Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Life Care Center Of Federal Way during CMS and state inspections, most recent first.
Incomplete and Inaccurate HD Assessments: The facility did not ensure complete and accurate pre/post HD assessments for four residents receiving dialysis. Records showed repeated incomplete or inaccurate assessments for residents with ESRD and other conditions, and a resident reported staff only checked vital signs before and after dialysis rather than performing a full assessment, while the DON stated the assessments should include general and focused dialysis checks.
A Dietary Aide prepared ready-to-eat salad items with contaminated gloves, touched multiple food prep surfaces, and continued without washing hands or changing gloves after being redirected by the FSD. Record review also showed multiple missed refrigerator and freezer temperature checks, unsafe temp readings in several units, and pre-filled log entries instead of actual readings. The FSD stated staff were not notifying them of unsafe temps and should document actual temps rather than pre-fill logs.
Resident Council concerns were repeatedly raised but not documented as grievances or shown to have been addressed, and no follow-up responses or rationale were provided back to residents. Meeting minutes reflected ongoing complaints about locked doors, cold food, delayed call lights, staff sleeping or socializing, noise at night, laundry issues, missing belongings, and other resident care and quality-of-life concerns, while the Grievance Log showed no Resident Council concerns were logged.
PASRR Level 2 referrals were not coordinated timely for two residents, and one resident with bipolar disorder, hallucinations, and physical behaviors also had no Level 2 determination on file. Records showed one resident with severe cognitive impairment, depression, and stroke had a later PASRR identifying serious mental illness after a prior screening found none, while another resident with bipolar disorder was tearful and stressed and had a referral sent but no documented Level 2 outcome.
A facility failed to provide required ADL assistance for several dependent residents, including showers, nail care, oral care, shaving, and grooming. One resident did not receive showers per the care plan and repeatedly reported missing preferred bathing, while others were observed with long, dirty fingernails, and another resident was seen with matted hair, facial hair, and dry, chapped lips despite being dependent on staff for personal hygiene and oral care.
Restorative nursing services were not consistently provided or documented for several residents with limited mobility and ROM needs. One resident with muscle weakness and difficulty walking was not placed on the RNP case load despite therapy recommendations for ambulation and Omnicycle use, another resident who requested exercise was not added to restorative services, a resident with contractures did not receive the ordered PROM or consistent splint use, and another resident with brain injury and weakness had splinting and ROM services that did not match the care plan or were not documented.
Menu Not Followed During Meal Service: Staff did not follow the planned menu during meal service, substituting mashed potatoes when sweet potato puree was unavailable and serving Salisbury steak with sausage gravy instead of the brown gravy listed. A cook stated the kitchen used leftover gravy from breakfast and did not check that all menu items were available, while the DON stated staff did not notify them about the shortage or communicate the change to residents. During lunch, one resident ate only a small amount of the meal, and two other residents left the Salisbury steak untouched because they did not like the food combination or the wrong gravy.
Failure to Follow PPE, EBP, and Hand Hygiene Requirements: Staff did not follow contact precautions for residents on TBP, did not use PPE as required for a resident on EBP, and did not perform hand hygiene during wound care. A housekeeping assistant entered a room on contact precautions without gown or gloves, CNAs provided care to a resident with C-Diff without proper PPE and moved between rooms with contaminated gloves and linens, an LPN entered an EBP room without PPE while administering meds, and another LPN layered gloves during wound care instead of performing hand hygiene between tasks.
Advance Directives were not in place for two residents. One resident with cognitive impairment and a brain injury had an expired guardianship letter on file, and the SSD confirmed the guardianship records were expired. Another resident with a history of major injury, HF, respiratory failure, unstable blood sugar, and mental health problems said they had named a brother as DPOA-HC, but the AD was not on file or accessible to staff, and Social Services confirmed it was missing.
A resident reported that a TV down the hall was too loud at night and that staff did not resolve the issue. Surveyors later heard loud TVs from rooms at the end of the hall and observed residents asleep with the TVs on and the volume turned up. The DON stated staff should have encouraged residents to lower TV volume at 10:00 PM and offered headphones for louder sound preferences.
A resident with severe cognitive impairment, stroke-related weakness, and dependence for transfers was observed in bed with folded pillows tucked under the mattress to create a barrier that limited movement and getting out of bed. The resident's record showed no evidence of an assessment supporting restraint use for convenience, and staff indicated the pillows may have been placed by night shift to prevent the resident from rolling out of bed. The DON stated this practice was not acceptable and could be considered a restraint.
A resident who left AMA did not have a discharge summary with a recap of the stay or medication reconciliation, and the DON stated life-sustaining meds and a recap should have been provided. Another resident transferred to the hospital during a health emergency had no documentation that a bed hold was offered to the resident or the representative, and the DON confirmed the offer was not made.
A resident’s MDS was not completed accurately to reflect the resident’s diet and RNP status. The MDS coded a therapeutic diet and active ROM exercises, but records and staff interviews showed the resident was on a mechanically altered diet with thin liquids and diet condiments, was not on a therapeutic diet, and received passive ROM instead of active ROM. The resident also had significant mobility limitations, contractures, and a left-hand splint.
Missed care conferences for two residents. The facility did not hold or document required care conferences with the IDT, residents, and representatives for two sampled residents. One resident with no memory impairment, adult failure to thrive, and schizophrenia had not had a quarterly care conference since the prior year, while another resident who was their own RP and able to understand and be understood never received the promised admission care conference despite an initial attempt to contact family.
The facility failed to follow physician orders for bowel care, BP medication parameters, and continuous oxygen for multiple residents. One resident with stroke and bowel incontinence went several days without a BM and did not receive ordered PRN laxatives, another resident with constipation did not have the ordered bowel protocol followed in sequence and also received a BP med when SBP was below the hold parameter, and a hospice resident ordered continuous O2 was observed without oxygen on multiple occasions.
Failure to Assess and Document Skin Conditions: The facility did not properly assess, document, or monitor skin conditions for two residents. One resident had a large dark purple bruise on the forearm that was not captured on weekly skin checks, and another resident had chronic lower-leg wounds with active wound care orders even though the chart noted the wounds had resolved and no further wound assessments were found. Staff, including the DON and UCC, acknowledged the missing documentation and that the wounds should have been assessed in the weekly skin checks.
Failure to provide effective pain management affected two residents. One resident with chronic back pain, muscle rigidity, and severe pain reported 9/10 pain while the MAR showed PRN pain medication ordered only for 1-4/10 pain, yet the medication was given at a higher pain level without physician notification. Another resident with heart failure, HTN, and stroke had pain documented at 10/10 on two occasions, but the record showed no pain assessment, physician notification, or interventions, and the resident stated pain was not being managed well.
Expired meds were found in the North med room, including opened inhalers with no open date, expired neb vials, and expired vaccines in the refrigerator. In the 200 Hall med cart, a cup with five unlabeled oral meds was stored in a drawer with no indication of what the meds were or which resident they belonged to; an LPN stated the meds should have been discarded but were not.
The facility failed to implement an Antibiotic Stewardship Program to review antibiotic appropriateness and track antibiotic use. Two residents received antibiotics, including one IV antibiotic with no stop date and one oral antibiotic course, but neither resident was listed on the facility’s line listing for infections or antibiotic use. The IP stated antibiotics were reviewed using McGeer’s criteria and should have been included on the tracking tool.
A resident with cognitive impairment and chronic pain diagnoses was admitted on multiple pain meds, including an opioid PRN, but the admission pain assessment was incomplete and the care plan had no pain interventions. The opioid was later changed to scheduled dosing without documented change-of-condition assessment, practitioner or RR notification, or clear monitoring. After several scheduled doses, the resident became sleepy, confused, and hypoxic, was sent to the hospital, received an opioid antagonist, and was diagnosed with an unintentional opioid overdose with respiratory failure.
The facility failed to develop and implement comprehensive care plans for several residents, leading to potential risks for unmet care needs. A resident with a gastrointestinal infection lacked a care plan for bathing needs, while another using a tilt-in-space wheelchair had no plan detailing its use. Additionally, a resident requiring oxygen therapy had a care plan not reflecting physician orders, and others had missing plans for bed rails and diabetes management. Staff acknowledged the importance of comprehensive care plans.
The facility failed to conduct quarterly care conferences for several residents and did not update a resident's care plan despite changes in their eating assistance needs. The absence of a Social Services Director and non-adherence to policy contributed to these deficiencies, placing residents at risk for unmet care needs.
The facility failed to clarify physician orders for three residents, leading to potential risks in care. A resident had bed rails without a physician order, another was on antidiabetic medication without monitoring orders, and a third lacked blood sugar monitoring despite diabetes. Additionally, three residents had no parameters for as-needed pain medications, risking inappropriate pain management.
The facility failed to maintain a safe environment by allowing hot water temperatures to exceed safe limits, not assessing a resident's wheelchair for safety, and leaving sharps and chemicals accessible in a shower room. A resident used a tilt-in-space wheelchair without a safety assessment, and staff left a shower room unsecured, exposing residents to potential hazards.
The facility's Dietary Manager lacked the necessary certification to perform their duties, as they had not completed the required training. The previous Dietary Director's early departure left Staff J in charge without proper qualifications. Additionally, the facility's RD did not work full-time, as they were also responsible for another facility, working only two days a week. This deficiency risked inadequate food and nutrition services for all residents.
