Below average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Landmark Care And Rehabilitation during CMS and state inspections, most recent first.
Failure to investigate a staff altercation witnessed by two residents. A resident with dementia and another resident with Parkinson’s disease and impaired cognition were at the nurse’s station when an NA and other staff yelled and cursed during a shift dispute. Staff noted the resident appeared fearful and nervous, but the DON treated it as a staff issue, did not complete an investigation or documentation, and no resident monitoring was initiated.
A resident’s room had two malfunctioning call lights, as reported by a resident representative who was unable to activate either device or see any corresponding hallway or wall indicator lights. Later observation with a NA confirmed that the call light for the bed near the door did not work at all and that the call light for the bed near the window only activated after multiple button presses. The Maintenance Director described a rotating monthly testing schedule for call lights and reliance on verbal reports or TELS work orders between test cycles, and the Administrator acknowledged that both call lights in the room needed replacement and that all resident call lights should function at all times.
Multiple residents with high fall risk experienced repeated, often unwitnessed falls resulting in injuries such as fractures and lacerations due to inadequate supervision, incomplete or delayed care plans, and failure to consistently implement or update individualized fall prevention interventions. Staff did not always follow established care plans or facility policies, and incident investigations were incomplete or missing.
A resident with severe cognitive and physical impairments developed a pressure-related blister on the left heel and a pressure injury with slough and eschar on the right ankle after staff failed to consistently implement and document required interventions, such as floating the heels, applying heel protectors, and completing skin assessments. The care plan did not address the new or worsening wounds, and staff did not properly use pressure-relieving devices as ordered.
The facility did not maintain adequate nursing staff, resulting in residents experiencing delays in assistance, unmet ADL needs, inconsistent restorative care, and insufficient monitoring of skin integrity and falls. Multiple residents suffered harm, including incontinence, untreated skin injuries, pressure ulcers, and injuries from falls, while staff interviews and grievance records confirmed ongoing staffing shortages and unresolved care concerns.
Three residents experienced unwitnessed falls resulting in significant injuries, including lacerations, fractures, and bruising, but these incidents were not reported to the state agency as required by both state guidelines and facility policy. The DON acknowledged that the reporting process was not followed in at least one case, and staff failed to recognize the reportability of another incident.
The facility did not complete thorough investigations for multiple residents who experienced falls, skin tears, or injuries of unknown source. Incident reports were missing or lacked sufficient detail, and required documentation such as witness statements and root cause analysis was not completed. As a result, the facility failed to rule out abuse or neglect in these cases.
A resident's funds were not refunded to their representative within the required timeframe after the resident's death. Despite assurances from the business office, the representative had not received the $11,800.00 refund for unused room and board several months after the resident passed away.
A resident with a history of stroke and joint replacement, who was cognitively intact and continent upon admission, experienced incontinence and embarrassment after waiting too long for toileting assistance. The care plan required staff to provide toileting support as needed, but documentation showed episodes of incontinence, and the DON confirmed staff are expected to follow care plans.
Two residents with mental health diagnoses were started on psychotropic medications without documented informed consent or evidence that they or their representatives were informed about the medications. The DON confirmed that obtaining consent was the responsibility of admission or floor nurses, but the process was missed for these residents.
A resident admitted with Parkinson's Disease, depression, and anxiety was incorrectly identified as having dementia on the PASARR Level 1 screening. Facility staff did not recognize or correct this error, and a Level 2 evaluation was not requested, despite the resident's mental health diagnoses.
Three residents with significant care needs did not receive proper assistance with grooming, nail care, and personal hygiene as required by their care plans. Observations showed unshaven facial hair, long and dirty fingernails, and unkempt appearance, with no documentation of care refusals. Staff interviews and records indicated that scheduled care was not consistently provided or documented, resulting in unmet ADL needs.
A Medication Assistant Certified was found to have an expired CPR certification, contrary to facility policy requiring current CPR/BLS training for staff responsible for emergency response. Staff development was unaware of the lapse, and the DNS acknowledged the expired certification, resulting in a risk of untrained staff being available during emergencies.
Two residents with significant medical conditions and mobility limitations were observed with untreated, actively bleeding skin wounds. Nursing staff did not provide timely assessment, treatment, or documentation for these wounds, and there was no evidence of physician or family notification. Care plans and treatment records lacked appropriate interventions, resulting in unmet care needs and ongoing skin integrity issues.
Three residents with cognitive and physical impairments did not consistently receive restorative nursing care as outlined in their care plans, including ROM exercises, transfer training, and hand splinting. Staff interviews and observations revealed missed or incomplete interventions, lack of measurable goals, and insufficient documentation, with staff turnover and unclear responsibilities contributing to the deficiencies.
A resident with a history of PTSD, bipolar disorder, and depression, who recently experienced a lower leg amputation and the loss of a spouse, did not receive trauma-informed care. The facility's care planning failed to address the resident's PTSD or identify specific triggers, and staff did not conduct a thorough assessment of trauma-related needs, resulting in inadequate support for the resident's mental health.
Two residents receiving hospice care did not have current, individualized hospice care plans integrated into their records, and documentation of hospice orders or input was missing. The facility did not follow its process for incorporating hospice care plans, resulting in incomplete care planning and unclear provider responsibilities.
The facility failed to develop baseline care plans within 48 hours of admission for five residents, each with specific medical conditions and care needs. The absence of documented goals, focus areas, or interventions in the care plans placed residents at risk of not receiving necessary care. Interviews with staff indicated that essential areas such as ADLs, pain, fall risks, skin integrity, and bowel and bladder continence were not addressed.
A resident's medical information was improperly disclosed to unauthorized family members by a staff member, violating HIPAA guidelines. The resident, hospitalized due to a urinary infection, had their condition and hospital location shared without consent. The facility's investigation could not identify the responsible staff member, and HIPAA education was provided without documentation.
The facility failed to timely implement its grievance process for three residents, leading to unresolved issues. A resident with a fracture experienced severe pain due to delayed medication, another with MS did not receive a shower for over two weeks, and a resident with dementia faced delays in assistance. Staff interviews revealed grievances were misplaced and not addressed promptly, contributing to the deficiency.
A resident with severe cognitive impairment was allegedly subjected to abuse by an OT who threw the resident's baby doll to the floor, causing distress. The incident was reported to the Director of Rehab, who did not log or report it to the State Agency, believing it to be a misinterpretation. The facility's administrator acknowledged the failure to report the incident.
A resident with severe dementia was allegedly subjected to emotional abuse by an OT who reportedly threw the resident's baby doll on the floor. The facility failed to investigate the allegation or remove the alleged perpetrator, placing the resident at risk for further distress. The Director of Rehab did not follow the proper process for handling abuse allegations.
The facility failed to document discussions about Advance Directives (AD) for two residents with severe cognitive impairment, risking their end-of-life care preferences. Staff acknowledged that AD discussions were not routinely documented, despite policy requirements for review and documentation. The Director of Nursing confirmed the facility's non-compliance with their AD process.
The facility failed to prevent and treat pressure ulcers in three residents, leading to worsening conditions. A resident developed new pressure injuries after admission, another experienced prolonged use of a malfunctioning air mattress exacerbating a Stage 4 pressure injury, and a third resident faced delays in receiving appropriate treatment for a heel wound. These deficiencies highlight inadequate preventive measures and delayed responses to wound care needs.
The facility failed to provide adequate nursing staff, resulting in residents not receiving scheduled showers, leading to hygiene issues and skin conditions. Care plans for residents with specific medical needs were not maintained, and follow-up appointments with specialists were delayed. Additionally, residents with dysphagia were left unsupervised during meals, posing a choking risk, and infection control practices were inadequate.
The facility failed to issue timely Notices of Medicare Non-Coverage (NOMNC) for three residents and an incomplete Advance Beneficiary Notice (ABN) for one resident. Residents received NOMNCs less than the required two days before discharge, and one ABN lacked the resident's care choice. Staff interviews indicated social services were responsible but did not follow the correct process.
Two residents in an LTC facility did not have comprehensive care plans addressing their specific medical needs. One resident, with conditions including heart failure and sleep apnea, lacked care plan interventions for their CPAP and oxygen use. Another resident, with chronic kidney disease, was unaware of their fluid restriction, which was not included in their care plan. Staff interviews confirmed the care plans were incomplete.
The facility failed to provide consistent showering and grooming care for residents dependent on staff for ADLs, affecting five residents. Despite care plans outlining specific shower schedules, residents experienced significant delays, with some going over a week without a shower. Staff shortages and insufficient time were cited as reasons for the deficiency, leading to unmet care needs and potential risks for skin integrity issues.
The facility failed to adequately monitor and assess the use of psychotropic medications for two residents. One resident was prescribed an as-needed antianxiety medication without a stop date or assessment, while another resident on antipsychotic medication did not receive AIMS assessments or quarterly IDT reviews. These oversights placed the residents at risk for adverse side effects and health deterioration.
