between the podiatrist and nursing staff. Observations showed untreated foot issues, and staff interviews revealed that podiatry records were not reviewed or communicated effectively.
The facility failed to report an abuse allegation to the State Agency in a timely manner for two residents with Alzheimer's disease. A staff member allegedly pushed and yelled at the residents and kicked one resident's walker. The DNS did not report the incident, believing an anonymous report by a NA sufficed, contrary to facility policy requiring immediate reporting.
Failure to Implement Effective Interventions to Prevent Resident-to-Resident Altercations
Penalty
Summary
The facility failed to ensure staff implemented interventions to prevent resident-to-resident altercations, resulting in multiple incidents involving residents with dementia and cognitive impairment. One incident involved a resident with dementia, stroke, and encephalomalacia, who had severe cognitive impairment but was independent with walking, and another resident with dementia and diabetes, who was also severely cognitively impaired but independent with mobility. A nursing progress note documented that both residents were in the hallway when the first resident pushed the second resident into the wall as the second resident walked by. The note stated the incident was not provoked and was difficult to anticipate or prevent at the time. The Director of Nursing Services later acknowledged that the resident who pushed could become aggressive and that this incident met the definition of abuse. Another incident involved a resident with dementia, depression, sleep difficulties, significant memory loss, and dependence on staff for transfers using a tilt-in-space wheelchair, and a second resident with dementia, agitation, restlessness, seizures, poor impulse control, and a history of entering other residents’ spaces. The care plan for the second resident indicated they were cognitively impaired, verbal, independent with walking, and that staff were to redirect the resident and provide constant oversight when such intrusive behaviors occurred. An incident investigation showed that while the first resident was seated in their tilt-in-space wheelchair in a hallway, the second resident came up from behind, pushed the wheelchair forward, and caused the seated resident to slide to the floor and land on their bottom. Staff reported that the second resident, who was also demented, had previously tried to help by wheeling other residents in their wheelchairs and that interventions were to redirect the resident to another area or activity. The Director of Nursing Services described this as an isolated event and confirmed that the resident pushing the wheelchair had been observed walking quickly, grabbing the wheelchair, and pushing it rapidly when the incident occurred.
Failure to Assess and Care Plan for Hot Beverage Spill Risks
Penalty
Summary
The deficiency involves the facility’s failure to identify and evaluate residents at risk for accidents related to hot beverage spills and to implement individualized, resident-centered care plans to mitigate these risks. Facility guidelines stated that hot beverages such as coffee and tea would be held between 120°F and 150°F before leaving the kitchen and acknowledged that residents with tremors, poor hand control, weakness, impaired cognition, or those moving about with hot beverages were at greater risk for burns. Another guideline noted that hot beverage spills were a frequent source of scald injuries and that vulnerable residents in wheelchairs carrying hot liquids were at increased risk, with specific temperatures and exposure times identified as capable of causing serious burns. Despite these written guidelines, staff interviews revealed there was no formal process to identify or assess residents at high risk for spilling hot beverages, and no residents had care plans addressing this hazard. One resident with stroke, severe dementia, behavioral disturbances, agitation, exit-seeking behavior, and generalized muscle weakness had a comprehensive assessment showing severely impaired cognition, wheelchair dependence, and a need for substantial/maximal assistance with transfers. This resident did not have a care plan addressing risks or hazards related to spilling hot beverages or interventions to reduce the risk of injury from such spills. Observations showed the resident self-propelling in a wheelchair in and out of the dining room while drinking hot tea, maneuvering using feet and hands on tables, chairs, and handrails, and exhibiting confusion and exit-seeking behavior at doors. An incident report documented that during a group activity the resident removed the lid from a hot tea, lost grip, and spilled the beverage into their lap; the hot water temperature was measured at 146°F after the spill. A progress note recorded that the resident was very confused and disoriented, with redness and some peeling skin on the right inner thigh at the spill site. Multiple staff, including nursing and activities staff, reported that the resident commonly dropped drinks and food, frequently removed lids from hot beverages, sometimes took hot beverages into the hallway while self-propelling, and had previously spilled hot tea on themselves, but this prior incident was not documented and did not result in an assessment or care plan interventions. Another resident with stroke, Alzheimer’s disease with behavioral disturbances, anxiety, depression, generalized muscle weakness, and a cognitive communication deficit also lacked a care plan addressing risks related to hot beverage spills. A licensed nurse’s progress note documented that this resident spilled hot coffee on their right thigh during an activity, with the nurse observing light pink discoloration after the resident pushed up their pant leg, although the resident refused a full assessment. Despite this documented incident, there was no individualized care plan identifying the resident’s risk for hot beverage spills or specifying interventions or assistive devices to reduce the risk of further accidents. Staff interviews indicated that residents in the dining area, including this resident, were confused, had short-term memory loss, and sometimes exhibited frustration when confused, and that many residents in that area were at higher risk for spilling hot beverages. However, key clinical and administrative staff were unaware of this resident’s prior spill, no investigation was completed, and no changes were made to the care plan related to the hot coffee incident. Across both residents, staff interviews consistently showed that while individual staff recognized that residents with dementia, confusion, tremors, constant movement, or who walked or self-propelled with hot beverages were at increased risk for spills, there was no facility-wide process to identify such residents, no formal assessments completed for hot beverage spill risk, and no resident-centered care plans implemented to address this specific hazard. Kitchen temperature logs showed that hot beverages were routinely prepared at 170°F and delivered at 150°F, in accordance with the facility’s stated maximum of 150°F, but without adjustment based on individual resident risk. Clinical staff, including a physician’s assistant, acknowledged that residents in the facility were at risk for accidents related to hot beverage spills and that a prior incident of spilling hot liquids would be a safety concern warranting care plan interventions, yet they were unaware of the incidents involving these residents and of the facility’s hot beverage temperature guidelines. This combination of unimplemented guidelines, lack of risk identification and assessment, absence of individualized care planning, and continued service of hot beverages at high temperatures led to the cited deficiency under WAC 388-97-1060(3)(g).
