Below average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Life Care Center Of Kirkland during CMS and state inspections, most recent first.
A resident reported via a grievance that they remained in a wet brief for most of the day until late afternoon, and this concern was logged by the facility as alleged neglect. The resident later stated they had requested incontinence care multiple times and that a CNA said she was busy and needed to take a break before eventually apologizing. Despite facility policy and the Purple Book guidelines requiring that all alleged neglect be reported to proper authorities, the Assistant DON did not report the allegation to the State Agency, citing perceived inconsistencies between the written grievance and the resident’s follow-up statement and an undocumented belief that the resident was seen during routine rounds. The DON and Executive Director later acknowledged that the allegation met criteria for reporting and should have been reported.
Expired food and dishwashing supplies were found in storage and in use. A bottle of cooking wine past its expiration date was observed in the kitchen dry storage room, and multiple containers of chlorine test paper used for the low-temp dishwasher rinsing phase were also expired. The FSD and Dietary Aide confirmed the test strips were expired, and record review showed staff used them for the dishwasher log entries three times daily over several months.
Incomplete Daily Nurse Staffing Posting: The facility failed to ensure the daily nurse staffing posting included the actual hours worked by RN, LPN, and CNA staff directly responsible for resident care per shift. Observations showed the posting did not include actual worked hours on multiple days, and interviews with the Staffing Coordinator, DON, and ED confirmed the posting process was not being completed as required.
Expired medications were found in two medication carts and a central supply room during observation and interview. An opened mupirocin ointment tube, an opened fiber powder bottle, and multiple packages of bisacodyl suppositories were past expiration, and the RN, Nurse Unit Manager, and DON acknowledged the medications were expired and should have been discarded.
Improper linen transport and hand hygiene during medication administration were observed. A laundry aide transported clean towels in a wired basket that was only partially covered with a bath towel, leaving clean linens exposed. In addition, an RN administered medication through a feeding tube after touching room blinds with gloved hands without changing gloves, and an LPN failed to perform hand hygiene between medication passes and after touching a resident's meal tray, then prepared and gave medication to another resident without hand hygiene.
A resident was started on Augmentin for a right toe infection, but the EHR did not show an assessment or evaluation for infection before the antibiotic was initiated. The IP stated residents are assessed for infection symptoms before antibiotics are started and that findings are documented, but no such documentation was found. The DON stated staff are expected to follow infection control policies and that an assessment for infection should have occurred before the antibiotic was given.
Advance Directive Not Obtained or Documented: The facility failed to obtain and document a copy of a resident’s advance directive after the resident indicated one had already been executed prior to admission. The EHR contained no advance directive and no documentation that staff requested a copy, offered assistance, or documented a refusal, and both the SSD and DON confirmed the missing documentation.
Failure to provide SNF ABN for two residents. The facility issued NOMNCs for two residents whose Medicare Part A skilled services ended, but the EHR did not show SNF ABNs after they remained in the facility. The SSD stated SNF ABNs should be issued when residents are no longer covered by Medicare but wish to stay, and the ED stated staff were expected to issue the forms.
Failure to Provide Bed Hold and Transfer Notices: The facility did not provide written bed hold and transfer notices to two residents and/or their representatives when they were transferred to the hospital, and the Ombudsman was not sent timely transfer/discharge information with the reason and location. Records for both residents lacked the required transfer notice form, and staff interviews confirmed the notices were not provided or documented as required.
Inaccurate MDS Medication Assessment: A resident’s admission MDS incorrectly indicated anticoagulant use in Section N0415 even though the MAR showed no anticoagulant was administered during the assessment period. During record review, the MDS Coordinator confirmed the discrepancy and stated the MDS would be modified; the DON stated MDS assessments were expected to be completed accurately.
A resident receiving scheduled offsite hemodialysis had a care plan that did not include the dialysis days, transportation arrangement, or dialysis center contact information. The NUM said the facility kept transportation and contact details in a binder, but confirmed these items were not in the resident’s care plan; the DON stated they should have been included.
A resident with intact cognition had a lighter and a box cutter left on the bedside table in his room, despite facility rules that dangerous items were not allowed in resident rooms. Staff observed the items more than once, and the resident stated he used the lighter for burning strings and that the box cutter was used for a model kit. The DON, Social Service Director, and RN all stated these items were not permitted and should be secured in storage.
A resident with left knee OA received PRN oxycodone repeatedly without documented evidence that ordered non-pharmacological pain interventions, such as repositioning or resting/immobilizing, were attempted first. The MAR showed multiple PRN administrations without the required documentation, and the NUR and DON stated staff were expected to follow the physician’s orders before giving PRN pain meds.
Controlled medications were not accurately reconciled for the Olympic medication cart. The controlled med book showed one remaining oxycodone tablet, but none was found in the locked med box, and an RN stated the dose had been given by night shift but not signed out. The DON stated controlled meds should be signed out when removed and counted and reconciled every shift.
Failure to Document Annual Flu Vaccine Offers: The facility did not ensure that two residents were offered the annual influenza vaccine or that the offer, refusal, or education was documented in the EHR. The policy required all residents to be offered flu immunization during flu season unless contraindicated or already immunized, but record review and staff interviews confirmed no documentation that the vaccine was offered or refused for either resident.
A resident did not receive appropriate care for existing pressure ulcers, and the facility did not take adequate steps to prevent new ulcers from developing, as observed and documented by surveyors.