The facility failed to implement Enhanced Barrier Precautions (EBPs) for seven residents with various medical conditions, including open wounds and indwelling devices. Observations showed no signage indicating the need for additional PPE, and staff interviews revealed a lack of awareness and implementation of EBPs. The Director of Nursing admitted to challenges in policy creation and staff education due to the absence of a full-time infection preventionist.
The facility failed to maintain mechanical lifts in a functional state, with all three lifts having malfunctioning emergency features and exposed wires. During a transfer, a resident was left suspended due to a lift malfunction. Staff were unaware of the primary manual lowering method, and issues had been reported to management for months without resolution.
Three residents experienced a lack of dignity due to missed showers, leading to distress and embarrassment. One resident with a skin condition reported odor issues, another had noticeable body odor and unkempt appearance, and a third faced physical discomfort and embarrassment due to infrequent bathing. These issues were observed through interviews and record reviews.
The facility failed to provide proper written notices of discharge to residents and their representatives, as well as to the LTC Ombudsman. This deficiency was identified in four cases, where residents were transferred without appropriate documentation. Interviews with staff indicated issues with the notification process, resulting in untimely, incomplete, or illegible forms.
A resident was transferred to the hospital without receiving a written bed hold notice, as required by the facility's policy. The Social Services Director, responsible for issuing such notices, acknowledged the oversight. Interviews with staff, including the DON and President of Clinical Operations, confirmed that the bed hold notification process was not followed.
The facility failed to accurately complete PASARR documentation for two residents, risking inappropriate placement and unmet mental health needs. One resident's PASARR omitted PTSD and bipolar disorder diagnoses, while another's lacked anxiety and depression documentation. The DON and President of Clinical Operations acknowledged the need for process updates.
The facility failed to provide baseline care plans within 48 hours for two newly admitted residents, as required by federal regulations. One resident with respiratory disease, congestive heart failure, and diabetes did not receive a care plan with specific medications or treatments, and dietary information was inconsistent. Another resident with malnutrition and dysphagia also lacked a timely care plan, with discrepancies in dietary needs. Staffing changes in social services may have contributed to these lapses.
The facility failed to ensure timely care conferences and updates to care plans for residents, leading to unmet care needs. A resident with Alzheimer's had not attended a care conference since April 2023, while another with bipolar disorder missed a conference within 90 days. A resident with a new urinary catheter had an outdated care plan, and a resident with a left-hand brace lacked proper documentation and physician orders.
A facility failed to follow through on specialist referrals for a resident with complex medical conditions, including Paget's disease and a sacral pressure injury with osteomyelitis. Despite urgent referrals for Infectious Disease, Rheumatology, and Urology consultations, the facility did not ensure these appointments were scheduled. A breakdown in the referral process was identified, as nursing orders were not forwarded to the Health Information Manager responsible for scheduling, placing the resident at risk for health decline.
The facility failed to prevent a reduction in range of motion for two residents. One resident with hemiplegia wore a brace daily without a physician order or care plan documentation, while another resident with a hand contracture lacked a splint and proper intervention. Staff interviews and observations confirmed these deficiencies.
The facility failed to provide adequate dining supervision for two residents with dysphagia, leading to potential choking risks. One resident was left unsupervised in the dining room despite needing assistance, while another was left alone in their room despite high aspiration risk. Additionally, toxic cleaning chemicals were left unsecured in five shower rooms, accessible to cognitively impaired residents.
The facility failed to justify the use of a urinary catheter for a resident with no documented medical need and improperly handled another resident's catheter during a transfer, risking infection. The first resident requested a catheter due to delays in toileting assistance, but records lacked appropriate orders. The second resident's catheter bag was incorrectly positioned during a lift transfer, contrary to guidelines.
A resident with a tracheostomy experienced inadequate respiratory care due to inconsistent documentation and lack of staff training. The resident's care plan required saline irrigated tracheal suctioning, which was inconsistently performed and often refused. Staff interviews revealed a lack of formal training in tracheostomy care, with some RNs performing deep suctioning without orders, while others refrained due to scope of practice concerns. The resident's POA was unaware of the facility's orders to call them for deep suctioning, leading to concerns about the resident's frequent respiratory distress.
A resident with end-stage renal disease did not receive dialysis care consistent with professional standards. The facility failed to complete required pre and post-dialysis assessments, did not adhere to the resident's fluid restriction, and lacked communication with the dialysis center. The care plan was incomplete, and there was no current written agreement or specific policies for dialysis services.
A facility failed to provide trauma-informed care for a resident with PTSD by not assessing or addressing their traumatic experiences. Despite the resident's history of significant trauma, the facility's screening process did not identify any notable symptoms, leading to an incomplete care plan. Staff interviews revealed a lack of adherence to the proper procedures for trauma-informed care, resulting in unidentified and unaddressed PTSD triggers.
The facility failed to ensure that nursing staff had the necessary competencies for PICC line care, as evidenced by the lack of specific training and return demonstrations for two staff members. This deficiency was identified through interviews and record reviews, revealing that staff relied on self-assessments without proper verification of skills, placing residents at risk for adverse outcomes.
A resident with PTSD and depression did not receive necessary behavioral health services at the facility. Despite expressing a desire for group therapy and counseling, the resident's care plan focused only on medication management. Staff interviews revealed a lack of appropriate referrals and actions to address the resident's mental health needs.
A significant medication error occurred when an LPN failed to follow a physician's order for heparin administration for a resident with a PICC line. The LPN administered the heparin flush before the antibiotic, contrary to the order, placing the resident at risk for complications. The error was acknowledged by the LPN and highlighted by the DON as a deviation from expected practice.
The facility experienced a systemic issue with providing timely and consistent wound care for pressure injuries, particularly over weekends. Three residents with conditions such as peripheral vascular disease, Type 2 Diabetes, atrial fibrillation, and epilepsy developed pressure injuries that worsened due to missed wound care. Staff, including RNs and LPNs, acknowledged concerns about incomplete dressing changes and non-adherence to physician orders. The deficiency report highlighted the importance of following professional standards for pressure injury treatment to prevent further harm and deterioration in residents' health.
The facility failed to obtain informed consent for psychotropic medications for two residents. Resident 3 was started on Quetiapine without informing the RR/POA, and Resident 4 was started on Duloxetine and Quetiapine without a completed consent form. Staff confirmed that the normal process for obtaining informed consent was not followed.
The facility failed to implement an effective QAPI program that identified or corrected deficiencies in the skin program, leading to inadequate pressure injury care for three residents. The Administrator acknowledged that the QAPI process did not address the deficient practice, resulting in resident harm.
Failure to Investigate Staff Altercation Witnessed by Residents
Penalty
Summary
The facility failed to investigate a staff altercation that was witnessed by two residents. The facility policy on abuse stated residents had the right to be free from abuse, neglect, misappropriation of property, and exploitation, and that all allegations of abuse would be immediately reviewed and investigated by designated staff. In this event, staff reported that a verbal confrontation occurred at the nurse’s station between a nursing assistant and other staff members while residents were present. Resident 1 had diagnoses including dementia and muscle weakness, and the comprehensive assessment showed impaired cognition and a need for one staff member for mobility. Resident 2 had diagnoses including Parkinson’s disease and heart disease, and the comprehensive assessment showed impaired cognition and a need for one to two staff members for mobility. Staff C stated that during the altercation, Resident 1 and Resident 2 were at the nurse’s station, and Resident 1 appeared fearful, with widened eyes and pointing at the nursing assistant. Staff E also stated Resident 1 appeared nervous and worried during the incident and relaxed after the nursing assistant was told to leave. Staff C stated they informed the DNS about the altercation but did not place the residents on alert charting for psychosocial harm monitoring. Staff B stated they knew about the verbal altercation between staff members, instructed the charge nurse to send the nursing assistant home, but did not perform an investigation because they viewed it as a staff issue. Staff B also stated they were not aware residents had been nearby and heard the altercation, and no incident report or documentation of the conversations was completed. The Administrator stated the incident should have been handled promptly with an investigation and follow-up with residents to ensure no lasting fears or concerns about their safety, and that the process to complete an investigation was not followed.
Failure to Maintain Functional Call Light Systems in Resident Room
Penalty
Summary
The deficiency involves nonfunctioning resident call light systems in a specific resident room and the facility’s failure to ensure that call lights were consistently operational. A resident representative reported that during a visit, both call lights in the room did not work despite multiple attempts to activate them, and neither the hallway light above the doorway nor the red indicator light at the wall plug illuminated. Subsequent observation with a nursing assistant confirmed that the call light for the bed by the door would not activate at all, and the call light for the bed by the window only activated after the button was pressed more than three times. The Maintenance Director reported that the facility’s process for checking call light operation was to manually test each call light on a rotating schedule, testing one half of the building one month and the other half the next month. The call light system test log showed that the call lights in the relevant room’s section had been tested and passed on a prior date, and the room was not scheduled to be tested again until a future month. The Maintenance Director stated that interim repairs depended on care staff verbally notifying maintenance or entering a work order into the TELS electronic system. The Administrator acknowledged that both call lights in the room required replacement and stated that all resident call lights should be working at all times.