Representative Signed Arbitration Agreement Without Authority
Penalty
Summary
The facility failed to ensure a resident’s representative was only given authority that had been delegated in the resident’s advance directives when it accepted a binding arbitration agreement. Resident 49 was admitted with diagnoses including moderate dementia with agitation, hearing loss, depression, and anxiety. The 12/02/2025 comprehensive assessment showed severely impaired cognition, inability to speak clearly, and that the resident was sometimes able to make needs known. The resident’s 07/22/2022 Power of Attorney for Health Care delegated the resident representative to make health care decisions, but did not give authority to agree to or enter into a facility binding arbitration agreement. The arbitration agreement was signed by the resident representative on 12/04/2023, and a staff witness signed it on 12/06/2023. During interviews, the Admissions Coordinator stated the agreement was discussed with the resident and/or representative upon admission and that for residents with severely impaired cognition, the representative designated as POA would sign the arbitration agreement. The Business Office Manager stated the facility reviewed POA paperwork to confirm the representative had authority to make decisions on behalf of the resident. The Social Services Specialist stated the advance directive was a legal document extending decision-making authority only within the guidelines specified in the document, and after reviewing Resident 49’s POA, stated the representative was not given authority to sign an arbitration agreement. The Administrator stated the facility should not have asked the POA to enter into or sign a binding arbitration agreement on behalf of Resident 49.
PASARR Level I Assessments Not Accurately Completed
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not accurately completed for 3 of 5 residents reviewed. The facility policy stated that the Social Worker or designee would ensure individuals with mental disorders or intellectual disability were appropriately evaluated and that Social Services would review PASARR and refer to the state designated authority when a patient was identified as having mental illness or intellectual disability. However, review of the records for Resident 24, Resident 2, and Resident 47 showed PASARR Level I assessments that did not identify indications of mental illness despite documented psychiatric and behavioral concerns in the chart. Resident 24 had diagnoses including dementia with agitation and diabetes, was severely cognitively impaired, and required substantial assistance with dressing, toileting, personal hygiene, and bathing; a psychiatric note documented persistent severe aggression and agitation. Resident 2 had diagnoses including dementia with agitation and anxiety, was severely cognitively impaired, required substantial assistance with dressing and personal hygiene, and was dependent on staff for showering and toileting; a psychiatric review note documented frequent aggression and paranoia. Resident 47 had diagnoses including dementia with agitation and atrial fibrillation, was severely cognitively impaired, and was dependent on staff for showers and personal hygiene; a psychiatric review note documented agitation, aggression, paranoia, and hallucinations. For all 3 residents, no PASARR Level II referral had been requested because the Level I assessments did not reflect the documented mental illness indicators.
Failure to Verify NA Registry Status
Penalty
Summary
The facility failed to obtain OBRA registry verification for 2 of 3 nursing assistants reviewed for staff qualifications. Staff M was hired on 12/10/2025 and began work on 01/11/2026, and Staff N was hired on 10/29/2025 and began work on 12/14/2025. Their personnel records contained no documentation of OBRA registry verification, even though the facility policy titled Abuse Prohibition stated potential employees would be screened for a history of abuse, neglect, and mistreatment by checking the appropriate licensing boards and registries. Washington State Board of Nursing guidance stated that a NA must be active on the OBRA Registry to work in a skilled nursing facility or nursing home, and that the registry identifies individuals ineligible to work because of abuse, neglect, or misappropriation findings. During interview, Human Resources staff stated OBRA verification was required before any NA was hired but that the process was not followed for Staff M and Staff N. The Administrator also stated OBRA verification was to be completed for regulatory compliance and the facility abuse prohibition policy, and confirmed the process was not followed.
Missing Influenza Vaccine Education and Consent Documentation
Penalty
Summary
The facility failed to ensure that 1 of 5 residents reviewed, Resident 16, had documentation in the medical record showing that the resident or the resident’s representative was provided education about the influenza vaccine before vaccination review. Resident 16 was admitted with diagnoses including dementia, depression, and hypertension, and the comprehensive assessment showed the resident was severely cognitively impaired and required substantial assistance with daily activities such as dressing, personal hygiene, and using the bathroom, while remaining independent with transfers and mobility. The record showed no documentation regarding the influenza vaccine administered on 10/22/2025. During interview, the Infection Preventionist/LPN stated they were unable to find paperwork in the resident’s record showing the resident’s representative had been given education on the risks and benefits of the influenza vaccine or had signed consent for administration.
Failure to Timely Review and Act on Urinary Lab Results Leads to Resident Harm
Penalty
Summary
The facility failed to ensure that physician orders from a urologist were completed and reviewed according to professional standards of practice for a resident with a history of diabetes, obstructive uropathy, and dementia. The resident, who was frequently incontinent and required extensive assistance with activities of daily living, experienced a change in urinary condition, including painful urination and hematuria. Orders were given for a urinalysis (UA) with culture and sensitivity (C & S), but there was no documentation that the UA was completed as ordered prior to a scheduled cystoscopy. After the cystoscopy, another UA was ordered and collected, but the results were not reviewed or acted upon in a timely manner. The medical record showed that the UA with C & S results, which indicated the presence of multi-drug resistant bacteria, were not reviewed by the facility's medical provider until 14 days after collection. During this period, the resident exhibited increased behavioral symptoms, including aggression and lethargy, but the pending laboratory results were not referenced or addressed in interdisciplinary team meetings or provider notes. Communication breakdowns occurred among licensed nurses, the medical provider, and the director of nursing, with staff assuming others had received and addressed the results. The director of nursing was unaware of the pending UA with C & S until contacted by the resident's representative. The delay in reviewing and acting upon the laboratory results contributed to the resident's hospitalization for septic shock due to urosepsis. Interviews with staff and the resident's representative confirmed that the facility did not respond promptly or thoroughly to the resident's change in condition, and the laboratory results were not followed up in accordance with facility policy or professional standards. The failure to ensure timely review and response to critical laboratory findings resulted in harm to the resident.