The facility failed to document education and consent for influenza and pneumococcal vaccinations for four residents. Three residents received the influenza vaccine without documented education, and there was no record of the pneumococcal vaccine being offered or their historical immunization status. Another resident's records lacked documentation of both vaccines being offered for the 2024-2025 season. The Infection Preventionist admitted to not obtaining and scanning immunization records into the residents' health records.
The facility failed to educate four residents and one staff member on the benefits and potential side effects of the COVID-19 vaccine, as required by their policy. Interviews revealed that the Infection Preventionist did not provide or document the necessary education, and the Director of Nursing confirmed the expectation for such education and documentation.
The facility did not ensure that nursing aides received the required training for continued competency, as evidenced by the lack of training documentation for Staff CC. An interview and record review revealed that since Staff CC's hire, there were no records of training on critical topics such as abuse prevention, infection control, and resident rights. The facility also lacked a staff development coordinator to track mandatory and specialized training needs.
The facility failed to honor the dignity and preferences of two residents. One resident was repeatedly disturbed at night for vitals and toileting, denied sleep medication, and addressed with terms they disliked. Another resident was not given adequate notice or preparation time for a care conference, leaving them feeling undignified. Staff acknowledged the need for better communication and adherence to the facility's dignity policy.
The facility failed to obtain consent for the Covid-19 vaccination for four residents, psychotropic medication for a resident with multiple mental health diagnoses, and the use of a tilt-in-space wheelchair for a cognitively intact resident. Staff acknowledged the absence of consent documentation, highlighting a lapse in ensuring residents' rights to be informed and to consent to their care.
The facility failed to ensure Advanced Directives (AD) were in place for three residents, as required. A resident with heart failure and a kidney condition, and two residents with moderate memory impairment and other diagnoses, had no AD documentation or evidence of being informed about their rights to formulate an AD. Staff interviews confirmed the lack of assistance provided to these residents.
The facility failed to maintain a safe and homelike environment, with observations of gouges and exposed drywall in resident rooms and a nightstand with exposed rough wood. A resident reported issues with cold water in their bathroom sink. The Maintenance Director was unaware of these issues, as they were not communicated by floor staff.
The facility failed to provide required written transfer notifications to two residents and their representatives, as well as to the LTCO, during hospitalizations. Staff interviews revealed that the social service department did not fulfill its responsibility to issue these notifications, impacting residents' ability to make informed decisions.
The facility failed to provide written notification of its bed hold policy to residents and/or their representatives at the time of hospital transfer, affecting three residents. Interviews revealed that the social service department and unit care coordinators did not provide the necessary notice, and documentation was absent in the residents' records. The DON emphasized the importance of informing residents of their rights and associated costs.
The facility failed to complete and incorporate PASRR Level II evaluations into the care plans for two residents with mental health needs. One resident with dementia and a history of stroke showed aggressive behavior, but no Level II referral was documented despite changes in condition. Another resident with dementia, anxiety, depression, and PTSD required a Level II evaluation, but no referral was made. Staff cited understaffing as a reason for not completing necessary screenings.
The facility failed to complete PASRR assessments for two residents, leading to a deficiency in the screening process. One resident with anxiety and depression did not receive a necessary level II evaluation, while another with dementia and bipolar disorder was not referred for a level II assessment after transfer. Staff interviews confirmed the PASRR process was not completed accurately, risking the residents' access to needed mental health services.
A resident with limited English proficiency did not receive necessary communication assistance as outlined in their care plan. The facility failed to provide translation services and communication aids, leading to potential miscommunication and unmet care needs. Staff interviews confirmed the oversight and the importance of providing these services.
A resident with a gastrointestinal infection requiring isolation and moderate memory impairment did not receive adequate bathing assistance over an 18-day period, despite needing substantial to maximal help. The care plan lacked directions for bathing needs, and the resident expressed a desire for assistance. An LPN confirmed the resident did not receive the necessary care.
The facility failed to monitor edema in three residents receiving diuretic medication, lacking physician orders for edema assessment and monitoring. Staff acknowledged the absence of documentation and the importance of monitoring edema every shift to manage conditions like heart failure and prevent complications.
The facility failed to provide fresh water to residents, leading to a risk of dehydration. Observations showed that residents were not offered fresh water unless they asked, contrary to facility policy. Staff interviews confirmed that water was not proactively provided, despite expectations from the Unit Care Coordinator and DON. This deficiency affected multiple residents, some with memory impairments or medical conditions requiring hydration.
A resident with COPD did not receive appropriate respiratory care as the oxygen flow rate was set incorrectly at 3 LPM instead of the prescribed 2 LPM. Additionally, the oxygen tubing was found disconnected from the concentrator. Staff interviews revealed a lack of awareness of the specific oxygen order, highlighting a failure to adhere to professional standards and physician's orders.
The facility failed to obtain informed consent and conduct a safety assessment before implementing bed rails and positioning a bed against the wall for two residents. One resident had bed rails installed without consent, and another had their bed placed against the wall without a safety assessment. Staff acknowledged the oversight, and the DON confirmed the expected procedures were not followed.
A facility failed to evaluate a resident with depression for mental health services, despite ongoing behaviors such as refusals of care and agitation. Staff documented these behaviors but did not assess them or notify the provider, as required. Interviews revealed a lack of communication and follow-up, placing the resident at risk for untreated mental health issues.
The facility failed to monitor medication refrigerator temperatures, leading to improper storage in one unit, and did not dispose of expired medications in another. Additionally, a resident with dementia had another resident's medication left in their room, posing a safety risk. Staff interviews revealed a lack of clarity and responsibility regarding these issues.
The facility failed to maintain confidentiality of resident records on the 100 hall medication cart. An LPN and an RN left a list with resident health information unsecured and in view. Both staff acknowledged their responsibility to protect resident information but did not comply. The DON confirmed the expectation to secure resident information to uphold privacy rights.
A facility failed to coordinate care with hospice services for a resident with Multiple Sclerosis, lacking a coordinated Care Plan and proper documentation. Staff interviews revealed confusion about hospice schedules and inadequate training, while the hospice binder and medical records were incomplete.
The facility failed to store respiratory equipment properly for a resident, did not follow physician orders for contact precautions for another resident with an MDRO infection, and did not implement Enhanced Barrier Precautions for a resident with pressure injuries. Staff were observed not using PPE correctly, and signage was missing or incorrect, as confirmed by facility staff.
The facility failed to provide necessary training and specialized training for staff, affecting their ability to meet residents' care needs. Staff I, K, and CC lacked documentation of required training, and the facility's training program did not include specialized training for dementia, behavioral health, or hospice care. Interviews revealed a lack of awareness and documentation of hospice care training, crucial for residents receiving such care.
The facility failed to ensure POLSTs were properly followed for three residents. A miscommunication during a Code Blue led to incorrect CPR initiation for a resident with selective treatment orders. Additionally, two residents' POLSTs were not readily available, risking unwanted lifesaving treatments.
A resident on hospice care, requiring two caregivers for bed mobility and incontinence care, fell and sustained an inoperable leg fracture when a caregiver attempted to provide care alone. The care plan and Kardex lacked information about the resident's use of an air mattress, contributing to the incident. The facility's investigation confirmed the caregiver's failure to follow the care plan, despite adequate staffing.
Incomplete and Inaccurate HD Assessments
Penalty
Summary
The facility failed to ensure accurate and complete pre- and post-hemodialysis assessments for 4 residents who were receiving HD services. Resident 55 had ESRD and was ordered to receive HD three times weekly; multiple pre/post HD assessments were documented as incomplete and/or inaccurate. Resident 11 had ESRD, dependence on HD, and a heart condition, with an order for HD three times weekly and supplemental treatments as needed; the record showed incomplete and/or inaccurate pre/post HD assessments, and the resident stated staff only checked vital signs before leaving for dialysis and after returning. Resident 62 had ESRD, dependence on HD, and muscle weakness, with an order for HD three times weekly; numerous pre/post dialysis assessments were incomplete and/or inaccurate. Resident 94 had ESRD, dependence on HD, and high blood pressure, with an order for HD three times weekly; several pre/post dialysis assessments were incomplete and/or inaccurate. Staff stated dialysis pre/post assessments should be completed fully and should include a general health assessment, a focused dialysis assessment, and monitoring for complications such as abnormal bleeding, infection, and low blood pressure, but the assessments for these residents were not completed to expectations.