Failure to Prevent Repeated Falls Due to Inadequate Supervision and Care Plan Implementation
Penalty
Summary
The facility failed to provide adequate supervision, assessment, monitoring, and timely revision of care plan interventions to prevent avoidable repeated falls for multiple residents. Four residents with significant fall histories and high-risk factors experienced repeated falls, many of which were unwitnessed and resulted in injuries such as fractures, lacerations, and bruising. In several cases, care plans were either not in place, not updated after falls, or interventions were not consistently followed by staff. For example, one resident with a history of falls and cognitive impairment had 14 falls within a short period, including a major injury resulting in a vertebral fracture, yet did not have a fall care plan in place until after the first fall, and subsequent care plan updates were lacking even after serious injury. Another resident with dementia and a history of falls was left unsupervised in their wheelchair, resulting in a fall that caused a head laceration requiring sutures. Observations showed this resident was left alone for extended periods, their bed was not kept in a low position as care planned, and staff did not consistently follow interventions such as laying the resident down after meals or keeping them at the nurse's station. Incident reports and care plan updates were incomplete or missing, and staff interviews confirmed that care plans were not always followed. A third resident with Parkinson's disease and frequent falls was observed in unsafe situations, such as being left alone in a malfunctioning wheelchair, unable to reach their call light, and wandering unsupervised. This resident experienced multiple unwitnessed falls resulting in head trauma, bruising, and skin tears. Staff interviews indicated a lack of effective intervention updates and insufficient supervision, especially during times of increased resident activity. Another resident with polyneuropathy and unsteady balance was left unattended in the bathroom, attempted to self-transfer, and sustained a toe fracture. Staff reported concerns about insufficient supervision and staffing, and the facility's own policies regarding fall risk assessment and individualized interventions were not consistently implemented.
Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to provide necessary care and services to prevent the development and worsening of pressure injuries for a resident with significant risk factors. The resident, who was admitted with severe dementia, protein-calorie malnutrition, reduced mobility, and heart disease, required maximum assistance for bed mobility and transfers and had a high risk for pressure injuries as indicated by a Braden Scale score of 11. Upon admission, the resident had no pressure injuries, but subsequently developed a fluid-filled blister on the left heel and a pressure injury with slough and eschar on the right lateral malleolus. Observations and record reviews revealed that the facility did not consistently implement or document required interventions. The resident was observed multiple times without pressure-relieving devices, such as a pressure-relieving mattress or heel protectors, and their heels were not floated as ordered. Nursing notes indicated that interventions such as floating the heels and applying heel protectors were ordered, but these were not consistently carried out or documented. Additionally, required skin assessments were not completed or documented on several occasions as indicated in the Treatment Administration Records. Further, the resident's care plan did not reflect the development of the pressure injuries or include interventions to prevent new injuries or worsening of existing ones. Staff interviews and observations confirmed improper application of devices intended to relieve pressure, and the Director of Nursing acknowledged that staff needed more education on proper techniques. These failures resulted in the resident developing and experiencing worsening pressure injuries.
Failure to Provide Sufficient Nursing Staff and Consistent Resident Care
Penalty
Summary
The facility failed to provide sufficient and competent nursing staff to meet the needs of all residents, as evidenced by observations, interviews, and record reviews. Residents experienced delays in receiving assistance, such as one resident who became incontinent after waiting too long for help, leading to embarrassment. Other residents did not receive adequate assistance with activities of daily living (ADLs), including grooming, nail care, and transfers, as observed by unshaven faces, long and dirty fingernails, and soiled clothing. Staff interviews revealed that restorative nursing programs (RNPs) lacked clear goals and were inconsistently implemented, with some staff making modifications without licensed nurse or therapist direction. Residents with mobility and skin integrity needs were not consistently monitored or provided with appropriate care. For example, one resident with hand contractures was not provided with a splint or hand roll, and another had skin tears with dried blood and no dressings in place, which the Director of Nursing Services was unaware of. Pressure injuries were not properly monitored or documented, as shown by missing daily skin assessments for a resident with a pressure-related blister, despite orders for regular monitoring. Multiple residents experienced falls and injuries due to inadequate supervision, including unwitnessed falls resulting in lacerations, head trauma, and fractures when staff were unavailable to assist. The facility's grievance logbook and resident council interviews documented ongoing concerns about insufficient staffing and long call light wait times, with no resolution. Staff interviews confirmed a lack of awareness regarding required RN coverage and reliance on agency staff due to turnover and shortages. These deficiencies were cited under multiple federal tags, including resident rights, quality of care, accident prevention, and pressure injury prevention, and represent a repeat citation from a previous statement of deficiencies.
Failure to Timely Report Significant Injuries from Unwitnessed Falls
Penalty
Summary
The facility failed to report allegations of potential abuse and/or neglect in a timely manner for three out of five residents reviewed for significant falls with injury. According to the Washington State Department of Social and Health Services (DSHS) Nursing Home Guidelines, substantial injuries of unknown sources and resident-to-resident altercations with physical abuse are incidents that require reporting to the DSHS Hotline. The facility's own policy also mandates prompt reporting of injuries of unknown source to local, state, and federal agencies, followed by thorough investigation by management. For one resident with dementia and a history of repeated falls, an unwitnessed fall resulted in a swollen eye, bleeding from the back of the head, and a laceration requiring sutures. This incident, which involved substantial injuries to areas not generally vulnerable to trauma, was not reported to the state agency. Another resident with end stage renal disease and repeated falls experienced an unwitnessed fall resulting in a vertebral fracture and hospitalization, but this incident was also not reported. The Director of Nursing Services acknowledged that the process for reporting unwitnessed falls with injuries was not followed in this case. A third resident, with polyneuropathy and repeated falls, was found on the floor of their restroom after an unwitnessed fall, resulting in bruising and a broken toe confirmed by x-ray five days later. This incident was similarly not reported to the state agency, as staff did not consider it reportable. These failures to report significant injuries from unwitnessed falls represent a lack of adherence to both state guidelines and facility policy.
Failure to Investigate Falls and Injuries of Unknown Source
Penalty
Summary
The facility failed to ensure thorough investigations were completed for five residents who experienced falls, skin impairments, or injuries of unknown source. In each case, the required incident reports were either not initiated or not completed with sufficient detail to determine the root cause of the incidents or to rule out abuse or neglect. For example, one resident with end stage renal disease and diabetes was observed with multiple skin tears that were not reported or investigated, and there were no treatment orders documented for these injuries. The Director of Nursing was unaware of these injuries until informed during the survey. Another resident with dementia and a history of repeated falls sustained an unwitnessed fall resulting in a head laceration and required emergency care, but the investigation lacked details such as the circumstances leading up to the fall, the resident's activities prior, and witness statements. Similarly, a resident with Parkinson's disease and frequent falls had 17 documented falls, most of which were unwitnessed and not thoroughly investigated to determine if abuse or neglect was involved. The incident reports did not include sufficient information to establish the cause of the falls or whether appropriate interventions were in place. Additional cases included residents with muscle weakness and repeated falls who suffered injuries such as fractures, but the investigations were incomplete, lacking witness statements and comprehensive reviews of the incidents. In all cases, the facility did not follow the required process for prompt and thorough investigation as outlined in state guidelines, resulting in incomplete documentation and failure to rule out abuse or neglect for injuries and falls.
Delayed Refund of Resident Funds After Death
Penalty
Summary
The facility failed to transfer resident funds to the Resident's Representative (RR) within 30 days following the death of a resident. The resident, who was on private pay hospice care, passed away after being readmitted from the hospital. The RR had paid a full month of room and board totaling $11,800.00. Despite a conversation between the Business Office Manager and the RR indicating that unused funds would be refunded, a review of the transaction report showed that the refund had not been issued as of seven months after the resident's death. The RR expressed concern about the delay in receiving the refund, and records confirmed the outstanding balance owed.