Failure to Notify Physician and Representative of Repeated Medication Refusals
Penalty
Summary
Facility staff failed to notify the resident's representative and physician of multiple medication refusals by a resident with diagnoses including dementia, heart failure, and diabetes mellitus. The resident, who had severely impaired cognition and required significant assistance with daily activities, was prescribed several medications to manage diabetes, including Glipizide, Humalog insulin, and Lantus insulin. The Medication Administration Record showed frequent refusals of these medications, particularly insulin, with some medications refused up to 22 out of 24 opportunities. Despite these repeated refusals, there was no documentation in the nursing progress notes indicating that the resident's representative or medical provider had been notified. Interviews with facility staff revealed inconsistent practices regarding notification of medication refusals. Some staff stated they would notify nursing management or the medical provider after more than one refusal, while others relied on verbal notifications or attempted to document notifications in the medical record. The Director of Nursing Services confirmed that notifications should have been made for these refusals, especially for medications with significant health impacts. The resident was subsequently admitted to the hospital for hyperglycemia and altered mental status, and the resident's representative reported being unaware of the extent of the medication refusals prior to the hospitalization.
Failure to Monitor Changes, Assess Wounds, and Provide Specialized Services
Penalty
Summary
The facility failed to thoroughly evaluate and monitor significant changes in a resident's respiratory condition and increased sedation from medications, resulting in actual harm. One resident with multiple diagnoses, including a recent fracture, heart disease, and chronic pain, exhibited signs of respiratory distress, confusion, and lethargy over a two-day period. Despite staff observations of abnormal skin color, slow responses, and complaints of pain and shortness of breath, there was a lack of timely and thorough assessment, delayed completion of ordered diagnostic tests, and inadequate monitoring of medication side effects. The resident ultimately experienced an opioid overdose and aspiration pneumonia, requiring emergency hospital intervention. Another resident with end-stage renal disease and a history of pressure injuries experienced a worsening coccyx wound that was not promptly assessed or reported to the provider. Nursing staff documented the wound's deterioration but failed to complete a full assessment, obtain measurements, or notify the provider in a timely manner. Communication breakdowns among staff and the interdisciplinary team led to a four-day delay in addressing the wound, during which the resident experienced severe pain. Staff interviews revealed confusion about wound assessment responsibilities and a lack of training in staging pressure injuries. Additionally, the facility did not follow through with specialized services for two residents. One resident with Alzheimer's disease and malnutrition was observed repeatedly leaning to one side in their wheelchair without the prescribed positioning wedge, as staff were unaware of the care plan and equipment needs due to poor communication between therapy and nursing. Another resident with a history of liver transplantation and chronic hepatitis did not receive timely referrals to a gastroenterologist or hepatologist as ordered, with staff citing workload and oversight as reasons for the delay. These failures placed residents at risk of not receiving necessary care and services to prevent decline in health and mobility.
Failure to Monitor and Address Significant Weight Loss in Resident at Nutritional Risk
Penalty
Summary
The facility failed to ensure that a resident at risk for weight loss received appropriate nutritional review and intervention. The resident, who had a history of skin breakdown, protein-calorie malnutrition, post-surgical recovery from a fractured thigh, rheumatoid arthritis, and urinary tract infections, experienced a significant unplanned weight loss of 18.67% over 40 days. Despite facility policies requiring regular nutritional assessments and weight monitoring, there was only one documented nutrition assessment shortly after admission, with no follow-up assessments or progress notes for nearly two months. Observations and interviews revealed that the resident consistently consumed less than the targeted amount of food, with meal intake ranging from 25% to 75%. Staff did not routinely offer alternative food options when the resident refused meals, and there was a lack of documentation regarding reasons for meal refusals or what alternatives were provided. The resident's care plan identified them as being at nutritional risk, but interventions were not effectively implemented or monitored, and significant weight changes were not communicated to the interdisciplinary team, physician, or dietitian as required by facility policy. Further, key staff members, including the ARNP, case manager, and registered dietitian, were unaware of the resident's significant weight loss and nutritional decline. The dietitian noted discrepancies in weight documentation and gaps in communication about the resident's condition. The resident was eventually hospitalized with low protein levels, electrolyte imbalance, and aspiration pneumonia, highlighting the lack of coordinated care and timely response to the resident's nutritional needs.
Failure to Provide Adequate Supervision and Proper Use of Fall Prevention Devices
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, a history of repeated falls, epilepsy, and lack of coordination did not receive adequate supervision and proper use of fall prevention devices as outlined in their care plan. The resident, who was dependent on staff for activities of daily living and enrolled in hospice care, was transferred to a drop seat wheelchair by a nursing assistant. However, the staff member failed to engage the drop-down seat into the reclining position, which was a required intervention to prevent the resident from falling forward. As a result of this omission, the resident fell forward out of the wheelchair in the dining room, sustaining a laceration to the left forehead that required hospital intervention for bleeding control and stitches. The incident was unwitnessed, and the facility's incident reporting log confirmed the fall and injury. Staff interviews revealed that the required post-fall procedures were followed after the incident, but the administrator acknowledged that the investigation into the event had not been completed at the time of the survey.