Unsafe Food Handling and Inconsistent Temperature Monitoring
Penalty
Summary
The facility failed to ensure food was prepared and stored under sanitary conditions in accordance with professional standards of food safety requirements in 1 of 1 kitchen observed. During lunch meal preparation, a Dietary Aide prepared three plates of garden side salad and handled ready-to-eat foods while wearing contaminated gloves. After touching multiple food preparation surfaces and slicing tomatoes, the Dietary Aide was instructed by the Food Services Director not to use a plastic tray and to use a cutting board instead, but continued preparing the salad without washing hands or changing gloves. The Dietary Aide stated they should have removed the contaminated gloves, washed their hands, and donned new clean gloves before continuing, but did not do so. Record review showed inconsistent monitoring of refrigerator and freezer temperatures. Refrigerator 1 had documented AM temperatures of 47F and 42F on separate dates, both outside the facility’s safe range, and the log also showed missed AM and PM temperature checks on other dates. Refrigerator 2 and Refrigerator 3 each had a missed PM temperature check on the same date. The logs also showed pre-filled temperature entries for future dates, including entries initialed by kitchen staff. Freezer 6 had a documented PM temperature of 1F, which was outside the facility’s set parameters, and the log also showed a missed PM temperature check on another date. Freezer 7 had documented AM temperatures of 2F and 1F on separate dates, both outside the facility’s set parameters, and a missed PM temperature check was also noted. The Food Services Director stated they were not notified of the unsafe temperatures or the inconsistent monitoring and stated kitchen staff should not pre-fill temperature readings and should document actual temperatures.
Resident Council Concerns Not Addressed or Documented
Penalty
Summary
The facility failed to ensure grievances and concerns raised during Resident Council meetings were addressed in a timely manner, and it did not provide a documented response or rationale for its response for the concerns discussed. Review of the facility’s Resident Council policy showed that concerns raised in resident groups were to be reviewed promptly and that the facility must be able to demonstrate its response and rationale. In interviews, two residents stated the facility did not do anything about many of the complaints and recommendations brought up at Resident Council. Resident Council meeting minutes from January through May 2026 showed repeated concerns and grievances were discussed, including locked facility doors, difficulty reaching Social Services, chipped paint and scratches in rooms, cold food, limited coffee availability, delayed call light response times, staff using phones or sleeping on shift, staff socializing instead of assisting residents, noise at night, laundry concerns, missing items from meal trays, lack of snacks after dinner, and a resident not receiving all belongings back after a hospital return and room move. For each month reviewed, the corresponding Grievance Log showed no Resident Council concerns were logged. The meeting minutes also showed no documentation that follow-up from prior meetings was communicated back to residents. The minutes from February through May 2026 reflected that prior-month concerns and old business were reviewed, but there was no documentation showing how the reported concerns were addressed or the facility’s response, including rationale. Staff stated that concerns raised at Resident Council should be offered grievance cards, logged into the grievance process, and followed with documentation of resolution or rationale when unresolved, and that residents should be informed at each meeting of actions taken to resolve prior concerns.
Delayed PASRR Level 2 Referrals and Missing Determinations
Penalty
Summary
The facility failed to ensure PASRR Level 2 referrals were coordinated timely for two residents reviewed for PASRRs and one resident reviewed for unnecessary medications. For Resident 12, the record showed a 10/20/2025 Level 1 PASRR completed by hospital staff found no serious mental illness and did not require a Level 2 referral, but a later 12/29/2025 Level 1 PASRR completed by facility staff identified a significant change in condition on 10/29/2025 and indicated serious mental illness, with a Level 2 evaluation referral required. Resident 12’s record contained no evidence that a PASRR Level 2 evaluation was completed. Resident 12’s MDS showed severe cognitive impairment, unclear speech, depression, stroke with weakness to one side, and use of antipsychotic, antianxiety, and antidepressant medications; observations showed the resident lying in bed awake and later sitting in a wheelchair with unclear speech. For Resident 56, the admission MDS showed diagnoses including bipolar disorder, and the resident was observed tearful and stressed while stating they wanted to talk to someone and had been offered therapy but nothing had been done. A PASRR Level 1 screening completed by a hospital social worker identified indicators of serious mental illness and required a Level 2 evaluation referral, and an email showed the state agency received the referral, but no Level 2 determination or evaluation report was found in the record. For Resident 38, the quarterly MDS showed diagnoses including stroke, anxiety, and bipolar disorder, with hallucinations and physical behaviors toward others. The record showed a corrected PASSR submitted on 01/12/2026 requiring a Level 2 evaluation, but there were no notes of follow-up, no evidence the evaluation occurred, and no Level 2 determination on file.
Failure to Provide Required ADL Assistance
Penalty
Summary
The facility failed to provide ADL assistance, including bathing, nail care, oral care, shaving, and grooming, for 5 of 9 sampled residents who were dependent on staff for these cares. The deficiency was identified through observation, interview, and record review and involved residents whose care plans and assessments showed they required staff assistance with personal hygiene and related ADLs. The facility policy stated residents unable to carry out ADLs were to receive the necessary assistance to maintain good personal and oral hygiene. Resident 5 was assessed as requiring maximum assistance with showers and dependent staff assistance for transfer to shower. Their care plan showed a preference for showers twice weekly with two staff assisting with transfers, but bathing documentation showed no shower was offered or provided after 05/12/2026. Resident 5 stated staff had not offered or provided a shower for about three weeks despite repeated requests, and the DON and unit care coordinator confirmed the resident should have been offered and provided showers per the care plan and shower schedule. Resident 10, Resident 12, and Resident 21 were observed with long, dirty, or overgrown fingernails despite care plans directing staff to check, clean, and trim nails on bath days and as needed. Resident 10 had long, dirty fingernails and chipped toenails; Resident 12 was repeatedly observed with long, dirty fingernails and black dirt under the nail beds; and Resident 21 stated the long, thick, curling fingernails were digging into their skin. Resident 25 was assessed as dependent for personal hygiene and oral care, with an order for oral care twice daily, yet was observed with matted hair, long facial hair, dry and chapped lips, and peeling lower lip. Staff confirmed the resident needed grooming, shaving, and mouth/lip care, but these cares were not provided as observed.
Restorative nursing services not provided or documented as planned
Penalty
Summary
The facility failed to provide restorative and functional maintenance services for residents with limited mobility and range of motion needs. The deficiency involved four residents who had restorative nursing programs (RNPs), care plans, therapy recommendations, or documented needs for ROM, splinting, ambulation, or other maintenance interventions, but the services were not consistently provided, were not accurately documented, or were not reflected in the care plans and restorative records. Resident 56 was admitted with wounds to both feet, muscle weakness, and difficulty walking. Therapy discharge summaries recommended an RNP for sit-to-stand transfers, ambulation with a walker and standby assist, and Omnicycle use three days per week for maintenance. The restorative communication tool reflected those recommendations, but the resident was not included on the restorative case load, the care plan did not include an RNP, and there was no evidence of restorative assessments or interventions for ambulation or Omnicycle use. The resident stated they had not had exercises for over three weeks and had been told they would receive RNP three times weekly, but it did not happen. Resident 41 was admitted with muscle weakness and a history of falls and was able to walk with supervision or touching assistance. The resident requested exercise or rehab and was told about the potential for an RNP, but the resident was not included in the restorative case load and the care plan did not show an RNP. Resident 21 had a chronic progressive neurological disorder, functional ROM limitations in both upper and lower limbs, weakness, and contractures. The care plan directed PROM to both upper and lower extremities three times weekly and splints to both hands/wrists, but observations showed the right hand splint was repeatedly not in place, the resident’s right hand was stiff and contracted, and restorative documentation showed only limited AROM entries with no documented PROM or splint/brace restorative services over the reviewed period. Resident 48 had a brain injury with left-sided weakness, memory deficits, and contractures. The care plan included splint/brace use and AROM or PROM, but observations showed the right ankle splint/brace was not in place and the left hand remained curled and stiff. Restorative flow sheets showed splint/brace assistance was provided for five minutes instead of the 15 minutes care planned, and no AROM or PROM was documented for two months. The last restorative program evaluation for this resident was more than a year old, and staff stated the ankle splint/brace program was no longer appropriate and should be removed from the care plan.
Menu Not Followed During Meal Service
Penalty
Summary
The facility failed to ensure the planned menu was followed for meal service. The facility policy stated menus were planned in advance and were to be followed as written to meet residents’ nutritional needs. On 06/01/2026, Staff O (Cook) was observed preparing mashed potatoes to replace the sweet potato menu item for residents on a mechanically altered texture diet because the kitchen had run out of sweet potato puree. Staff O stated they did not check the menu to ensure all listed food items were available, and Staff N (Food Services Director) stated the kitchen staff did not notify them about being out of the puree and residents did not receive timely communication about the menu change. Later that same day, Staff O was observed preparing white sausage gravy and stated it would be served with Salisbury steak, even though the menu called for brown gravy with that entrée. Staff O stated they used the sausage gravy because there was extra left over from breakfast and acknowledged they should have prepared the gravy outlined in the menu but did not. During lunch observations, Resident 21 was assisted by a family member and had ground Salisbury steak topped with sausage gravy, of which only a small bite was eaten; the resident stated the food did not taste good together. On 06/21/2026, Resident 72 was eating sliced ham while the Salisbury steak with sausage gravy on the tray was left untouched, and Staff S stated a piece of ham had to be requested because the resident did not like the food served. Resident 72 stated the Salisbury steak had been their original choice, but it was served with the wrong gravy. Resident 54 also had double portions of Salisbury steak topped with sausage gravy left untouched and stated the combination tasted bad.