Failure to Provide Dignified Toileting Assistance
Penalty
Summary
Staff failed to provide care and services in a respectful and dignified manner for a resident who was admitted with a history of stroke and right shoulder joint replacement. The resident's comprehensive assessment indicated intact cognition and a need for one-person assistance with activities of daily living, including toileting. Despite being continent of bowel upon admission, the resident reported having to wait an extended period for help to use the restroom, resulting in incontinence and feelings of embarrassment. Review of the resident's care plan specified that the resident should be toileted on awakening and as needed, consistent with their continent status. However, nursing assistant task reports documented episodes of bowel incontinence on two occasions. The Director of Nursing Services confirmed that staff are expected to follow residents' care plans, indicating a failure to adhere to the established plan for toileting assistance.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for the use of psychotropic medications for two residents who were reviewed for unnecessary medication use. For one resident with diagnoses including depression, anxiety, and insomnia, there was no documentation that the resident or their representative was informed about the initiation of an antipsychotic medication, nor was there a signed consent for its use. Similarly, another resident with chronic PTSD, bipolar disorder, and depression was started on two antidepressant medications without any record of informed consent or documentation that the resident or their representative had been informed about the medications. Interviews with facility staff revealed that admission nurses were responsible for obtaining consents at admission, or floor nurses if a new order was received. The Director of Nursing Services acknowledged that the consents for the psychotropic medications were not signed for these two residents at the time of admission, attributing the omission to an oversight by the admitting nurses.
Failure to Accurately Complete PASARR Level 1 Screening
Penalty
Summary
The facility failed to ensure that the Pre-admission Screening and Resident Review (PASARR) Level 1 was accurately completed for one resident upon or prior to admission. The resident was admitted with diagnoses including Parkinson's Disease, depression, and anxiety, and was noted to be cognitively impaired but able to make needs known. The PASARR Level 1 form incorrectly designated the resident as having a dementia diagnosis, which was not present at the time of admission, and this error was not identified by the facility. Staff interviews confirmed that the resident did not have a dementia diagnosis and that a PASARR Level 1 with a request for a Level 2 evaluation was not initiated, despite the presence of mental health issues such as anxiety and depression.
Failure to Provide Adequate ADL Assistance and Grooming
Penalty
Summary
The facility failed to provide adequate care and assistance with activities of daily living (ADLs) for three residents who required support with grooming, nail care, and personal hygiene, as outlined in their care plans. For one resident with a history of stroke, muscle weakness, chronic kidney disease, and diabetes, observations revealed unshaven facial hair and long, unclean fingernails with debris, despite the resident expressing a desire to be shaved and no documented refusals of care. Staff interviews confirmed that nail care was expected to be provided during showers or by nurses for diabetic residents, but records showed no refusals or documentation of care being provided. Another resident, also with a history of stroke and joint replacement, was observed lying in bed with a stained shirt, unshaven facial hair, and long, dirty fingernails. The resident expressed frustration about not receiving enough assistance. Task records indicated scheduled showers, but there was no documentation of showers being given or refused on several dates, suggesting a lack of care provision and documentation. A third resident, dependent on staff for all ADLs due to severe cognitive impairment, was repeatedly observed with uncombed hair, long and dirty fingernails, and wearing the same nightgown for days. Family members reported concerns about the resident's appearance and lack of mobility. Staff interviews indicated that nail care and grooming were expected but not consistently documented or performed, and there was no evidence of care refusals. Multiple observations confirmed ongoing unmet grooming and hygiene needs for this resident.
Expired CPR Certification Among Licensed Nursing Staff
Penalty
Summary
The facility failed to ensure that staff responsible for providing cardiopulmonary resuscitation (CPR) maintained current CPR certification, as required by facility policy and state regulations. Specifically, one of five licensed nursing staff reviewed, a Medication Assistant Certified (MA-C), was found to have an expired CPR certification that lapsed four months prior to the review. The facility's policy requires personnel to have completed training in CPR or basic life support (BLS), including defibrillation, and directs licensed staff to initiate CPR/BLS for unresponsive individuals unless there are orders prohibiting CPR. Record review and staff interviews revealed that the staff development personnel were unaware of the expired certification, believing that Nursing Assistants did not require CPR certification and that the Director of Nursing Services (DNS) was responsible for tracking certifications. The DNS acknowledged awareness of the expired certification and indicated plans to update staff certifications. This lapse resulted in the potential for a lack of properly trained staff to respond to emergencies requiring CPR.
Failure to Provide and Document Skin Integrity Care for Two Residents
Penalty
Summary
The facility failed to provide appropriate care and documentation for skin integrity issues for two residents. One resident, with a history of end stage renal disease, diabetes, and on antiplatelet medication, was observed with untreated skin tears on the right forearm and left hand. The resident reported that the wounds had not been cleaned or dressed by nursing staff, and that the injuries continued to bleed, especially given their medication that increased bleeding risk. Review of the medical record showed no treatment orders or documentation of skin assessments on several required dates, and there was no evidence that the resident’s physician or family had been notified of the new skin impairments. The care plan included general interventions for skin integrity and antiplatelet medication monitoring, but these were not followed in practice for the observed injuries. Another resident, with contractures, dry skin, and limited mobility, was observed with an open, bleeding wound on the right hand. The resident was noted to be in pain and uncomfortable, and blood was seen on their bed linens. Staff were notified of the bleeding, but subsequent observations showed continued bleeding and open wounds without evidence of treatment. The care plan identified a moderate risk for skin alteration but did not include specific interventions for prevention or care of skin impairments. The treatment administration record did not show any treatment for the right hand wound, and although a physician had previously requested notification of changes to the skin, there was no documentation of such notifications or interventions. In both cases, the facility did not ensure that care and services for skin integrity were provided according to professional standards of practice. There was a lack of timely assessment, treatment, documentation, and communication with physicians and families regarding new or ongoing skin issues. This failure resulted in residents having untreated, actively bleeding wounds and unmet care needs.
Failure to Consistently Provide Restorative Nursing Care for ROM and Splinting
Penalty
Summary
The facility failed to provide consistent and appropriate restorative nursing care to three residents who were enrolled in Restorative Nursing Programs (RNP) for positioning, range of motion (ROM), and hand splinting. Observations, interviews, and record reviews revealed that the facility did not follow the documented care plans for these residents, resulting in missed or incomplete services intended to prevent further decline in ROM and hand contractures. The facility's policy required resident-centered goals and monthly licensed nurse assessments, but these were not consistently implemented or documented. One resident with dementia, osteoporosis, and a history of falls was supposed to receive transfer training, grooming, and ambulation as part of their RNP. However, staff interviews indicated that the transfer program was not being performed as outlined, and there was a lack of measurable goals or instructions. Observations showed the resident was often moved between locations without evidence of the prescribed restorative interventions. Staff cited high turnover and lack of clear direction as contributing factors to the inconsistency. Another resident with contractures, fibromyalgia, and torticollis was to receive passive and active ROM exercises and assistance with dining using adaptive equipment. Observations showed the resident was often left in bed with uneaten meals, and staff reported that restorative aides were not consistently providing ROM or dining assistance. Documentation showed multiple missed sessions, and there was no assessment or summary from licensed nurses regarding the effectiveness of the RNP. A third resident with dementia and muscle weakness was to have a hand splint applied daily, but observations and record reviews confirmed that the splint was not being used, and staff were unclear about their responsibilities for its application and documentation.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident with a known history of PTSD, bipolar disorder, and depression. The resident, who had recently undergone a lower leg amputation and lost their spouse, expressed feelings of depression, fear about their future, and ongoing PTSD symptoms such as flashbacks and nightmares related to their experiences in the Vietnam War. Despite these disclosures, the resident reported not having shared details of their PTSD symptoms with staff, and there was no evidence that staff had conducted a thorough assessment of the resident's trauma history or identified specific triggers. Interviews with facility staff revealed that while a general care plan for mood disorders was in place, it did not address the resident's PTSD or recent traumatic experiences, such as the amputation and loss of their spouse. The Social Services Director acknowledged awareness of the resident's PTSD diagnosis but had not developed a care plan with interventions specific to PTSD or identified triggers. Documentation showed only a brief mention of PTSD in a trauma screening questionnaire, with no further information on triggers or interventions. As a result, the resident's trauma-related needs were not adequately assessed or addressed in their care plan.
Failure to Integrate and Maintain Hospice Care Plans for Residents Receiving Hospice Services
Penalty
Summary
The facility failed to develop and maintain current hospice care plans in collaboration with contracted hospice services for two residents who were receiving hospice care. For one resident with end stage renal disease, the care plan did not reflect the unique needs associated with hospice care and lacked documentation of hospice orders or input. Additionally, there was no hospice care plan present in the resident's electronic health record. For another resident with a history of stroke and dementia, the care plan similarly did not address the specific needs related to hospice care and was missing documentation of hospice orders or input. The facility's policy required that each resident's care plan include both the most recent hospice care plan and the facility's care plan to support the resident's well-being. However, interviews with the Director of Nursing Services revealed that the process for integrating hospice care plans into the facility's records was not followed for these two residents. The hospice care plans were either not uploaded or not incorporated as required, resulting in incomplete documentation and lack of clarity regarding provider responsibilities for hospice services.