Failure to Accurately Review and Validate PASARR Documentation on Admission
Penalty
Summary
The facility failed to accurately review and validate Preadmission Screening and Resident Reviews (PASARR) for three out of five residents reviewed. Specifically, residents were admitted with diagnoses such as dementia, depression, anxiety, and obsessive-compulsive disorder, and were receiving psychotropic medications. However, their PASARR documentation did not consistently reflect these diagnoses or the need for a Level II evaluation, as required. For example, one resident's PASARR indicated no serious mental illness (SMI) despite documented depression and anxiety, while another's PASARR failed to list depression or OCD, even though both were present upon admission. Interviews with staff revealed that the admissions process involved reviewing PASARRs prior to admission, but there was no consistent verification of PASARR information against residents' actual diagnoses. Staff reported challenges in obtaining corrected PASARRs from hospitals and were not always aware when PASARRs were inaccurate. Additionally, there was confusion among staff regarding responsibility for verifying PASARR accuracy and awareness of updated PASARR processes, despite recent training. These lapses resulted in residents being admitted with incomplete or incorrect PASARR documentation.
Failure to Complete Timely OBRA Registry Verification for Nurse Aides
Penalty
Summary
The facility failed to ensure that Omnibus Budget Reconciliation Act (OBRA) registry verifications were completed for five nurse aides prior to their employment and provision of direct, unsupervised care to residents. Personnel files for these nurse aides showed either delayed verification or no documentation of OBRA registry checks, with one staff member's registry verified over five months after starting work and others lacking any verification at the time of review. The facility's policy required screening potential employees for a history of abuse, neglect, and mistreatment by checking licensing boards and registries, but this process was not followed as required. Interviews with Human Resources and the Administrator confirmed that OBRA registry verifications were not completed timely for the affected nurse aides, and that the issue was only identified during an internal audit. The lack of timely registry verification meant that the facility did not confirm whether these nurse aides met competency evaluation requirements or had any disqualifying findings before they began working with residents.
Failure to Maintain Safe and Sanitary Resident and Shower Rooms
Penalty
Summary
The facility failed to maintain a safe, comfortable, and sanitary environment in multiple resident rooms and shower rooms, as evidenced by direct observations and resident interviews. Specific deficiencies included bathrooms with persistent water on the floor, stained and cracked flooring with exposed cement, mildew odors, damaged drywall and paint, missing trim with jagged edges, and deep gouges in walls and doors. In the shower rooms, there were missing tiles, cracked flooring, exposed concrete, black and brown substances on tiles, and significant soap scum buildup on handrails. These environmental issues were present in five out of eight resident rooms and two out of three shower rooms reviewed. Interviews with staff revealed that the maintenance director was not consistently informed of these issues due to a lack of regular facility rounds and reliance on staff to report problems through an electronic maintenance log. The maintenance director confirmed that room checks were only performed when residents moved or were discharged, and that ongoing issues were not being systematically identified or addressed. The administrator acknowledged that the expected process of daily rounds and regular interdisciplinary checks was not followed, resulting in these deficiencies being overlooked.
Failure to Refer Resident with Indwelling Catheter for Urologist Assessment
Penalty
Summary
A resident was admitted to the facility with a urinary retention catheter following a hospital stay, during which the catheter was placed and the resident developed a urinary tract infection (UTI). The resident had a history of heart disease and was alert and oriented at the time of admission. The medical record indicated that the resident was not on a urinary catheter prior to admission and had experienced multiple UTIs and antibiotic treatments since being at the facility. Observations and interviews confirmed the ongoing use of the urinary catheter and repeated episodes of UTIs. Despite the resident's repeated UTIs and continued use of the urinary catheter, there was no evidence that the facility referred the resident to a urologist to assess the necessity of the catheter or to determine the cause of the recurrent infections. The Resident Care Manager confirmed that no referral had been made to obtain further evaluation or orders regarding the catheter's continued use or possible removal. This lack of referral and assessment contributed to the deficiency cited in the report.
Failure to Provide Safe and Continuous Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents requiring continuous oxygen therapy. For one resident with anemia and heart disease, staff did not follow physician orders to monitor oxygen levels every shift, clean the oxygen concentrator filter weekly, or replace oxygen tubing and nasal cannula every seven days. Observations revealed the resident's oxygen tubing was cloudy and unlabeled, the nasal area and skin behind the ears were irritated and red, and there was no sterile water attached to the concentrator for humidification. Staff were unaware of the missing humidification and labeling, and the oxygen concentrator filter was found to be dirty with visible dust buildup. For another resident with interstitial pulmonary disease and dementia, staff failed to ensure continuous oxygen delivery as ordered. The resident was observed multiple times with an empty portable oxygen tank, resulting in an oxygen saturation reading of 86%. The resident expressed feeling unwell, and staff were unaware that the oxygen tank was empty. Physician orders required verification that oxygen saturation remained above 92% during transfers and showers, but this was not monitored or maintained. These failures were identified through direct observation, interviews, and record review.