Failure to Follow PPE, EBP, and Hand Hygiene Requirements
Penalty
Summary
The facility failed to ensure staff used appropriate PPE for residents on transmission-based precautions, failed to use PPE in accordance with enhanced barrier precautions for a resident with skin conditions, and failed to perform hand hygiene during wound care. The report states these failures placed residents and staff at risk for exposure to and development of contagious, communicable infectious diseases. Resident 91 was admitted with an active infectious disease and diagnoses including a multidrug resistant organism, a bone infection, and an amputation of the left great toe. The resident’s care plan called for contact precautions for the duration of the infection, and a sign outside the room instructed staff to put on a gown and gloves before entering. A housekeeping assistant entered the room without the required PPE, exited without gloves or hand hygiene, and was carrying a bag of garbage bags. Staff later stated they should have followed contact precautions but did not. Resident 53 had a positive C-Diff result after hospitalization, was ordered contact enteric precautions, and had a care plan directing contact enteric precautions and private room placement if available. During observation, two CNAs provided peri care without gowns, one CNA wore the same gloves into another resident’s room, removed gloves and used hand sanitizer, then returned to Resident 53’s room without gown or gloves. One CNA also carried a bag of linens from Resident 53’s room into another room. Staff stated they were supposed to wear gown and gloves every time they entered the room and wash hands with soap and water before leaving, but did not. Resident 56 had HIV, chronic lower leg wounds, and high blood pressure, and was sharing a room with Resident 53. The resident later developed loose stools and was placed on contact enteric precautions. Staff stated that a resident with C-Diff should be admitted to a private room and that the entire room would be considered contaminated when a resident with C-Diff resides there, but could not explain why Residents 53 and 56 shared a room. For Resident 84, an EBP sign was posted outside the room, but an LPN entered without gloves or gown while holding crushed medications and applesauce, cleaned the resident’s mouth with no gloves after the resident spit out medication, and attempted to administer nasal spray without gloves. The LPN stated they did not see the sign but should have followed it. During wound care for Resident 91, an LPN donned multiple pairs of gloves and layered them through the procedure instead of performing hand hygiene between dirty and clean tasks and glove changes. The LPN removed gloves several times, did not perform hand hygiene, and continued wound care. The unit care coordinator stated staff were expected to perform hand hygiene between dirty and clean cares and glove changes and were not supposed to layer gloves in place of hand hygiene.
Advance Directives Not Available or Current for Two Residents
Penalty
Summary
The facility failed to ensure Advance Directives were in place for 2 of 3 residents reviewed. For one resident, who had memory deficits, disorganized thinking, mental health problems with behavioral disturbance, and a brain injury with resulting weakness to one side of the body, the care plan showed the resident elected full code and was under the care and supervision of a court-appointed guardian/conservator. However, the resident's guardianship letter on file had expired, and the Social Services Director confirmed the guardianship records were expired during interview. For another resident, who had a history of a fall with major injury, heart and respiratory failure, unstable blood sugar levels, and mental health problems, the resident stated they had an Advance Directive and had named their brother as Durable Power of Attorney for Healthcare. Review of the medical record did not show any Advance Directive listed that was accessible to staff as required, and Social Services staff confirmed the resident's AD was not on file. Staff also stated that without the paperwork, the facility could not honor the brother as the DPOA-HC in an emergency if the resident could no longer make medical decisions.
Loud TV Volume Disturbed Sound Levels on 100 Hall
Penalty
Summary
The facility failed to maintain comfortable sound levels in the environment on 100 hall. Resident 27 stated in interview that the television down the hall was too loud at night and that they had reported it to staff, but the issue was not resolved. During an observation at the nurse’s station, loud televisions could be heard from rooms at the end of the hallway, and upon entering those rooms, residents were observed asleep with the televisions on and the volume turned up. The DON stated staff should encourage residents to lower television volume at 10:00 PM and provide headphones for residents who prefer louder sounds at night, and stated that this did not occur but should have.
Failure to Assess and Monitor Physical Restraint Use
Penalty
Summary
The facility failed to comprehensively assess and monitor the need for physical restraints for Resident 12. Resident 12 was readmitted to the facility and, on the 05/04/2026 Quarterly MDS, was documented as cognitively severely impaired, with unclear speech, diagnoses of stroke with weakness on one side of the body, and dependence on staff for transfers from bed to wheelchair. The MDS also indicated the resident was not currently using any form of physical restraints. Observations on 05/27/2026, 05/28/2026, and 05/29/2026 showed Resident 12 lying or sleeping in bed with the bed against the wall, in the lowest position, with a floor mat on one side. Two folded pillows were tucked under the left side of the mattress on the first two observations, and three folded pillows were tucked under the mattress on the third observation, creating a barrier bump that prevented the resident from moving in bed or getting out of bed. Staff W stated night shift staff might have tucked the pillows under the mattress to prevent the resident from rolling out of bed. Review of the resident's record showed no evidence that the facility assessed the resident's condition to warrant use of restraints for convenience, and the DON stated that placing pillows under the mattress to prevent movement or getting out of bed was not acceptable and could be considered restraints.
Missing discharge documentation and bed-hold notification
Penalty
Summary
The facility failed to provide a discharge summary that included a recap of the resident’s stay and reconciliation of all medications for Resident 4, who had diagnoses of bone infection, heart failure, and unstable blood sugar dependent on insulin. The record showed Resident 4 admitted to the facility and later wished to discharge against medical advice. The health record did not include a discharge summary or documentation that medications were offered or provided to support the discharge process. During interview, the DON stated staff were expected to offer and provide life-sustaining medications if available, provide a recap of the resident’s stay, and that the provider would not write or call in prescriptions for residents discharged AMA; after reviewing the record, the DON stated staff did not offer or provide a recap of the stay or send the resident with life-sustaining medications, but should have. The facility also failed to offer a bed hold for Resident 86, who had diagnoses of respiratory failure, kidney disease, and low blood pressure and was transferred to the hospital due to a health emergency. The record stated the facility was not able to contact the resident’s representative, and there were no notes showing that a bed hold was offered or attempted for the unplanned discharge. During interview, the DON stated staff were expected to offer a bed hold at the time of discharge or to the resident’s representative, and after reviewing the record stated that did not happen but should have.
Inaccurate MDS Coding for Diet and ROM Program
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) for one resident was completed accurately to reflect the resident’s condition and health status. The resident’s 05/14/2026 quarterly MDS identified the resident as alert, able to verbalize needs, with heart failure, a chronic progressive neurological disorder affecting movement, and a mechanically altered and therapeutic diet. The MDS also indicated functional limitations in range of motion in both upper and lower limbs and that the resident received active ROM exercises during the look-back period. During observation and interview on 05/27/2026, the resident was lying in bed with very minimal ability to move independently and had a left-hand splint applied. The resident stated they did not like eating mashed-up foods and wanted more regular food items. Record review showed the nutrition care plan listed a mechanically altered diet with thin liquids and diet condiments, but did not show a therapeutic diet. The functional care plan showed limited mobility, weakness, and contractures, and an RNP intervention showed passive ROM exercises to prevent further deformities. The nutrition assessment showed the resident was on a regular diet, and the RD did not check therapeutic or fortified foods as applicable. In interview, the MDS coordinators stated the resident was not capable of actively participating in RNP exercises and that passive ROM was provided instead of active ROM, and the RD stated the resident was not on a therapeutic diet.
Missed Care Conferences for Two Residents
Penalty
Summary
The facility failed to conduct care conferences for residents and their representatives and the applicable interdisciplinary team members for 2 of 3 sampled residents reviewed for care planning. The facility policy stated that each resident’s comprehensive care plan would be timely, reviewed and revised by an IDT, and that the resident and representative, if applicable, would be involved in developing the care plan and making decisions about care. The policy also stated care plans were to be revised based on changing resident needs. Resident 5’s record showed a quarterly MDS dated 03/06/2026 indicating no memory impairment, diagnoses of adult failure to thrive and schizophrenia, and no behaviors during the assessment period. The last care conference offered and provided for Resident 5 was 12/01/2025, and no quarterly care conference had been offered or provided since then. Resident 5 stated they understood the facility would only offer a care conference annually and would appreciate one every few months to stay informed and ask questions. Staff G stated care conferences were expected within four days of admission, quarterly, and as needed, and confirmed Resident 5 had not had one offered since December 2025. Resident 41’s admission record showed the resident was their own responsible party and had family contacts listed. An admission MDS dated 04/02/2026 showed medically complex conditions and that the resident was able to understand and to be understood. A progress note dated 04/07/2026 showed Staff H attempted to contact two family members to schedule a care conference but was unsuccessful, and no further attempts were documented. Resident 41 stated the facility told them a care conference would be held, but it never occurred. Staff G stated the facility process was to hold a care conference within 72 hours after admission, and confirmed Resident 41 did not have a care conference with the IDT.