Failure to Develop Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for five residents, which is a requirement to ensure that residents receive necessary care and services. Each resident had specific medical conditions and care needs that were not addressed in their baseline care plans. For instance, Resident 1, who was admitted with paralytic syndrome and a sacral pressure wound, had no documented focus areas, goals, or interventions related to their care needs. Similarly, Resident 2, with diagnoses including ischemic infarction and nutritional anemia, also lacked a baseline care plan addressing their specific needs. The deficiency was further highlighted by the absence of documented goals, focus areas, or interventions for Residents 3, 4, and 5, who had various medical conditions such as heart failure, stroke, and COPD. Interviews with facility staff revealed that the process for developing a baseline care plan should include areas such as ADLs, pain, fall risks, skin integrity, and bowel and bladder continence. However, these elements were missing from the baseline care plans reviewed, placing residents at risk of not receiving necessary care and services.
Breach of Resident Confidentiality
Penalty
Summary
The facility failed to ensure the privacy, security, and confidentiality of a resident's medical information when a staff member disclosed confidential details to a visiting family member. The incident involved Resident 2, who was admitted to the facility with an infection in their digestive system and later developed a urinary infection that required hospitalization. During the resident's hospital stay, a staff member informed the resident's brother and sister-in-law, who were not listed as contacts, about the resident's urinary infection and the hospital to which they were admitted. This breach of confidentiality was reported by the resident's representative, who was upset that unauthorized family members were given access to sensitive information. The facility's investigation into the complaint was inconclusive, as the staff member responsible for the breach could not be identified. The description provided by the resident's representative did not match any staff member, and the Director of Rehab, Staff D, was unable to confirm the identity of the individual involved. Despite this, Staff D provided HIPAA education to the therapy staff, although there was no documentation to verify that this training occurred. The facility's administrator, Staff A, acknowledged the complaint but could not take disciplinary action without identifying the responsible staff member.
Failure to Timely Implement Grievance Process
Penalty
Summary
The facility failed to ensure residents received care and services according to standards of practice by not timely implementing their grievance process for three residents. Resident 3, who had a fracture and muscle weakness, reported inadequate pain management, experiencing severe pain for over three hours before receiving medication. The grievance was not assigned to the nursing manager until 11 days later, and the resident was discharged without resolution. Resident 4, diagnosed with Multiple Sclerosis and muscle weakness, reported not receiving a shower for over two weeks. The grievance was documented but not investigated or resolved 10 days after being reported. Resident 5, with moderately impaired cognition due to dementia, reported delays in receiving assistance after using the call light. This grievance also lacked investigation and resolution 10 days after being reported. Interviews with staff revealed issues with the timeliness of the grievance process, with grievances being misplaced and not addressed promptly. The Assistant Director of Nursing Services and the Administrator acknowledged the delays and mismanagement in handling the grievances, contributing to the deficiency in care and service delivery.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report a suspected allegation of abuse involving a resident with severe cognitive impairment due to dementia, depression, and anxiety. The incident involved an occupational therapist, identified as Staff C, who allegedly took a baby doll from the resident and threw it to the floor, causing distress to the resident who treated the doll as their own child. This incident was reported by a collateral contact to the Director of Rehab, Staff D, who did not log or report the incident to the State Agency, believing the allegation to be a misinterpretation and not in line with Staff C's character. The failure to report the incident was confirmed during interviews with facility staff. Staff D admitted to receiving the report but chose not to escalate it to the administration or the State Agency. The facility's administrator, Staff A, acknowledged that the allegation should have been reported. The lack of reporting placed residents at risk for unidentified and ongoing abuse or neglect, as the incident was not properly investigated or addressed according to regulatory requirements.
Failure to Investigate Allegation of Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of abuse involving a resident with severe cognitive impairment due to dementia. The incident involved an occupational therapist, identified as Staff C, who allegedly threw a baby doll belonging to the resident onto the floor, causing distress to the resident. The allegation was reported by a collateral contact, but the Director of Rehab, Staff D, did not initiate an investigation, citing disbelief in the allegation and considering it vague and non-harmful. Staff D admitted to not following the facility's process for handling abuse allegations, which includes protecting the resident and reporting the incident. The resident, who was admitted with a diagnosis of dementia, was emotionally attached to a baby doll, which they carried around the facility. The failure to remove the alleged perpetrator, Staff C, from contact with the resident placed the resident at risk for further emotional distress and potential abuse. The facility's administrator, Staff A, acknowledged that an investigation should have been initiated upon receiving the allegation, indicating a lapse in following the correct procedures for handling such reports.
Failure to Document Advance Directives Discussions
Penalty
Summary
The facility failed to document discussions regarding Advance Directives (AD) in the medical records for two residents, which placed them at risk of not having their end-of-life care preferences followed. Resident 1, who had severe cognitive impairment, was unsure of who made decisions on their behalf, and no AD documents were found in their medical record. Staff D, the Social Services Director, acknowledged that Resident 1 had verbally designated a Resident Representative but admitted that this was not documented in the medical record. Similarly, Resident 2, who also had severe cognitive impairment, could not identify their decision maker, and their medical record lacked AD documentation. Staff C, the Resident Care Manager, stated that they relied on the Responsible Party listed on the resident's face sheet for decision-making in the absence of an AD. The facility's policy required that ADs be reviewed upon admission, quarterly, and documented in the care plan, but this process was not being followed. Staff D mentioned that residents were given a Five Wishes booklet upon admission and that AD discussions were supposed to occur during the 72-hour care conference, but these discussions and decisions were not routinely documented. Staff B, the Director of Nursing, confirmed that the facility had not been adhering to their established process for handling ADs, which contributed to the deficiency identified by the surveyors.
Failure to Prevent and Treat Pressure Ulcers in Residents
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the occurrence of avoidable pressure ulcers and to implement timely wound treatments for three residents. Resident 20, who was admitted with no skin breakdown, developed a Stage II pressure injury on the right buttock and an unstageable wound on the left buttock, experiencing significant pain. Despite being admitted without skin issues, the resident's condition deteriorated, with wounds showing partial thickness skin loss and slough, indicating inadequate preventive measures and delayed treatment. Resident 41, who had a Stage 4 pressure injury on the sacrum, experienced prolonged use of a malfunctioning air mattress that exacerbated their condition. The air mattress, which was supposed to provide pressure relief, was overinflated and caused additional pressure on the resident's wound. Despite multiple requests from an outside wound care consultant to repair or replace the mattress, the issue persisted for 23 days, leading to continued discomfort and potential worsening of the pressure injury. Resident 60, admitted with a deep tissue injury on the right heel, experienced a delay in receiving appropriate treatment. The wound care consultant recommended surgical debridement and further diagnostic tests due to concerns of infection and potential bone involvement. However, there was a significant delay in obtaining and acting upon wound swab results, which were not reviewed by the facility provider until 11 days after being reported. This delay in treatment and lack of follow-up on the consultant's recommendations contributed to the deterioration of the resident's wound.
Deficiencies in Staffing and Resident Care
Penalty
Summary
The facility failed to provide sufficient numbers of competent nursing staff to meet the needs of all residents, leading to multiple deficiencies in care. Residents reported not receiving scheduled showers, resulting in personal hygiene issues and skin conditions. For instance, one resident with a skin condition experienced embarrassment due to odor, while another resident reported skin breakdown and yeast infections due to infrequent bathing. The facility's grievance logbook and resident council meeting interviews corroborated these issues, highlighting the persistent problem of insufficient staffing. The facility also failed to maintain proper care plans and follow-up for residents with specific medical needs. One resident with a left-hand brace did not have a care plan or physician's order for its use, and another resident requiring a splint for their hand was observed without it on multiple occasions. Additionally, the facility did not ensure timely follow-up appointments with specialist physicians, as evidenced by a resident with an urgent referral for infectious disease consultation that was delayed, resulting in inadequate assessment and management of their condition. Furthermore, the facility did not provide adequate supervision to prevent accidents and ensure safety during meals. Residents with dysphagia and specific dietary requirements were left unsupervised while eating, posing a risk of choking. Infection control practices were also lacking, with no enhanced barrier precautions signage for residents with open wounds and indwelling medical devices. Staff interviews revealed a lack of competency in administering medications through PICC lines, and the facility did not have a full-time infection preventionist to address these issues.