Failure to Monitor and Administer High-Risk Medications Appropriately
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary drugs due to inadequate monitoring, administration, and care planning for high-risk medications. For one resident with chronic lymphocytic leukemia and dementia, the care plan did not address cancer, the use of cytotoxic medication, or include interventions for monitoring adverse side effects or guidance for specialized handling. During medication administration, staff were observed not using gloves when handling Imbruvica, a cytotoxic medication, and staff interviews revealed a lack of awareness regarding necessary precautions and monitoring for side effects such as hemorrhage. For another resident with a history of liver transplantation, liver cancer, and chronic hepatitis, the physician's orders for Tacrolimus did not specify the need for administration at the same time each day, which is required to maintain therapeutic blood levels. The resident's medication administration records showed multiple instances where Tacrolimus was given late, early, or missed entirely. Additionally, laboratory tests to monitor therapeutic levels of Tacrolimus had not been obtained since admission, and the care plan did not address the transplant, immunosuppressive therapy, or monitoring for side effects and special administration instructions. Staff interviews indicated a lack of knowledge regarding the handling and monitoring of both cytotoxic and immunosuppressant medications. The contracted pharmacist confirmed the need for routine monitoring and administration protocols but had not ordered necessary lab tests, and the DON acknowledged the absence of additional monitoring or education for residents on immunosuppressant therapy. These deficiencies were observed and confirmed through record review, staff interviews, and direct observation.
Failure to Serve Palatable and Appropriately Tempered Meals
Penalty
Summary
The facility failed to provide appetizing and palatable meals to three residents, as evidenced by multiple observations and interviews. Meal temperatures were initially within guidelines when checked prior to service, but significant delays occurred between meal preparation and actual serving. For example, meal trays were prepared and placed in carts, but were not served to residents until 17 minutes later. When meals were finally served, test trays and resident meals were found to be below appropriate serving temperatures, with hot foods such as chicken fried steak and green beans served cold or lukewarm, and cold items like milk and pineapple above the recommended cold temperature. Residents reported dissatisfaction, describing their meals as cold, not appetizing, and not tasty. Staff interviews confirmed the issue, with dietary and administrative staff acknowledging that meals were not at the correct temperatures and that delays in meal service contributed to the problem. The facility's own policy required prompt notification and delivery of meals, but this was not consistently followed, resulting in residents receiving food that was not palatable or at a safe and appetizing temperature.
Failure to Thoroughly Investigate Resident Fall
Penalty
Summary
The facility failed to thoroughly investigate a fall involving a resident with dementia, muscle weakness, lack of coordination, and a history of repeated falls. The resident was admitted with severe cognitive impairment and was dependent on staff for activities of daily living. On the date of the incident, the resident fell in the dining room, resulting in a laceration to the left forehead and subsequent transfer to the emergency room for evaluation and treatment. Review of the facility's incident reporting log and investigation documentation revealed that witness statements were missing from the investigation of the fall. Interviews with staff confirmed that witness statements were not obtained or could not be located for the incident. Staff members described the expected procedure of reporting and documenting incidents, including the completion of witness statement forms by all staff present. However, it was acknowledged by both the Resident Case Manager and the Administrator that the required witness statements were not included in the investigation file for this incident. This lack of documentation indicated that the facility did not complete a thorough investigation as required.
Resident Abuse by Staff Member
Penalty
Summary
The facility failed to protect a resident from physical abuse by a staff member, which was substantiated through an investigation. The resident, who had been admitted with Alzheimer's Disease, depression, and anxiety, exhibited severe cognitive impairment and required assistance with personal care. The resident was involved in an incident where they displayed agitated and aggressive behavior, attempting to kick a staff member. In response, the staff member, identified as a Registered Nurse, retaliated by kicking the resident in the left lower leg multiple times. The facility's investigation confirmed the abuse, leading to the termination of the staff member's employment. Witnesses, including a Nursing Assistant, corroborated the incident, stating they observed the staff member kick the resident four times. The Director of Nursing immediately removed the staff member from the floor and conducted a skin assessment on the resident, finding no injuries. A Resident Representative acknowledged the resident's occasional aggressive behavior but did not believe it justified the staff's abusive response.
Failure to Ensure Timely Medical Evaluation for Resident
Penalty
Summary
The facility failed to ensure timely medical evaluation for a resident who experienced a decline in condition and multiple falls after returning from a hospital stay. The resident, diagnosed with epilepsy and dementia, had severely impaired cognition and was independent in daily tasks. However, they experienced seizures, falls, and head injuries, leading to multiple hospital transfers. Despite elevated Phenytoin levels noted in the hospital discharge summary, the facility staff did not question the continuation of the medication or ensure the resident was seen by a medical provider promptly. The resident was readmitted to the facility with elevated Phenytoin levels, but the staff did not arrange for a timely evaluation by the facility's medical provider. The resident continued to experience falls and seizures, resulting in further injuries and hospital visits. The facility's staff, including the Resident Care Manager and Infection Preventionist, acknowledged that residents should be seen by a medical provider within a week of hospital readmission, but this was not done for the resident in question. Interviews with facility staff, including the Director of Nursing and Medical Director, confirmed the expectation for residents to be evaluated within a week of hospital readmission. However, the resident was not seen by the facility medical provider until 13 days after readmission, despite multiple emergency room visits and elevated medication levels. This delay in medical evaluation contributed to the resident's continued health decline and repeated hospitalizations.
Failure in Safe Supervision During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure safe supervision and handling during mechanical lift transfers, resulting in harm to a resident. The policy titled Safe Resident Handling/Transfer Equipment required two trained staff to operate a mechanical lift for dependent lifting, transferring, or repositioning. However, during a transfer, only one staff member, Staff C, a Nursing Assistant, was actively involved in the process, while another staff member, Staff F, an LPN, was merely observing and did not assist. This lack of adherence to the policy led to a mechanical lift accident. The incident involved a resident with severe dementia, brain cysts, and mood disorders, who was totally dependent on staff for transfers. The resident was being transferred from a wheelchair to a bed using a mechanical lift when one of the sling straps loosened from the lift bar, causing the resident to fall and sustain a head laceration. The resident required hospital evaluation and treatment, including six staples to the head. Interviews revealed that Staff C had requested assistance from Staff F, but Staff F did not participate in the transfer, contrary to the facility's policy requiring two staff members to be actively involved. Staff E, responsible for staff development, confirmed that both staff members should have hands-on involvement during such transfers. The facility's administrator acknowledged the unsafe practice of having only one staff member conduct the transfer.