Failure to Follow Physician Orders for Bowel Care, BP Medication Parameters, and Continuous Oxygen
Penalty
Summary
The facility failed to follow physician orders for bowel care, blood pressure medication parameters, and continuous oxygen administration for multiple residents. The report states that these failures placed residents at risk for medication errors, unmet care needs, and other negative health outcomes. The deficiency was identified through observation, interview, and record review. Resident 8 was admitted with diagnoses including high blood pressure, stroke, and muscle weakness, and was incontinent of bowel and dependent on staff for toileting assistance. The resident had physician orders for multiple PRN laxatives and a bowel protocol, but task documentation showed no bowel movements for four days and the MAR showed no laxatives were given. The DON stated the resident was monitored every shift and should have received an as-needed laxative after three days without a bowel movement, but staff did not give one. Resident 83 had diagnoses including high blood pressure and constipation, was incontinent of bowel and bladder, and required substantial to maximal assistance with toileting hygiene. The resident had bowel protocol orders that required stepwise treatment, including a suppository, then an enema if the suppository was not effective, but documentation showed repeated periods of several days without a bowel movement and the ordered sequence was not followed. The resident also had a BP medication order to hold the medication if systolic BP was below 110, but the medication was administered when the recorded systolic pressures were 103 and 101. Resident 12, who had stroke with left-sided weakness and received hospice care, had an order for oxygen at 2 liters per minute continuously by nasal cannula, but observations showed the resident without oxygen on multiple occasions while in bed and while in a wheelchair.
Failure to Assess and Document Skin Conditions
Penalty
Summary
The facility failed to ensure residents’ skin was assessed, documented, monitored, and treated as required for 2 of 5 residents reviewed for non-pressure skin issues. Facility policy titled, Area of Focus: Basic Skin Management, required weekly head-to-toe skin assessments with a thorough description of all skin alterations. For Resident 5, the record showed the resident had no memory impairment, was at risk for skin injuries, required staff assistance with all ADLs, and had diagnoses of general muscle weakness and adult failure to thrive. A care plan directed staff to complete weekly skin assessments every Saturday and to assess for skin alterations, but a weekly skin assessment on 05/23/2026 documented no skin alteration to the right forearm. During observation and interview on 05/28/2026, Resident 5 had a six-centimeter by four-centimeter dark purple bruise to the right forearm and stated staff were not monitoring it. A later weekly skin assessment on 05/30/2026 again did not document the bruise, and the DON and Unit Care Coordinator stated staff did not assess and document the bruise as they should have. For Resident 11, the quarterly MDS showed the resident had diagnoses including wounds to the lower legs, heart failure, and kidney disease, and had non-pressure related wounds to the lower extremities. The care plan called for weekly skin checks, and physician orders remained active for wound care to the right leg and left leg. The record included a progress note stating the wounds had resolved on 05/08/2026, but no further wound assessments were found and the wound care orders were still in place. Resident 11 stated they had chronic wounds to the lower legs, and during observation staff provided wound care with wounds present on both legs. Staff later stated the resident had chronic wounds since admission, and the Unit Care Coordinator stated the wounds should have been seen in the weekly skin assessments but were not.
Failure to Provide Effective Pain Management
Penalty
Summary
Provide safe, appropriate pain management for a resident who requires such services was not ensured for 2 of 3 sampled residents reviewed for pain management. The facility’s pain management policy stated pain care would be provided consistent with professional standards of practice and the resident’s comprehensive assessment and care plan. For Resident 21, the record showed diagnoses including muscle pain and spinal cord degeneration with back pain, and the quarterly MDS indicated severe pain that affected sleep and day-to-day activities. The care plan identified back pain, muscle rigidity, and chronic pain, with interventions to evaluate pain management effectiveness and notify the physician if interventions were unsuccessful or if the complaint was a significant change from the resident’s past pain experience. During observation, Resident 21 was noted with facial grimacing and a tense body while lying in bed and reported pain rated 9/10, stating the pain was not managed effectively. The MAR showed PRN pain medication ordered only for pain rated 1-4/10, yet the resident had pain rated 7/10 on one occasion and received the PRN medication that was not intended for that pain level. For Resident 38, the quarterly MDS showed occasional moderate pain, and the care plan directed staff to respond immediately to pain complaints and evaluate pain medication effectiveness. The record showed pain rated 10/10 on two occasions, but there were no notes showing physician notification, pain assessment, or interventions provided, and the resident later reported the facility was not managing pain well.
Expired and Unlabeled Medications Found in Storage Areas
Penalty
Summary
The facility failed to ensure expired medications were discarded timely in the North Medication Room and failed to ensure medications were labeled appropriately in the 200 Hall Medication Cart. In the North Medication Room, observation showed three inhalers that had been opened with no open date, two boxes of nebulizer medication vials with expiration dates of 07/10/2025 and 10/29/2025, and vaccines stored in the refrigerator with expiration dates of 02/12/2025, 05/02/2025, 07/31/2025, and 10/23/2025. A 2024 Medication Storage Guidance from Omnicare stated the inhalers were to be discarded three months after opening, and Staff D stated the inhalers should have been dated when opened but were not. In the 200 Hall Medication Cart, observation showed a medicine cup containing five oral medications, including tablets and capsules of varying shapes and colors, stored in the top drawer with no label identifying the medications or the resident for whom they were intended. Staff U stated they were not aware the medication cup was in the drawer and did not know which resident it was for, and stated the medications should have been discarded but were not.
Failure to Track Antibiotic Use on Line Listing
Penalty
Summary
The facility failed to implement an Antibiotic Stewardship Program to promote appropriate antibiotic use and reduce unnecessary antibiotic use for 1 of 5 residents reviewed for unnecessary medications and 1 of 1 supplemental residents. The facility’s Infection Prevention and Control Program and Plan stated that antibiotic surveillance would be conducted to review the appropriateness of antibiotics in the facility to prevent unnecessary antibiotic use. Resident 91 was receiving an intravenous antibiotic starting on 05/27/2026 with no stop date, and Resident 53 received an oral antibiotic from 05/12/2026 through 05/19/2026. However, the facility’s May 2026 Line Listing did not identify either resident as having an infection or receiving antibiotics. During interview, the Infection Preventionist stated they reviewed antibiotic orders for appropriateness using McGeer’s criteria and included the review on the Line Listing for tracking and trending infections, and acknowledged that neither Resident 91 nor Resident 53 was listed but should have been.
Incomplete pain assessment and opioid monitoring led to overdose event
Penalty
Summary
The facility failed to implement its pain assessment and management policy for a resident admitted with cognitive impairment, limited mobility, and chronic pain diagnoses involving the hip, knees, and bilateral legs. On admission, the resident was prescribed multiple pain medications, including an opioid as needed, but the admission nursing assessment did not identify a pain diagnosis, pain location, effects on quality of life, or non-pharmacological pain relief methods. The April care plan contained no pain focus area or interventions, and the record did not show a complete individualized pain assessment or a pain management plan developed with the resident, representative, and practitioner. The medication record showed the resident received the opioid three times after admission for reported pain levels of 8/10, 7/10, and 10/10, with documentation that the doses were effective. On the same day the resident was evaluated by the practitioner, the opioid order was changed from as-needed to scheduled three times daily. Nursing progress notes from that period did not document a change in condition, the reason for the medication change, or notification of the practitioner or resident representative. The DON later reviewed the record and stated there was no complete pain assessment on admission, no care plan for pain, no documentation supporting the opioid order change, no notification of the resident representative, and no alert monitoring initiated after the opioid was changed to scheduled dosing. After the opioid was changed to scheduled administration, the resident received repeated doses over the next several days. On the day of the event, staff and the resident representative reported the resident was sleepy, confused, hallucinating, unable to hold the phone, and not making sense. Staff documented low oxygen saturation, increased oxygen, notified the practitioner, and the resident was sent to the hospital by medics after the representative called 911. The hospital record showed the resident arrived unresponsive with low oxygen and low pulse, received an opioid antagonist by medics, and was diagnosed with unintentional opioid overdose with respiratory failure and admitted to the ICU.
Deficiencies in Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to ensure comprehensive and implemented care plans for six residents, leading to potential risks for unmet care needs and negative health outcomes. Resident 139, who required substantial assistance with bathing and had a gastrointestinal infection, did not have a care plan addressing their bathing needs. Staff acknowledged the omission, indicating the care plan should have included directions for bathing type and frequency. Resident 63, with a history of heart failure and using a manual wheelchair, was observed in a tilt-in-space wheelchair without a care plan detailing its purpose or proper use. Similarly, Resident 6, who required oxygen therapy, had a care plan that did not reflect the physician's order to increase oxygen during respiratory distress. Staff confirmed the importance of aligning care plans with physician orders. Other deficiencies included Resident 8, who had bed rails without a corresponding care plan, and Resident 69, whose bed was against the wall without a care plan addressing safety concerns. Resident 14, treated for prediabetes, lacked a diabetes care plan. Staff interviews highlighted the necessity of comprehensive care plans to ensure staff awareness and proper care delivery.
Failure to Conduct Care Conferences and Update Care Plans
Penalty
Summary
The facility failed to facilitate quarterly care conferences for five residents and did not revise care plans as required for one resident. The facility's policy mandates that care plans be reviewed and revised after each Minimum Data Set (MDS) assessment, which occurs at least quarterly. However, residents 63, 77, 8, 14, and 64 did not have care conferences held as per the policy. Resident 63, who had intact memory, expressed a desire to participate in care conferences but was not given the opportunity due to the absence of a Social Services Director. Resident 77, with moderate memory impairment, and other residents also did not have documented care conferences since their admission or baseline care plan. Resident 80's care plan was not revised despite changes in their eating assistance needs. Initially, the care plan required staff to provide one-on-one assistance with eating. However, interviews revealed that Resident 80 often fed themselves and did not consistently receive assistance. Staff interviews indicated that Resident 80's mood influenced their need for assistance, and the care plan was not updated to reflect these changes. The Director of Nursing acknowledged that the care plan should have been updated once the resident's needs changed. The lack of care conferences and failure to update care plans placed residents at risk for unmet care needs and other negative health outcomes. The facility's policy requires care conferences to be held within 48 hours of admission, quarterly, and upon request by the resident or their representative. The absence of a Social Services Director and failure to adhere to policy contributed to these deficiencies, as confirmed by staff interviews.