Failure to Issue Timely Medicare Notices
Penalty
Summary
The facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) as required for three residents reviewed for beneficiary notification. Resident 280, who was admitted with diagnoses including diabetes and repeated falls, received their NOMNC on the same day as their discharge, which was less than the required two days' notice. Similarly, Resident 281, admitted with heart failure and pneumonia, was issued a NOMNC one day before their discharge, again failing to meet the two-day notice requirement. Resident 67, with diagnoses of heart failure and muscle weakness, also received their NOMNC on the last covered day, and the form was not dated, further indicating non-compliance with the notification requirements. Additionally, the facility failed to provide a complete Skilled Nursing Facility (SNF) Advance Beneficiary Notice (ABN) for Resident 67. The ABN issued was incomplete as it did not indicate the resident's choice for continued care, and like the NOMNC, it was signed but not dated. Interviews with facility staff, including the Administrator, Director of Nursing, and President of Clinical Operations, revealed that social services were responsible for issuing these notices, but the process was not followed correctly, leading to these deficiencies.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive resident-centered care plans for two residents, which placed them at risk of not receiving appropriate care. Resident 4, who was admitted with diagnoses including heart failure, obstructive sleep apnea, diabetes, and end-stage renal disease, required supervision for daily activities and used a CPAP machine and intermittent oxygen therapy. However, the care plan for Resident 4 did not include any focus area or interventions related to the use of oxygen or the CPAP machine, despite the resident reporting that their CPAP machine had been broken for a week. Resident 60, admitted with a history of surgical removal of the left leg, peripheral vascular disease, and chronic kidney disease, required maximum assistance for daily activities and had a fluid restriction of 1500 ml per day. Despite this, Resident 60 was unaware of the fluid restriction and reported drinking as much as they wanted, with staff refilling their tumbler multiple times a day. The care plan for Resident 60 lacked focus areas, goals, or interventions related to their chronic kidney disease and fluid restriction. Interviews with facility staff confirmed that the care plans were not comprehensive and should have included these critical aspects of care.
Inconsistent Showering and Grooming Care for Residents
Penalty
Summary
The facility failed to provide consistent showering and grooming care for residents who were dependent on staff for activities of daily living (ADLs). This deficiency was observed in five residents, who did not receive showers as per their care plans, leading to unmet care needs and potential risks for skin integrity issues. The facility's policy stated that residents unable to perform ADLs independently should receive necessary services to maintain personal care, but this was not adhered to. Resident 5, who was cognitively intact and dependent on staff for bathing and grooming, reported not receiving showers as scheduled, resulting in skin breakdown and long, unkempt nails. Despite filing grievances, the resident continued to experience missed showers due to staff shortages. Similarly, Resident 28, with moderate cognitive impairment, went several days without a shower, as documented in their task flow sheets, and was observed with oily hair and long nails. Other residents, including Resident 54, Resident 55, and Resident 10, also experienced significant delays in receiving showers, with some going over a week without one. These residents expressed concerns about the lack of staff and the impact on their personal hygiene. Staff interviews confirmed the issue, citing insufficient time and staffing to complete all assigned care tasks, including showers, as the primary reason for the deficiency.
Inadequate Monitoring of Psychotropic Medications
Penalty
Summary
The facility failed to ensure adequate monitoring and assessment for the use of psychotropic medications for two residents. Resident 7 was prescribed an as-needed antianxiety medication without a stop date, and there was no assessment conducted for its use. The Director of Nursing acknowledged the oversight and confirmed the absence of a stop date and assessment for the medication. This lack of monitoring and assessment could potentially lead to unnecessary medication use and adverse side effects. Resident 26, who was on an antipsychotic medication since admission, did not have any AIMS assessments or quarterly Interdisciplinary Team (IDT) reviews conducted to evaluate the appropriateness of the medication or the possibility of a gradual dose reduction. The Director of Nursing admitted that Resident 26 was missed during the IDT reviews due to a room change and that there was no effective system in place to ensure AIMS testing was completed. These failures placed the residents at risk for adverse side effects and deterioration in their mental and physical health status.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBPs) for seven residents who were reviewed for infection control practices. These residents had various medical conditions, including cancer, tracheostomy, palliative care, indwelling catheters, open wounds, stage 4 pressure injuries, diabetes, peripheral vascular disease, and bacterial infections. Despite these conditions, there was no signage outside their rooms indicating the need for additional personal protective equipment (PPE) during high-contact care activities. This oversight was observed during a survey conducted on May 19, 2024. Interviews with staff revealed a lack of awareness and implementation of EBPs. A nursing assistant stated that no residents required PPE unless a wound was exposed, indicating a misunderstanding of the EBP requirements. The Director of Nursing acknowledged the need for EBPs for residents with open wounds and indwelling medical devices but admitted to difficulties in creating a policy and educating staff due to the absence of a full-time infection preventionist. The President of Clinical Operations also recognized the failure to identify the need for EBPs. This deficiency was a repeated citation from a previous Statement of Deficiencies dated May 4, 2023.
Deficient Maintenance of Mechanical Lifts
Penalty
Summary
The facility failed to maintain resident care equipment in a fully functional manner, specifically concerning three mechanical lifts used for resident transfers. Observations revealed that all three lifts had malfunctioning emergency manual safety features, with loose and stripped components that were no longer operational. Additionally, the motor boxes of the lifts were broken, with exposed wires hanging down, and the remote control for one lift did not match its make and model. During a transfer, Lift 1 malfunctioned, leaving a resident suspended in the air for two minutes before it resumed functioning, highlighting the risk posed by the faulty equipment. Interviews with staff revealed a lack of awareness regarding the primary method to manually lower the lift arm in case of a malfunction, as outlined in the equipment manual. Staff were only familiar with the visible red emergency feature, which was not functioning. It was also reported that staff had been notifying management about the malfunctioning lifts for several months without any resolution. The Director of Nursing acknowledged the safety issues with the lifts and admitted to being unaware of the primary safety feature for manual lowering.
Failure to Maintain Resident Dignity Through Regular Showers
Penalty
Summary
The facility failed to provide care that promoted respect and dignity for three residents, as evidenced by the lack of regular showers. Resident 54, who was cognitively intact and required assistance with bathing, did not receive a scheduled shower on a Saturday and was informed there was insufficient staff to provide one on the following day. This led to the resident experiencing embarrassment due to a skin condition that caused odor when not bathed regularly. Similarly, Resident 10, also cognitively intact and dependent on staff for personal care, missed several scheduled showers, resulting in noticeable body odor and unkempt appearance, which the resident found distressing. Resident 5, with diagnoses including heart and liver disease and depression, was also affected by the facility's failure to adhere to the shower schedule. The resident, who was supposed to receive showers twice a week, reported only receiving one shower per week and expressed frustration over the situation. The lack of regular bathing led to physical discomfort and embarrassment due to odor and potential skin issues. These deficiencies were observed through interviews and record reviews, highlighting the facility's failure to maintain the residents' dignity and respect as outlined in their admission agreement.
Failure to Provide Proper Discharge Notices
Penalty
Summary
The facility failed to provide a written notice to residents and their representatives regarding the intention and justification for discharge, as well as failing to notify the LTC Ombudsman. This deficiency was identified in the cases of four residents who were reviewed for facility-initiated discharges. The facility's policy required that before transferring or discharging a resident, a written notice should be provided to the resident and/or their representative, and the reason for the transfer/discharge should be recorded in the resident's medical records. Additionally, the facility was supposed to notify the Office of the State LTC Ombudsman before or as close as possible to the actual time of the transfer/discharge. In the case of Resident 50, who was admitted with diagnoses including respiratory failure and dependence on renal dialysis, there was no notice of transfer/discharge issued when the resident was transferred to the hospital due to fluid overload. Similarly, Resident 4, admitted with heart failure, diabetes, and end-stage renal disease, was transferred to the emergency department without a notice of transfer/discharge being issued. For two other residents, the notices provided to the LTC Ombudsman were either undated or illegible, lacking necessary details such as the effective date of the transfer/discharge. Interviews with facility staff revealed that the process for notifying the LTC Ombudsman was not functioning properly, with forms being untimely, incomplete, or illegible.
Failure to Issue Bed Hold Notice During Hospital Transfer
Penalty
Summary
The facility failed to issue a written notice of bed hold to a resident or their representative at the time of hospital transfer, as required by their policy. This deficiency was identified during a review of the medical record for a resident who was transferred to the hospital. The resident, who had been readmitted to the facility with diagnoses including respiratory failure and dependence on renal dialysis, was transferred to the hospital, but there was no documentation of a bed hold notice in their medical record. Interviews with facility staff revealed that the responsibility for issuing bed hold notices fell to the Social Services Director, who acknowledged that a notice should have been issued at the time of the resident's transfer. The Director of Nursing noted that bed hold notifications are typically handled the day after an emergency transfer. The President of Clinical Operations confirmed that the process for bed hold notification was not followed, indicating a lapse in adherence to the facility's policy.