Failure to Protect Resident from Physical Abuse by Staff
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by staff, as evidenced by an incident involving a registered nurse (RN) identified as Staff C. The incident occurred when Staff C pushed a resident, who had been exhibiting increased wandering behaviors, causing the resident to fall. This action was taken while attempting to redirect the resident out of another resident's room. The facility's investigation substantiated the abuse, with statements from other staff members corroborating that Staff C admitted to pushing the resident in response to being hit in the chest by the resident. The resident involved had been admitted with diagnoses of dementia, malnutrition, and anxiety, and was noted to have severe cognitive impairment. The facility's policy explicitly prohibited abuse and mistreatment of residents, and the Director of Nursing confirmed that physical force was never acceptable. The investigation revealed that Staff C's shift had ended prior to the incident, and they should not have been on the floor with residents. The incident was documented in the medical record, and the abuse was substantiated, leading to the termination of Staff C's employment.
Failure to Conduct Annual Performance Reviews for Nursing Assistants
Penalty
Summary
The facility failed to complete annual performance reviews for five Nursing Assistants (NAs), which is a requirement under WAC 388-97-1680. The personnel records for Staff R, T, U, V, and W showed either missing or outdated performance reviews. Staff R had only one review dated two years after their hiring date, while Staff T, U, and W had no documented reviews at all. Staff V had a single review from 2019, despite being hired in 2015. This lack of compliance with the annual review requirement placed residents at risk of receiving care from potentially unqualified staff. Interviews with facility staff revealed a breakdown in the process for conducting these reviews. Staff Y, the HR/Payroll Manager, described a flawed system where performance review forms were distributed to management but often not returned. Staff B, the Director of Nursing Services, indicated that they were responsible for the reviews but did not receive the necessary forms from HR. The Administrator, Staff A, acknowledged awareness of the issue, admitting that the process for annual performance reviews was ineffective.
Infection Control Deficiencies in Hand Hygiene and PPE Use
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBPs) and proper hand hygiene practices among staff members, which are critical measures to prevent the transmission of multidrug-resistant organisms (MDROs) in skilled nursing facilities. Observations revealed that six staff members, including registered nurses and nursing assistants, did not perform hand hygiene before and after resident contact, while handling food trays, or when moving between tasks in the dining area. This lack of adherence to hand hygiene protocols was observed multiple times, with staff members touching resident plates, cutting food, and serving meals without washing their hands or using gloves. Additionally, the facility did not ensure the use of personal protective equipment (PPE) in rooms designated for enhanced barrier precautions. Staff members were observed entering EBP rooms without donning the required PPE, despite the presence of signage indicating the need for such precautions. Interviews with staff confirmed a lack of awareness and adherence to the facility's infection control policies, which are based on CDC guidelines. These failures placed all residents at risk for exposure to MDROs and potential serious medical complications.
Failure to Honor Resident's Right to Make Healthcare Decisions
Penalty
Summary
The facility failed to honor a resident's right to make their own healthcare decisions by incorrectly designating a representative without the resident's consent. Resident 16, who was admitted with chronic obstructive pulmonary disease and kidney disease, was found to have moderately impaired cognition but was still able to make their own decisions. Despite this, the facility allowed the resident's son-in-law to act as their representative without proper documentation or consent from the resident. The son-in-law refused consent for an antidepressant medication that the resident had requested, which was against the resident's wishes. The facility's admissions process was flawed, as the Admissions Coordinator completed the paperwork with the son-in-law without verifying the legal authority or speaking directly with the resident. The admission agreement clearly indicated that no representative was designated, yet the son-in-law was treated as such. This oversight led to a violation of the resident's rights, as they were not allowed to exercise their right to make their own healthcare decisions, despite being cognitively intact at the time of admission.
Failure to Provide Required Medicare Notices
Penalty
Summary
The facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) and a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) as required for residents receiving Medicare-covered services. Specifically, Resident 37 did not receive the NOMNC within the required two-day notice period before the end of their Medicare Part A stay, and there was no documentation of an SNFABN being issued. Resident 37, diagnosed with Alzheimer's disease and requiring maximum assistance for activities of daily living, continued to stay in the facility without exhausting their Medicare benefits. The Business Office Manager acknowledged the failure to provide timely notice. Additionally, Resident 162, who had a history of falls and was admitted with a broken hip and tailbone, did not receive the required SNFABN before their last covered day of skilled services. The Minimum Data Set Coordinator confirmed that both Resident 37 and Resident 162 should have received the SNFABN. The facility's Administrator also acknowledged the necessity of completing and delivering these notices in a timely manner according to regulations.