Deficiencies in Physician Orders and Pain Management
Penalty
Summary
The facility failed to ensure physician orders were clarified for three residents, leading to potential risks in their care. Resident 8 had bilateral quarter bed rails in use without a physician order, despite an evaluation indicating their use. Staff interviews confirmed the absence of a necessary physician order for the bed rails, which was expected by the facility's Director of Nursing. Resident 14, who had moderate memory impairment and was diagnosed with prediabetes, was prescribed an antidiabetic medication without a corresponding physician order to monitor for signs and symptoms of low or high blood sugar levels. This oversight was acknowledged by staff, who emphasized the importance of such monitoring to maintain safe blood sugar levels. Resident 13, with a history of diabetes and chronic pain syndrome, lacked physician orders to monitor blood sugar levels despite being on medications that could affect these levels. Additionally, there were no parameters for the administration of as-needed pain medications for Residents 13, 14, and 8, which could lead to inappropriate pain management. Staff interviews highlighted the necessity of having parameters to prevent overmedication or undermedication and the importance of implementing nonpharmacological interventions for pain relief.
Facility Fails to Maintain Safe Environment and Assess Wheelchair Safety
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards in two of its units, specifically Units 100 and 200. Observations revealed that hot water temperatures in several rooms exceeded the facility's safety policy limit of 120 degrees Fahrenheit, with temperatures reaching as high as 125.1 degrees Fahrenheit. This posed a risk of burns to residents, particularly those with conditions that increase their susceptibility to such injuries. Interviews with maintenance staff indicated that a component failure in the hot water line led to these unsafe temperature levels. Additionally, the facility did not ensure that a tilt-in-space wheelchair provided to a resident was assessed for safety prior to use. The resident, who had intact memory and a history of heart failure and traumatic fracture, was using the wheelchair as a placeholder due to their longer frame. However, there was no evidence of a safety assessment being conducted for this wheelchair, and the therapy department had not reassessed it as part of their quarterly evaluations. The Director of Nursing expressed that all wheelchairs should be periodically assessed for safety. Furthermore, the facility failed to store sharps and chemicals safely in one of the shower rooms. A certified nursing assistant left a resident unattended in the shower room, where razors and a bottle of disinfectant cleaner were accessible. The staff member admitted to not having a key to lock the cabinet containing these items, which should have been secured to prevent resident access. The Director of Nursing confirmed the expectation that such items be stored behind locked doors to ensure resident safety.
Dietary Manager Lacks Required Certification
Penalty
Summary
The facility failed to ensure that the Dietary Manager, referred to as Staff J, possessed the required qualifications to perform their duties in the facility's kitchen. Staff J admitted during an interview that they had not completed the necessary dietary manager training. This situation arose because the previous Dietary Director left earlier than expected, leaving Staff J in charge without the proper certification. Additionally, the facility's Registered Dietician (RD), identified as Staff Q, did not work full-time at the facility, as they were also responsible for a sister facility. Staff Q confirmed that they only worked at the facility on Tuesdays and Thursdays, which did not meet the full-time requirement when the dietary manager lacked the necessary certification. This deficiency placed all residents at risk of receiving meals prepared by staff without the required competencies and skills to provide adequate food and nutrition services.
Failure to Document Vaccine Education and Administration
Penalty
Summary
The facility failed to provide necessary education and documentation for influenza and pneumococcal vaccinations for four residents. Specifically, Residents 8, 14, and 13 received the influenza vaccine without documented education on its risks and benefits, and there was no record of the pneumococcal vaccine being offered or their historical immunization status. Resident 64's records lacked documentation of both influenza and pneumococcal vaccines being offered for the 2024-2025 season, as well as their historical immunization status. During an interview, the Infection Preventionist acknowledged the absence of documentation for education and consent for the influenza vaccines for these residents. They also admitted to not obtaining and scanning the residents' immunization records from the department of health into their health records. The Infection Preventionist emphasized the importance of educating residents and obtaining consent prior to vaccine administration to ensure residents are informed about the risks and benefits, as well as the necessity of verifying vaccination status upon admission to prevent communicable diseases.
Failure to Educate on COVID-19 Vaccination
Penalty
Summary
The facility failed to provide education on the benefits and potential side effects of the COVID-19 vaccination to four out of five sampled residents and one sampled staff member. Specifically, Residents 8, 14, 13, and 64 did not have documented evidence of receiving education about the COVID-19 vaccine's benefits and potential side effects. Additionally, Resident 64 was not offered the COVID-19 booster vaccine for the 2024-2025 period. Staff U, a Restorative Aide, also did not receive the required education on the vaccine's risks and benefits. Interviews with facility staff revealed a lack of awareness and adherence to the facility's COVID-19 Vaccination Program Policy. Staff I, the Infection Preventionist, admitted to not educating staff and residents on the vaccine and failing to document the education provided. The Director of Nursing, Staff B, confirmed the expectation that Staff I should educate and document the education for all employees and residents. This oversight placed residents, their representatives, and staff at risk of not being able to make informed decisions regarding their medical care.
Failure to Ensure Required Training for Nursing Aides
Penalty
Summary
The facility failed to implement a system to ensure that nursing aides received the required training for continued competency, specifically for one nursing aide, Staff CC. This deficiency was identified during an interview and record review conducted by Staff C, the Regional Director of Clinical Services. It was found that since Staff CC's hire date, there were no training documents related to essential topics such as abuse, neglect, exploitation, infection control, communication, resident rights, or cultural competency. Additionally, the facility lacked a staff development coordinator to track nursing assistants' continuing education and annual training requirements, including mandatory topics and those related to the special needs of the resident population.
Failure to Honor Resident Dignity and Preferences
Penalty
Summary
The facility failed to uphold the dignity and preferences of Resident 31, who was admitted with a cognitive communication deficit and required assistance with personal care. Despite expressing a desire to be consulted on decisions and daily routines, Resident 31 reported being woken up multiple times during the night for vitals and toileting, which disrupted their sleep. The resident also requested as-needed sleep medication, which was denied by the nursing staff without consulting the provider. Additionally, Resident 31 felt disrespected by staff addressing them with terms they did not prefer and was disturbed by loud noise from other residents' televisions at night. Resident 16, who had intact memory and communication abilities, was not given adequate notice or preparation time for a care conference. The resident's collateral contact was not informed about the conference, and Resident 16 was awoken without warning by the former Social Services Director and other staff, leaving them without time to dress or groom themselves. This lack of preparation was noted as undignified by Resident 16, who expressed frustration over the situation. Interviews with staff revealed a lack of adherence to the facility's dignity policy, which emphasized respecting residents' preferences and individuality. Staff acknowledged the need for designated quiet times and better communication with residents regarding their care preferences. The facility's failure to honor residents' preferences and provide adequate notice for care conferences resulted in feelings of diminished self-worth and embarrassment for the residents involved.
Failure to Obtain Resident Consent for Vaccinations, Medications, and Equipment
Penalty
Summary
The facility failed to obtain resident consent for the administration of the Covid-19 vaccine for four residents. Specifically, Residents 8, 14, and 13 received the Covid-19 vaccination without documented consent, and Resident 64 was not offered the vaccine for the 2024-2025 booster, nor was consent obtained. This lack of documentation and consent was confirmed by Staff I, the Infection Preventionist, who acknowledged the absence of consent records for these residents. Additionally, the facility did not secure consent for the administration of psychotropic medication for Resident 14. The resident, who had diagnoses including anxiety disorder, depression, bipolar, and psychotic disorder, was administered an antipsychotic medication starting on May 24, 2024, but consent was not obtained until January 10, 2025, over seven months later. Staff F, the Unit Care Coordinator, admitted that consent should have been obtained prior to the medication's administration. Furthermore, the facility failed to obtain consent for the use of a tilt-in-space wheelchair for Resident 63, who was cognitively intact and expressed concerns about awaiting training for the wheelchair. The resident was observed in the wheelchair, which cannot be adjusted by the user, without any record of consent being obtained. Staff B, the Director of Nursing, confirmed that consent should have been obtained prior to the use of the wheelchair.