Inaccurate PASARR Documentation for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy and completion of the Preadmission Screening and Resident Review (PASARR) for two residents, which placed them at risk for inappropriate placement and not receiving necessary mental health services. Resident 10 was admitted with diagnoses including dementia, PTSD, and heart failure, and required substantial assistance for daily activities. The PASARR form for Resident 10 did not include the diagnosis of PTSD or bipolar affective disorder, which was noted in the provider's admission note but not listed on the diagnosis list or PASARR. The Director of Nursing acknowledged that a new PASARR was needed due to the addition of the bipolar disorder diagnosis. Resident 36 was admitted with diagnoses of anxiety, insomnia, and major depressive disorder, and was receiving medication for depression. The comprehensive assessment showed severe cognitive impairment, yet the PASARR did not document the diagnoses of anxiety and depression. The Director of Nursing stated that PASARRs were reviewed by Social Services and should include all diagnoses upon admission and with any new diagnosis or change. The President of Clinical Operations noted that the PASARR process needed updating, emphasizing the need for nursing staff to review provider notes to ensure all diagnoses were accurately listed.
Failure to Provide Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop and provide a baseline care plan within 48 hours of admission for two newly admitted residents, which is a requirement under the F-655 Federal regulation. Resident 20, who was admitted with diagnoses including respiratory disease, congestive heart failure, and diabetes, did not receive a baseline care plan that documented specific medications or treatments. Although a care plan meeting was held, the dietary information was inconsistent with the nursing admission progress note, and there was no evidence that Resident 20 received a copy of the baseline care plan. Similarly, Resident 59, readmitted with diagnoses such as malnutrition, dysphagia, repeated falls, and chronic pain, also did not receive a baseline care plan within the required timeframe. The care plan meeting for Resident 59 lacked specific medications or treatments, and the dietary information did not align with the nursing admission progress note, which indicated a need for supervision during meals due to dysphagia. Interviews with the residents and staff revealed that the social services department was responsible for initiating the baseline care plan, but staffing changes may have led to lapses in the process.
Deficiencies in Care Plan Coordination and Updates
Penalty
Summary
The facility failed to ensure ongoing review, coordination of care conferences, and revisions to care plans for four residents, leading to unmet care needs and decreased quality of life. Resident 28, diagnosed with Alzheimer's disease, anxiety, and depression, had not participated in a care conference since April 2023, despite requiring maximal assistance for activities of daily living and having moderate cognitive impairment. Similarly, Resident 35, with diagnoses including anxiety, depression, bipolar disorder, and PTSD, had not attended a care conference within 90 days of the last one held in January 2024, and there was no documentation of attendance by their behavior therapist and representative. Resident 54, who was cognitively intact and had a newly placed urinary catheter, did not have their care plan updated to reflect this change. The care plan inaccurately indicated that the resident used the bathroom for bladder elimination, and the Kardex was not updated to include specific care and monitoring instructions for the catheter. This oversight occurred despite a progress note indicating the catheter was ordered in April 2024. Resident 55, with left side hemiplegia and other conditions, wore a left-hand brace daily, but their care plan lacked updates regarding the brace's use, skin checks, and responsible parties for its management. The Kardex did not reflect the brace, and there was no physician order for it. During an observation, the resident's skin was found reddened under the brace, highlighting the lack of proper documentation and care planning for the brace's use.
Failure to Follow Through on Specialist Referrals for Resident Care
Penalty
Summary
The facility failed to provide goods and services that met professional standards of care for a resident with complex medical conditions, including Paget's disease, Type 2 Diabetes, and a Stage 4 sacral pressure injury with chronic osteomyelitis. Despite urgent referrals made by an outside wound care consultant for an Infectious Disease (ID) specialist to address the sacral wound osteomyelitis, the facility did not ensure these referrals were followed through. The resident attended an ID appointment 27 days after the initial urgent referral, but the sacral wound was not assessed due to a lack of communication about the wound's condition. Subsequent requests for a new ID appointment with a staff attendant for accurate reporting were also not fulfilled. Additionally, the resident requested a Rheumatology consult for a new diagnosis of Paget's disease, and a referral was made, but no follow-up occurred. The resident also developed a new wound on the penis due to pressure from a urinary catheter, leading to a referral for a Urology consult, which was not scheduled. Interviews with facility staff revealed a breakdown in the referral process, as orders from nursing were not forwarded to the Health Information Manager, who was responsible for scheduling appointments. This failure to act on referrals placed the resident at risk for a decline in health status.
Failure to Prevent Reduction in Range of Motion
Penalty
Summary
The facility failed to provide adequate services to prevent a potential reduction in range of motion for two residents. Resident 55, who has left side hemiplegia and muscle weakness, was observed wearing a left-hand brace daily. However, there was no physician order for the brace, and it was not included in the resident's care plan. The care plan lacked details on the use of the brace, such as skin checks, a schedule for wearing the brace, and the responsible staff for these tasks. The Kardex also did not reflect the use of the brace, despite an active range of motion task being noted. Interviews with staff revealed that the brace was removed nightly and replaced in the morning, but there was no documentation or evaluation regarding the brace in the resident's records. Resident 25, who has a left-hand contracture due to a stroke, was observed with a closed fist and reported not having seen their splint in months. The care plan indicated the need for a left-hand roll to be placed daily, but observations showed the resident did not have the splint or any alternative intervention like a rolled-up washcloth. A nursing assistant confirmed the absence of the splint and improvised with a washcloth, but this was not consistently observed. The Director of Rehab noted that the resident had regained some mobility and should have been wearing a splint with a finger spreader, but this was not being implemented.
Inadequate Supervision and Unsafe Environment in LTC Facility
Penalty
Summary
The facility failed to provide adequate supervision during dining for two residents, leading to potential choking and aspiration risks. Resident 20, who was admitted with diagnoses including pneumonia, dysphagia, and diabetes, required extensive assistance with activities of daily living and was on a specialized diet due to swallowing difficulties. Despite this, Resident 20 was observed eating alone in the independent dining room on multiple occasions, struggling with their food and expressing distress. Staff interviews revealed a misunderstanding about the need for supervision in the independent dining room, with some staff expressing concerns about the safety of leaving residents unsupervised. Similarly, Resident 59, who had dysphagia and was at high risk for choking and aspiration, was left unsupervised while eating in their room. Despite requiring supervision and specific eating precautions, Resident 59 was observed eating alone, and staff noted that the resident often refused assistance. The Speech Language Pathologist confirmed the resident's high risk and the need for constant supervision during meals, yet the facility failed to ensure this level of care. Additionally, the facility did not maintain a safe environment in five shower rooms, where toxic cleaning chemicals were left unsecured and accessible to residents with cognitive impairments. Observations showed unlocked doors and cabinets containing hazardous materials like Micro Kill wipes and Bleach 360 cleaning solution. Staff acknowledged that these items should have been secured to prevent access by residents, indicating a lapse in maintaining a safe and functional environment.
Inadequate Justification and Improper Handling of Urinary Catheters
Penalty
Summary
The facility failed to provide adequate justification for the placement of a urinary catheter for Resident 54, who was cognitively intact and had diagnoses including Polymyalgia Rheumatica, type 2 diabetes, and osteoarthritis. The resident's care plan indicated the need for assistance with toileting, but there was no documented rationale or specific diagnosis to support the use of a urinary catheter. The resident expressed that the catheter was requested due to delays in receiving assistance for toileting, and the facility's records lacked appropriate orders for the catheter's use, size, frequency of changes, or follow-up care. Additionally, the facility did not ensure proper catheter care for Resident 3, who required assistance with activities of daily living and had a urinary catheter. During a transfer using a mechanical lift, staff members positioned the catheter drainage bag at the same height as the resident's head and placed it in the resident's lap, contrary to guidelines that require the bag to be kept below the bladder level to prevent infection. Staff acknowledged the incorrect handling of the catheter bag, which was not in line with the facility's policy or professional standards.
Inadequate Respiratory Care for Resident with Tracheostomy
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident with a tracheostomy, leading to an increased risk of complications. Resident 2, who had a total laryngectomy and a permanent tracheostomy stoma, was observed with a crusty ring of brown substance around the stoma and a suction machine half full of yellow fluid. The resident's medical records indicated that they were supposed to receive saline irrigated tracheal suctioning twice a day, but this was inconsistently documented and often refused by the resident. Interviews with staff revealed a lack of formal training and competency in performing tracheostomy care and suctioning. Staff members, including RNs and LPNs, expressed uncertainty about their training and scope of practice regarding deep suctioning. Some staff performed deep suctioning without a physician's order, relying on their previous experience, while others refrained from performing the procedure due to lack of training. The facility's Assistant Director of Nursing, an LPN, acknowledged that they had not trained staff on these procedures, as it was outside their scope of practice. The resident's POA, who was trained in tracheostomy care, was unaware of the facility's orders to call them for deep suctioning. They expressed concern over the resident's frequent respiratory distress and had filed a grievance. The Director of Nursing confirmed the absence of a physician order for deep suctioning and recognized the need for competency training for RNs in tracheostomy care and suctioning. The deficiency in care was linked to inadequate staff training and unclear communication regarding the resident's care plan.