Facility Fails to Maintain Sanitary and Homelike Environment
Penalty
Summary
The facility failed to maintain a sanitary and homelike environment in Hall C, the shower room, and several resident rooms. Observations over a week revealed a persistent strong odor of urine in Hall C, with staff acknowledging the issue but unable to identify its source. The furniture in Hall C was in disrepair, with peeling leather, gouges, and fecal matter observed on a chair and the floor beneath it. The shower room was dimly lit, with missing tiles exposing concrete, and a ceiling fan coated with lint. The grout lines in the shower tiles showed discoloration, and the shower door had paint scrapes and smears of unknown substances. In the resident rooms, furniture was worn and damaged, with dressers and nightstands showing scratches and missing handles. The bathrooms had strong urine odors, sticky floors, and missing paint or trim. Staff interviews revealed that the furniture surfaces were not cleanable, and there were ongoing issues with removing urine odors from the flooring. The Director of Nursing Services and Housekeeping Supervisor acknowledged the deficiencies, noting that the furniture and room conditions were not up to standard and required attention.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide a written notice of transfer or discharge to the representative of the Office of the State Long Term Care Ombudsman for two residents reviewed for transfer or discharge notice requirements. This deficiency was identified during interviews and record reviews. The facility's policy, revised on 11/15/2022, mandates that a written notice of transfer or discharge must be provided to the Ombudsman when the facility initiates a discharge of a resident transferred to a hospital or other acute care setting. Resident 38, who had Alzheimer's disease and dementia with severely impaired cognition, was transferred to the emergency department following a change in health condition. However, there was no documentation of a notice of transfer or discharge to the Ombudsman in the resident's medical record. Similarly, Resident 59, who had a right leg fracture and depression with moderately impaired cognition, was transferred to the hospital and did not return to the facility. There was no documentation of a notice of transfer or discharge to the Ombudsman for this resident either. Staff interviews confirmed the absence of such documentation, indicating a failure to adhere to the facility's notification process.
Failure to Provide Bed Hold Notice During Hospital Transfers
Penalty
Summary
The facility failed to issue a written notice of bed hold at the time of hospital transfer for two residents, which is a requirement to inform residents or their representatives about their right to hold their bed and any associated charges. For Resident 16, who had chronic obstructive pulmonary disease and kidney disease, the Bed Hold Notice Policy and Authorization form was incomplete, lacking the monetary rate for the per day charge and a resident signature. The form contained illegible handwriting and signatures, indicating a lack of proper documentation. Similarly, for Resident 38, who had Alzheimer's disease, the Bed Hold Notice Policy and Authorization form was also incomplete, missing the daily monetary amount to hold the bed and documentation of whether the resident or their representative wanted to hold the bed. Interviews with facility staff revealed that the expected procedure was not followed, as the nursing staff should have completed the form with the required information and ensured it was signed appropriately. This oversight placed the residents at risk of not being informed about their rights and potential charges during their hospital stay.
Failure to Update PASARR for Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure the accuracy of the Pre-Admission Screening and Resident Review (PASARR) for two residents, which is a federally required form to prevent inappropriate placement in nursing homes. Resident 16 was admitted with diagnoses including chronic obstructive pulmonary disease, kidney disease, and depression. Despite a diagnosis of depression being noted in a provider progress note and added to the resident's admission record, there was no documentation of an updated PASARR to reflect this mental health condition. Similarly, Resident 52 was admitted with diagnoses including bipolar disorder and later received new diagnoses of anxiety and dementia with behavioral disturbance. The admission PASARR indicated a mood disorder but did not include these additional mental health conditions. There was no documentation of an updated PASARR for these new diagnoses. Interviews with facility staff revealed a breakdown in the process of updating PASARRs when new mental health-related diagnoses were added, as the Director of Nursing Services and the Administrator acknowledged the failure but could not explain why the process was not followed for these residents.
Failure to Provide Consistent Oral Care for Dependent Resident
Penalty
Summary
The facility failed to provide consistent oral care for a resident who was dependent on staff for activities of daily living (ADL). The resident, who had diagnoses including dementia, dysphagia, muscle weakness, and contractures, was admitted with a physician's order for oral care every shift. Observations over several days revealed that the resident's teeth and mouth were consistently coated with a thick white film, indicating a lack of proper oral hygiene. Interviews with staff members, including nursing assistants and a registered nurse, revealed uncertainty about whether the resident's oral care had been performed, despite the expectation that staff would provide all necessary personal care for dependent residents. The Director of Nursing Services acknowledged that the system in place to assist with residents' oral care was not functioning effectively. The facility's policy on ADLs, revised in May 2023, stated that residents unable to perform ADLs would receive the necessary assistance to maintain good personal and oral hygiene. However, the observations and staff interviews indicated that this policy was not being followed, resulting in unmet care needs for the resident.
Failure to Implement Resident Preferences for Outdoor Activities
Penalty
Summary
The facility failed to implement resident preferences for outdoor activities, affecting five out of six residents reviewed for activities. The facility's policy, dated February 1, 2023, mandates that residents' preferences and choices should be incorporated to enhance their self-worth. However, observations and interviews revealed that residents were not provided opportunities to go outside, despite their expressed desires and care plans indicating the importance of outdoor activities for their well-being. Resident 56, with diagnoses including COPD, dementia, and heart failure, expressed a strong desire to go outside, but reported rarely having the opportunity due to staff being too busy. Similarly, Resident 7, who has anoxic brain damage, dementia, and depression, stated they were bored and not invited to go outdoors, despite their care plan highlighting the importance of outdoor activities. Residents 13, 14, and 25 also expressed a desire to go outside, with Resident 13 describing the facility as "like a prison" due to the lack of outdoor access. Interviews with staff members, including the Activities Director and Nursing Assistants, revealed a lack of initiative in facilitating outdoor activities. The Activities Director mentioned that outdoor group activities were only provided during certain months, and staff were not actively offering residents the opportunity to go outside. Nursing Assistants stated they were not responsible for taking residents outdoors, and some were informed they could not do so. The Administrator indicated that residents needed to request outdoor access and be assessed for wandering freely, but this process was not effectively communicated or implemented.