Failure to Ensure Advanced Directives for Residents
Penalty
Summary
The facility failed to implement a system to ensure that Advanced Directives (AD) were in place for three residents reviewed for ADs. The facility did not provide information indicating that residents were informed, educated, or offered assistance to formulate an AD. This deficiency was identified through record reviews and interviews with staff and residents. Specifically, Resident 63, who had intact cognition and diagnoses including heart failure and a kidney condition, had no AD documentation on file, nor was there evidence that they received materials explaining their right to formulate an AD. Similarly, Resident 14, who had moderate memory impairment and diagnoses including a drop in blood pressure with change in position and high cholesterol, stated they did not have an AD and were not offered assistance in obtaining one. Resident 77, with moderate memory impairment and diagnoses including diabetes and Parkinson's, also had no AD documentation or evidence of being informed about their right to formulate an AD. Staff interviews confirmed the lack of documentation and assistance provided to these residents, highlighting a systemic failure to ensure residents' rights to formulate an AD were upheld.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment for residents, as evidenced by observations of multiple rooms with deep gouges and exposed drywall behind the head of resident beds. These deficiencies were noted in several rooms across two units, specifically Units 400 and 100. Additionally, a nightstand in one of the rooms had its trim ripped off, exposing rough wood. These conditions were observed during a survey conducted on various dates in March 2025. Furthermore, a resident reported that the water in their bathroom sink was consistently too cold, requiring a wait of at least five minutes for it to warm up. The Maintenance Director, Staff Y, acknowledged that it was their responsibility to maintain a homelike environment but was unaware of the needed repairs in the affected rooms. Staff Y stated that they relied on floor staff to report maintenance issues through a communication book, but these issues had not been communicated to the maintenance department.
Failure to Provide Required Transfer Notifications
Penalty
Summary
The facility failed to provide timely and required written notifications to residents and their representatives regarding transfers or discharges, as well as to the State Long-Term Care Ombudsman (LTCO). This deficiency was identified for two residents who were hospitalized. Resident 8, who had no memory impairment, was hospitalized for respiratory symptoms but did not receive a written transfer notification. Similarly, Resident 69, who had moderate memory impairment and whose representative participated in their assessment, was also hospitalized without receiving the necessary written notification. Interviews with staff revealed that the social service department did not provide the required written transfer notices to residents or notify the LTCO of resident transfers. Staff members acknowledged the oversight, with the Social Service Assistant admitting to not providing the notices and the Unit Care Coordinator confirming that residents or their representatives did not sign to acknowledge receipt of the transfer notification forms. The Regional President stated that it was the responsibility of the social service department to ensure these notifications were provided.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of its bed hold policy to residents and/or their representatives at the time of transfer to a hospital or within 24 hours, as required by their policy. This deficiency was identified for three residents who were reviewed for hospitalizations. Resident 8, who had no memory impairment, was hospitalized for respiratory symptoms but did not receive the required notification. Similarly, Resident 69, who had moderate memory impairment and whose representative assisted in their assessment, was hospitalized without the representative receiving the bed hold policy notification. Resident 64, who had no memory impairment and an indwelling urinary catheter, also did not receive the notification upon hospitalization. Interviews with staff revealed that the social service department and unit care coordinators did not provide the necessary written notice of the bed hold policy to residents or their representatives at the time of transfers. Staff E, a Social Service Assistant, confirmed the lack of notification, while Staff F, a Unit Care Coordinator, acknowledged the absence of documentation in the residents' records. The Director of Nursing, Staff B, stated that nurses were expected to provide and document the notification, emphasizing the importance of informing residents of their rights and the costs associated with holding their bed during hospitalization.
Failure to Complete and Incorporate PASRR Level II Evaluations
Penalty
Summary
The facility failed to ensure that a Level II Preadmission Screening and Resident Review (PASRR) evaluation was completed and incorporated into the Care Plan for two residents. Resident 26, who had non-Alzheimer's dementia, depression, and a history of stroke, exhibited behavior problems such as aggression towards staff. Despite a Level I PASRR screening indicating that Level II services were not required, a significant change in Resident 26's condition was noted, but no documentation showed a Level II referral was made. Similarly, Resident 43, who had non-Alzheimer's dementia, anxiety, depression, and PTSD, required a Level II evaluation referral according to their Level I PASRR screening. However, there was no documentation of a Level II referral being made for Resident 43. Interviews with facility staff revealed that the social services department was understaffed, which hindered the review and completion of PASRR Level II screenings. Staff acknowledged the importance of these referrals for addressing mental health needs but admitted that the facility was not actively working on PASRR Level II referrals and lacked a process to update PASRR screenings for residents with changes in condition. This oversight placed residents at risk for unmet mental health care needs and other negative health outcomes.
Failure to Complete PASRR Assessments for Residents
Penalty
Summary
The facility failed to ensure that Pre-Admission Screening and Resident Review (PASRR) assessments were completed for two residents, leading to a deficiency in the screening process. Resident 64, who was admitted with diagnoses including anxiety disorder and depression, had indicators of Serious Mental Illness (SMI) on their PASRR level I assessment. However, no level II evaluation was conducted, as it was incorrectly determined that the resident did not show indicators of SMI. This oversight left the resident at risk of not receiving necessary mental health services. Similarly, Resident 69, who was admitted with diagnoses including dementia, depression, and bipolar disorder, had a PASRR level I assessment completed at a sister facility, which indicated the need for a level II referral due to SMI indicators. Upon transfer to the current facility, the PASRR level I was not reviewed for accuracy and completion, and no level II referral was made. Staff interviews revealed that the PASRR process was not completed accurately, which was crucial for ensuring residents received the mental health services they needed.
Failure to Provide Communication Assistance for Non-English Speaking Resident
Penalty
Summary
The facility failed to provide necessary communication assistance to Resident 77, who was identified as needing an interpreter due to a language barrier. The resident's primary language was not English, and the care plan specified that translation services and communication assistive devices should be provided. However, during an observation and interview, Resident 77 reported that they were unaware of any translation assistance or devices available to them, and no communication aids or translator service phone numbers were found in their room. Staff interviews revealed that the Unit Care Coordinator acknowledged not providing the required communication aids as outlined in the care plan. The Director of Nursing also confirmed the expectation that staff should provide communication boards and translation service contact information to residents with limited English proficiency. The lack of these services placed Resident 77 at risk of miscommunication and unmet care needs, as they were unable to effectively communicate with staff.
Failure to Provide Bathing Assistance to Resident
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living, specifically bathing, to a resident who was dependent on staff assistance. Resident 139, who was admitted with a highly transmissible gastrointestinal infection requiring isolation, required substantial to maximal assistance with bathing due to moderate memory impairment. Despite the facility's policy to assist residents unable to perform their own ADLs, Resident 139 received only one bed bath over an 18-day period, with only one documented refusal of bathing. The care plan for Resident 139 did not include directions addressing their bathing needs, and there was no other care plan addressing the need for bathing assistance. During an interview, Resident 139 expressed a desire for assistance with bathing and showed signs of poor hygiene, such as long and soiled fingernails. Staff X, an LPN, acknowledged the importance of providing bathing assistance and confirmed that Resident 139 did not receive the required assistance.
Failure to Monitor Edema in Residents
Penalty
Summary
The facility failed to ensure that three residents with edema received the necessary care and services in accordance with professional standards of practice. Resident 8, who had a diagnosis of heart failure with edema, was receiving diuretic medication but did not have a physician's order to assess and monitor edema. Staff F confirmed the lack of documentation for monitoring the resident's edema, which should have been done every shift to manage heart failure with edema effectively. Resident 13, diagnosed with heart failure with edema and kidney failure, also received diuretic medication but lacked a physician's order to assess and monitor edema. The facility failed to monitor the resident's weight as per physician orders, with only 10 out of 27 opportunities being documented. Staff F acknowledged the importance of monitoring edema and weight changes to prevent fluid overload or dehydration. Resident 64, who had bilateral lower extremity edema, was on diuretic medication but similarly lacked a physician's order for edema monitoring. Staff F and the Director of Nursing both stated that edema should be monitored every shift, and weight should be monitored more frequently for residents with edema.
Failure to Provide Fresh Water to Residents
Penalty
Summary
The facility failed to ensure fresh water was offered to five residents, leading to a risk of dehydration and decreased quality of life. Observations and interviews revealed that residents were not provided with fresh water unless they specifically requested it. This was contrary to the facility's policy, which stated that fluids should always be available to residents, and a hydration cart may be utilized. Residents 8, 14, 13, 69, and 64 were observed multiple times without fresh water available, and they reported that staff did not offer fresh water proactively. Staff interviews confirmed the deficiency, with a Certified Nursing Assistant stating that residents received fluids only on their meal trays unless they asked for more. The Unit Care Coordinator and the Director of Nursing both expressed that staff were expected to offer fresh water every shift and emphasized the importance of doing so to ensure residents remain hydrated. Despite these expectations, the observations indicated a consistent failure to provide fresh water, placing residents at risk of dehydration.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as Resident 43, who required oxygen therapy due to a diagnosis of chronic obstructive pulmonary disease (COPD). The resident's care plan and physician's orders specified that oxygen should be administered at a flow rate of 2 Liters Per Minute (LPM) continuously via nasal cannula. However, multiple observations revealed that the oxygen flow rate was set at 3 LPM instead of the prescribed 2 LPM. Additionally, during one observation, the oxygen tubing was found disconnected from the concentrator and lying on the floor, indicating a failure to ensure proper oxygen delivery. Interviews with staff members, including a Licensed Practical Nurse (LPN) and the Unit Care Coordinator, confirmed the discrepancies in oxygen administration. The LPN was unaware of the specific oxygen order and mistakenly believed the flow rate could be set between 2 to 3 LPM. The Unit Care Coordinator emphasized the importance of checking oxygen levels, tubing connections, and settings to ensure the correct rate is administered. The Director of Nursing also stated that oxygen should be administered according to the physician's orders and that nurses should regularly check residents' oxygen needs. These failures in adhering to the prescribed oxygen flow rate and ensuring proper equipment setup placed the resident at risk of respiratory discomfort and decreased quality of life.