Deficiency in Dialysis Care and Communication
Penalty
Summary
The facility failed to provide dialysis services consistent with professional standards of practice for a resident with end-stage renal disease. The resident's medical record indicated a need for pre and post-dialysis assessments on specific days, but these assessments were frequently not completed. Interviews with staff revealed an expectation for these assessments to be documented, yet they were often missed, and the resident's weight was not consistently monitored before and after dialysis sessions. The facility also did not adhere to the resident's fluid restriction, which was set at 32 ounces per day. The resident reported that their fluid intake was not monitored by the facility, and documentation of fluid intake was inconsistent, with missing records for several shifts. Staff interviews indicated a lack of communication between the facility and the dialysis center regarding the resident's fluid restriction, and the care plan did not specify the allowed fluid intake or other critical dialysis-related interventions. Additionally, there was a lack of communication and collaboration between the facility and the dialysis center. The resident reported not receiving paperwork to take to dialysis sessions, and the facility did not receive post-dialysis information from the dialysis center. The written agreement between the facility and the dialysis center had not been reviewed annually as required, and there were no specific policies or procedures in place for dialysis services beyond the outdated agreement.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with PTSD, as they did not assess, monitor, or treat the resident's past traumatic experiences in accordance with professional standards. The resident, who was cognitively intact, had a history of significant trauma, including the suicide of a close family member and military service during the Vietnam War. Despite these factors, the trauma screening questionnaire completed by the facility's staff indicated that the resident did not have a notable probability of experiencing trauma-related symptoms that could influence care. This oversight resulted in the absence of a care plan addressing the resident's PTSD diagnosis and associated triggers. Interviews with facility staff revealed a lack of adherence to the established process for trauma-informed care. The Social Services Director and Social Services Assistant acknowledged that the resident's trauma screening was not followed up with further assessments or inquiries to identify potential triggers. The Director of Nursing and the President of Clinical Services confirmed that the correct procedure would have involved conducting a second screening and reaching out to the resident's family for additional information. The failure to follow these steps resulted in the resident's PTSD triggers being unidentified and unaddressed in their care plan.
Deficiency in PICC Line Care Competency
Penalty
Summary
The facility failed to ensure that licensed nurses had the necessary competencies and skill sets to safely and efficiently perform care for residents with Peripherally Inserted Central Catheter (PICC) lines. This deficiency was identified through observations, interviews, and record reviews involving two nursing staff members, Staff Q and Staff R. Both staff members were responsible for the care and medication administration through PICC lines but lacked specific training and documented demonstration of competencies in this area. Staff Q admitted to not receiving facility-specific training for PICC line care and relied on general nursing training, while Staff R expressed willingness to attend training if it were available but had not received any. Neither staff member performed a return demonstration of their skills, which is a critical component of verifying competency. The Director of Nursing, Staff B, had reviewed and signed off on self-assessments completed by Staff Q and Staff R, which rated their competencies as proficient. However, these assessments were based on self-evaluation without a return demonstration. Interviews with the facility's Advanced Registered Nurse Practitioner and the President of Clinical Operations highlighted the importance of monitoring PICC lines for complications and performing return demonstrations to verify competencies. Despite these expectations, the facility did not ensure that such demonstrations were conducted, leaving residents at risk for adverse outcomes related to PICC line care.
Failure to Address Behavioral Health Needs
Penalty
Summary
The facility failed to ensure that the mental and psychosocial health needs of a resident diagnosed with Post Traumatic Stress Disorder (PTSD) and depression were identified and met. The resident, who was cognitively intact and required substantial assistance for daily activities, expressed feelings of depression, low energy, and isolation. Despite these symptoms, the resident's care plan only included monitoring for medication side effects and effectiveness, without addressing the resident's expressed desire for group therapy and counseling services. Interviews with facility staff revealed a lack of appropriate action to address the resident's behavioral health needs. The Social Services Director acknowledged awareness of the resident's PTSD but relied on medication and family reassurance rather than offering behavioral health services. The Director of Nursing admitted that the resident should have been referred to behavioral health services based on their trauma history. Additionally, the President of Clinical Operations stated that staff should have asked the resident about their interest in behavioral health services and made a community referral, which was not done.
Significant Medication Error Due to Incorrect Heparin Administration
Penalty
Summary
The facility failed to ensure that a resident's physician order for heparin was implemented correctly, resulting in a significant medication error. During a medication administration observation, it was noted that Staff R, an LPN, did not follow the physician's orders for Resident 276. The resident, who was admitted with diagnoses including a left knee infection, high blood pressure, and diabetes, had specific orders for the administration of cefazolin via a PICC line. The orders required flushing the PICC line with normal saline before and after administering the antibiotic, followed by a heparin flush. However, Staff R administered the heparin flush before the antibiotic, contrary to the physician's orders. Resident 276's medical record indicated they required supervision with activities of daily living and were cognitively intact. The error was confirmed during an interview with Staff R, who acknowledged not following the physician's orders correctly. The Director of Nursing, Staff B, stated that the expectation was for nurses to adhere to physician orders and professional standards of practice. This failure placed the resident at risk for adverse complications due to the significant medication error.
Inconsistent Wound Care for Pressure Injuries on Weekends
Penalty
Summary
The facility failed to provide timely and consistent wound care for pressure injuries to three residents reviewed, leading to serious consequences. Resident 1, admitted with peripheral vascular disease and Type 2 Diabetes, developed a Stage 4 pressure injury on their sacrum during their stay. Despite requiring twice daily wound care and antibiotic ointment application, the resident did not receive proper care over weekends, resulting in worsening of the wound and delayed initiation of oral antibiotics for osteomyelitis. Resident 2, admitted with atrial fibrillation and weakness, had an unstageable coccyx pressure injury that also did not receive daily wound care over weekends, as observed by staff and confirmed by the resident's representative. Resident 8, admitted with epilepsy and Type 2 Diabetes, had a Stage 2 left lateral knee pressure injury that was neglected over a weekend, contrary to physician orders for daily wound care. Staff members, including Registered Nurses and Licensed Practical Nurses, acknowledged concerns about missed wound care on weekends for these residents. The report highlighted instances where dressing changes were not completed as ordered, with dressing dates indicating neglect over weekends. The lack of adherence to physician orders for wound care, especially on weekends, was a recurring issue noted in the report. The observations and interviews with staff, residents, and their representatives revealed a pattern of missed wound care, indicating a systemic failure in providing essential services for pressure injury treatment and prevention of infection. The report emphasized the critical nature of timely and consistent wound care to prevent further harm and deterioration in residents' health status. The deficiency report outlined specific details of the pressure injuries, including the stages of the wounds and the required treatments for each resident. It highlighted the importance of following professional standards of care for pressure injuries, as defined by the National Pressure Injury Advisory Panel. The report also referenced facility policies related to skin integrity and wound care, emphasizing the need for care consistent with professional standards to prevent pressure ulcers and promote healing. The findings indicated a significant gap in the facility's provision of wound care services, leading to adverse outcomes for the residents involved.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents and/or their resident representatives (RR) provided informed consent before implementing psychotropic medications for two residents. Resident 3 was started on Quetiapine without a completed psychotropic medication consent form, and the RR/POA was not informed about the medication's risks, benefits, or alternative therapies. The RR/POA only became aware of the medication after noticing the resident's altered state during a visit. Similarly, Resident 4 was started on Duloxetine and Quetiapine without a completed psychotropic medication consent form, despite being cognitively intact and able to make their needs known. During interviews, staff members confirmed that the normal process of obtaining informed consent for psychotropic medications was not followed for these residents. Staff E, a Licensed Practical Nurse/Resident Care Manager, and Staff B, the Director of Nursing, both acknowledged that informed consents were not obtained for Residents 3 and 4. This failure to follow the facility's policy on psychotropic medication use resulted in residents and their representatives not being fully informed about the medications being administered.
Failure to Implement Effective QAPI Program for Pressure Injury Care
Penalty
Summary
The facility failed to implement an effective Quality Assurance Performance Improvement (QAPI) program that identified or corrected deficiencies related to the facility's skin program. This deficiency did not meet professional standards for pressure injury care for three residents reviewed for pressure injuries. During an interview, the Administrator acknowledged that their QAPI process had not identified or corrected the deficient practice related to the management and treatment of pressure injuries, which resulted in resident harm.
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 148 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 Yakima
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Crescent Health Care | 0.3 mi | ★★★★★ | 19 | 0 |
| Summitview Rehab And Health Center | 0.6 mi | ★★★★★ | 1 | 0 |
| Good Samaritan Health Care Ctr | 1.4 mi | ★★★★★ | 17 | 0 |
| Garden Village | 2.1 mi | ★★★★★ | 34 | 0 |
| Willow Springs Care And Rehabilitation | 2.6 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Landmark Care And Rehabilitation.
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.