Failure to Implement Restorative Care for Residents
Penalty
Summary
The facility failed to provide necessary services to prevent a reduction in range of motion for two residents, identified as Residents 2 and 15, who were reviewed for range of motion and/or use of splints. Resident 2, who was admitted with diagnoses including dementia, dysphagia, muscle weakness, and contractures in both hands, had a physician's order for daily use of hand splints. However, multiple observations revealed that Resident 2 was not wearing the prescribed splints or alternatives like rolled washcloths, as required. Staff interviews indicated a lack of clarity and adherence to the restorative therapy schedule, contributing to the deficiency. Resident 15, also with severe dementia and dependent on staff for daily care, was observed with hands in a fist position without any splints or washcloths to prevent contractures. Despite having contractures, there was no restorative therapy program documented in their physician orders. Interviews with staff revealed confusion and miscommunication regarding the implementation and responsibility for restorative programs, with the physical therapy department, MDS coordinator, and resident care managers not effectively coordinating to ensure the resident received necessary care. The deficiency was further highlighted by the lack of a restorative program for Resident 15, as confirmed by staff interviews. The physical therapy department was expected to provide a restorative plan to the MDS coordinator, but this process was not completed, leaving Resident 15 without the necessary interventions to prevent further decline. The Director of Nursing Services acknowledged the expectation for a restorative plan to be implemented, but the failure in communication and execution led to the deficiency observed by the surveyors.
Inappropriate Enteral Feeding Practices
Penalty
Summary
The facility failed to ensure appropriate treatment and services related to enteral feeding for a resident, identified as Resident 52, who was dependent on tube feeding through a percutaneous endoscopic gastrostomy (PEG) tube. The deficiency was observed when inappropriate connections were used between the PEG tube and the tube feeding spike set, leading to potential contamination and loss of caloric intake due to fluid leakage. During observations, it was noted that a brown paper towel was wrapped around the end of the tube feeding spike set and the receiving end of the PEG tube, with dried formula splatters on the floor and the pole holding the tube feed. Interviews with staff revealed that the Registered Nurse, identified as Staff J, used the paper towel to maintain traction on the slippery tube feeding spike set, despite not being trained to do so. Staff J admitted to devising this method independently due to the lack of proper equipment. The Director of Nursing Services, Staff B, stated that licensed nurses were expected to report equipment issues to administrative staff for resolution. The Administrator, Staff A, also expected licensed nurses to ensure all necessary equipment and supplies were available before starting procedures and to report any missing items to the Resident Care Manager or DNS.
Failure to Provide Continuous Oxygen Supply
Penalty
Summary
The facility failed to ensure a continuous supply of oxygen for a resident, identified as Resident 56, who required continuous oxygen due to chronic obstructive pulmonary disease (COPD) and heart failure. The resident was observed on multiple occasions without their prescribed oxygen supply while being transported within the facility. On one occasion, the resident was brought into the dining room without oxygen and was visibly short of breath, holding their oxygen tubing in hand. Staff later retrieved an oxygen concentrator from the resident's room. Another observation noted the resident being returned to their room without oxygen, and staff had to go back to get the oxygen machine. Interviews with facility staff revealed that the facility did not have portable oxygen available for use within the facility, relying instead on oxygen concentrators that require electricity. Staff members acknowledged that the resident would be without oxygen for a few minutes during transport within the facility. The Director of Nursing Services stated that continuous oxygen monitoring was expected for the resident when moving throughout the building and that a physician order would be needed to transfer the resident without oxygen. If such an order was denied, portable oxygen tanks would be used to ensure continuous oxygen supply during movement within the facility.
Incomplete and Non-Individualized Podiatry Records
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurate for three residents who were reviewed for foot care. The residents involved had significant medical conditions, including dementia, multiple sclerosis, Alzheimer's disease, and paraplegia, which made them dependent on staff for activities of daily living and resulted in impaired cognition. The podiatry notes for these residents were not individualized and were identical for each resident, indicating a lack of proper documentation and communication regarding the care provided. Observations revealed that one resident had visible foot issues, such as black crust and thick, flaky toenails, which were not adequately addressed. Interviews with staff, including a Licensed Practical Nurse, Resident Care Managers, and the Director of Nursing Services, highlighted that there was no effective communication or hand-off process between the podiatrist and the nursing staff. The podiatrist's notes were not reviewed by nurses or care managers, and the records from the podiatrist's visits were delayed, leading to a lack of awareness about the specific care provided to each resident.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to report an allegation of abuse/neglect to the State Agency in a timely manner for two residents, both diagnosed with Alzheimer's disease and having severely impaired cognition. The incident involved a staff member allegedly pushing and yelling at the residents and kicking one resident's walker. The Director of Nursing Services (DNS) was informed of the incident by a nursing assistant (NA) who had reported the abuse anonymously to the State Agency. However, the DNS did not make an official report from the facility, mistakenly believing the NA's anonymous report fulfilled the facility's reporting obligation. The facility's policy required immediate reporting to the State Agency, within two hours for serious bodily harm allegations and within 24 hours for non-serious bodily injury allegations. The Administrator acknowledged that the facility's normal process was not followed, as the anonymous report by the NA did not meet the requirement for a facility report. This oversight placed the residents at risk for unidentified and ongoing abuse/neglect, as the facility did not ensure the proper reporting protocol was followed.
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 70 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 Moses Lake
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Columbia Crest Center | 0.8 mi | ★★★★★ | 31 | 0 |
| Columbia Basin Hospital | 18.4 mi | ★★★★★ | 25 | 0 |
| Mckay Healthcare & Rehab Ctr | 20.9 mi | ★★★★★ | 1 | 0 |
| Othello Post Acute | 21.1 mi | ★★★★★ | 13 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.