Failure to Obtain Consent and Conduct Safety Assessment for Bed Rails and Bed Positioning
Penalty
Summary
The facility failed to obtain informed consent and conduct a safety assessment before implementing bed rails and positioning a bed against the wall for two residents. For one resident, bilateral quarter bed rails were installed without documented consent, despite an evaluation for their use being conducted. An observation confirmed the presence of these bed rails, and staff acknowledged the oversight in obtaining consent, emphasizing its importance to ensure the resident's agreement with the installation. For another resident, the bed was positioned against the wall without a safety assessment or consent. Staff interviews revealed that the expected protocol of obtaining consent and completing a safety assessment was not followed. The Director of Nursing confirmed that staff were expected to adhere to these procedures to prevent potential injuries or entrapment, but they were not executed in these cases.
Failure to Address Resident's Mental Health Needs
Penalty
Summary
The facility failed to ensure that Resident 80, who was diagnosed with depression and other cognitive issues, was evaluated for potential mental health services to address ongoing behaviors. Despite being on an antidepressant medication, Resident 80 exhibited behaviors such as refusals of care, agitation, and refusals to eat, which were documented by the staff on multiple occasions in March 2025. However, there was no evidence that the facility assessed these behaviors or notified the resident's provider of these changes, as required by the care plan. Interviews with staff revealed a lack of communication and follow-up regarding Resident 80's refusals of care. Staff E, a Social Services Assistant, stated they would have contacted the family if they had been aware of the refusals. Staff H, the Unit Care Manager, acknowledged that staff were expected to report refusals of care, but this did not occur. The Director of Nursing, Staff B, confirmed that the facility should have notified the doctor about Resident 80's refusals, as it could impact their overall care. The failure to notify the provider and assess the resident's behaviors placed Resident 80 at risk for untreated mental health issues.
Medication Storage and Monitoring Deficiencies
Penalty
Summary
The facility failed to ensure proper monitoring and storage of medications and biologicals, leading to several deficiencies. In the 100/200 unit medication room, the refrigerator temperature was observed to be 49 degrees Fahrenheit, which is above the recommended range of 36 to 46 degrees. There was no temperature log available to confirm routine monitoring. Interviews with staff revealed a lack of clarity regarding who was responsible for checking the refrigerator temperatures, with the Infection Preventionist, Director of Nursing, and Regional VP all expressing uncertainty about the process. In the 300/400 unit medication room, expired medications were found, including an antibiotic with a use-by date of 03/06/2025 and a suspension powder that expired in 2023. The Unit Care Coordinator admitted responsibility for disposing of expired medications but failed to do so. Additionally, a bottle of medicated powder with another resident's name was found on Resident 31's nightstand. Resident 31, who has a cognitive communication deficit and non-Alzheimer's dementia, was at risk due to this oversight. Staff interviews confirmed that medications should not be left in residents' rooms, especially for those with confusion.
Confidentiality Breach of Resident Records
Penalty
Summary
The facility failed to ensure the confidentiality of resident records for one of the four medication carts reviewed, specifically the 100 hall medication cart. During observations and interviews, it was noted that both a Licensed Practical Nurse (LPN) and a Registered Nurse (RN) left a list containing health information of all residents on the 100 hall unsecured and in view when they walked away from their medication carts. Both staff members acknowledged their responsibility to maintain confidentiality of resident information but admitted to not doing so. The Director of Nursing (DON) confirmed the expectation that all resident information should be secured before staff leave it unattended, emphasizing the importance of maintaining confidentiality for residents' right to privacy.
Lack of Coordination with Hospice Services for Resident
Penalty
Summary
The facility failed to ensure effective coordination of care between the facility and hospice staff for Resident 25, who was receiving hospice services for conditions including Multiple Sclerosis and muscle weakness. The facility did not develop a coordinated Care Plan that included the hospice plan of care or a description of services provided by both the facility and hospice. The Kardex and medical records lacked documentation of the hospice plan of care and visit notes, and the hospice binder at the nurse's station was incomplete, containing only the demographics page of Resident 25's hospice admission. Interviews with staff revealed a lack of communication and coordination between the facility and hospice services. Staff were unsure of the hospice nurse's schedule and did not receive training on hospice care. The Unit Care Coordinator acknowledged the importance of integrating hospice services into the Care Plan but noted that hospice documentation was not consistently placed in the hospice binder. The Director of Nursing stated that coordination with hospice was crucial but was unsure where hospice notes were kept, and these notes were not scanned into the resident's medical record.
Infection Control Deficiencies in Equipment Storage and PPE Use
Penalty
Summary
The facility failed to properly store respiratory equipment for Resident 69, who was admitted with no respiratory infections but later transferred to an acute care hospital for a respiratory illness. Upon return, a physician ordered respiratory medication via a Small Volume Nebulizer (SVN) machine. Observations revealed that the SVN machine was stored on the roommate's nightstand instead of Resident 69's area, which was confirmed by both the Unit Care Coordinator and the Director of Nursing as inappropriate for infection prevention. For Resident 84, who had a Multidrug-resistant Organism (MDRO) infection and required contact precautions, the facility did not follow the physician's order. Instead of implementing the required contact precautions, Enhanced Barrier Precautions were observed, which did not align with the physician's directive. The Director of Nursing acknowledged that the signage on the door did not reflect the correct precautions. Resident 25, who had pressure injuries, was not provided with the necessary Enhanced Barrier Precautions (EBP) during care. Staff were observed not wearing protective gowns while providing care, and there was no EBP signage on the door. Additionally, a housekeeping staff member improperly disposed of a gown outside the room, contrary to protocol. The Infection Preventionist and other staff confirmed the lack of proper signage and adherence to EBP protocols, indicating a need for further training.
Deficiency in Staff Training and Specialized Care
Penalty
Summary
The facility failed to ensure that qualified nursing staff received necessary training and specialized training, affecting four out of five staff members sampled for training. Specifically, Staff I (Infection Preventionist), Staff K (LPN), and Staff CC (CNA) did not have documentation of receiving training upon hire or annual training as required by the facility's assessment. The facility's training program was found lacking, as there was no Staff Development Coordinator to track training, and the responsibility was left to staff to seek out training themselves. The available online training curriculum did not include specialized training for dementia care, behavioral health, or hospice care. Interviews with various staff members revealed a lack of awareness and documentation regarding specialized training, particularly in hospice care, which was crucial given the number of residents receiving such care. Staff S (CNA) confirmed not receiving hospice care training, and Staff H (Unit Care Coordinator) and Staff B (Director of Nursing) were unaware of any specialized hospice training being provided. This deficiency placed residents at risk for unmet care needs and a diminished quality of life, as the staff were not adequately prepared to meet the specific needs of residents requiring specialized care.
Failure to Implement POLST System
Penalty
Summary
The facility failed to implement a system to ensure Physician's Orders for Life Saving Treatments (POLSTs) were properly followed for three residents. For Resident 32, a miscommunication occurred during a medical emergency when a Code Blue was announced. Staff I, the Infection Preventionist, initially provided incorrect information from the POLST book, leading to the initiation of CPR on Resident 32, who had a selective treatment order. The root cause of this error was identified as the organization of the POLST book by room number rather than by resident name, which led to the incorrect identification of the resident's treatment preferences. For Residents 16 and 60, the facility failed to ensure that their POLST forms were readily available. During a review, it was found that there was no POLST for Resident 16 in the POLST book or in the resident's chart, and a new POLST form was needed. Similarly, there was no POLST for Resident 60 in the POLST book. These deficiencies placed the residents at risk of receiving unwanted CPR or other lifesaving treatments, as their treatment preferences were not easily accessible to the staff.
Failure to Follow Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to ensure staff provided care according to a resident's care plan, resulting in a fall and injury. The resident, who was on hospice services and dependent on staff for bed mobility and incontinence care, was supposed to be assisted by two caregivers as per their care plan. However, during an incident, a caregiver attempted to provide incontinence care alone, without the required assistance, leading to the resident rolling off an air mattress and sustaining an inoperable leg fracture. The care plan and Kardex did not include information about the use of an air mattress, which was a factor in the incident. The facility's investigation revealed that the caregiver did not follow the care plan, which required two caregivers for bed mobility and incontinence care. Despite having enough staff on duty, the caregiver did not seek assistance, resulting in the resident's fall and subsequent injuries. The investigation also noted that the facility's documentation showed multiple instances where only one caregiver was provided for the resident's care, contrary to the care plan requirements. Interviews with staff confirmed the failure to adhere to the care plan, which led to the resident's fall and injury.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 1,119 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Federal Way
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hallmark Manor | 1.1 mi | ★★★★★ | 3 | 0 |
| Avalon Care Center Federal Way, L.l.c. | 1.9 mi | ★★★★★ | 26 | 0 |
| Garden Terrace Healthcare Center Of Federal Way | 2 mi | ★★★★★ | 0 | 0 |
| Judson Park Health Center | 4.4 mi | ★★★★★ | 0 | 0 |
| North Auburn Care | 4.7 mi | ★★★★★ | 11 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.