A resident with moderately impaired cognition reported missing money, and while the facility initiated an investigation and took immediate actions such as contacting police and searching the room, they failed to interview staff and other residents as required by policy. Multiple staff confirmed they were not interviewed, and facility leadership acknowledged the investigation was incomplete.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
The facility did not provide written summaries of baseline care plans to several residents or their representatives, as required by policy. Staff interviews and record reviews confirmed the absence of documentation or signatures indicating that these care plans were given or discussed, resulting in unmet procedural requirements for new admissions.
Staff did not use N95 masks correctly or receive timely fit-testing, with several staff wearing masks improperly and lacking training. Additionally, Enhanced Barrier Precautions were not followed for a resident with a PICC and wounds, as staff failed to use required PPE during high-contact care and no signage or PPE cart was present. Leadership confirmed these lapses occurred despite facility policies and recent infection outbreaks.
A resident with dementia and muscle weakness, dependent on staff for toileting, did not consistently receive or have documented assistance with toileting as required by their care plan. Staff interviews and chart reviews revealed multiple shifts where toileting care was either not provided or not documented, and the resident's representative reported inadequate care during one shift.
A facility failed to ensure a resident-centered discharge plan was in place, as required by their policy. The discharge planning process, which should begin upon admission, was not properly documented for a resident. The baseline care plan lacked a marked discharge plan, and the Initial Discharge Planning Evaluation form was left blank. Staff interviews confirmed that the discharge process was not adequately initiated, placing the resident at risk for unmet care needs.
A resident with intact cognition reported feeling neglected after not being changed for several hours, resulting in a soiled state. The incident was not reported to the State Agency within the required timeframe due to miscommunication among staff, placing the resident at risk for ongoing neglect.
A resident in an LTC facility reported neglect after being left unchanged for an extended period, resulting in them being soaked in urine and having a BM. The facility's investigation was incomplete, lacking statements from key staff and failing to remove the RN involved from duties, contrary to policy. Inconsistencies in staff accounts and missing documentation further compromised the investigation.
A resident with severe cognitive impairment and a history of elopement exited an LTC facility unnoticed, likely with a visitor, as alarms did not activate. Despite being identified as at risk, the resident's care plan interventions were insufficient, leading to the resident being found by police outside the facility.
The facility failed to develop comprehensive care plans for five residents, leading to unmet care needs. A resident with nutritional concerns and a pressure ulcer lacked appropriate care plans. Another resident using CPAP therapy did not have a care plan for its use. A resident on antiplatelet medication lacked monitoring for bleeding risks. A resident with communication difficulties had a care plan that was not effectively implemented. Lastly, a resident using oxygen therapy did not have a care plan for its use.
The facility failed to properly label and store medications, as observed in two medication carts. An opened insulin pen was found unlabeled in a plastic bag with a resident's name, and another cart contained an unlabeled insulin pen, expired heparin syringes, and an unlabeled nasal spray. Staff acknowledged these issues, highlighting lapses in medication labeling and storage practices, which placed residents at risk.
The facility failed to maintain food safety standards in the kitchen and Baker Dining Room. Unlabeled food items were found in storage, and staff did not perform hand hygiene between glove changes. Additionally, a CNA assisted a resident with their meal using bare hands, contrary to expected practices. The Dietary Manager, Infection Preventionist, and Executive Director acknowledged these lapses.
A resident with aphasia and dementia was found without an accessible call light, despite being dependent on staff for daily activities. Observations showed the call light was not within reach, and staff were unable to locate it. The resident was observed calling out for help without response from staff, highlighting a failure to ensure the call light was properly positioned.
A resident with moderately impaired cognition alleged that a staff member was stealing their medication and attempting to poison them. Despite the resident's report to the police and a handwritten statement given to facility staff, the allegations were not reported to the State Agency as required by the facility's policy. Several staff members were aware of the allegations, but they were not logged in the incident reporting log, indicating a failure in the facility's reporting procedures.
A resident with moderate cognitive impairment alleged that a nurse was stealing their medication and attempting to poison them. Despite the resident providing a written statement and reporting the incident to staff, no investigation was conducted. Interviews revealed that key staff members were either unaware of the allegations or failed to act, violating facility policy and state regulations.
A facility failed to provide a written transfer/discharge notice to a resident and their representative, as required by policy. The resident was hospitalized, but there was no documentation of the notice in their electronic health record. Interviews with staff revealed that the usual procedure was not followed, and the notice was not mailed as intended.
A resident experienced significant health changes, including a 6.83% weight loss and a new facility-acquired DTI, but the facility failed to complete the required SCSA MDS. The MDS Coordinator and DON acknowledged the oversight, which placed the resident at risk for delayed care planning.
A facility failed to complete a quarterly MDS assessment on time for a resident, as required by the RAI manual. The assessment, due within 14 days of the ARD, was completed 10 days late. The MDS Coordinator acknowledged the delay, and the DON confirmed the expectation for timely completion. This placed the resident at risk for delayed care needs.
The facility failed to accurately assess four residents using the MDS tool, leading to incorrect documentation of behavior changes, continence status, discharge status, and insulin administration. These inaccuracies were confirmed by staff during interviews and record reviews.
A facility failed to conduct a proper PASRR Level I and did not refer a resident with anxiety and depression for a Level II evaluation. The resident, who was admitted with generalized anxiety disorder, experienced a significant change in condition, but the necessary screenings and referrals were not completed, as confirmed by staff interviews.
The facility failed to clarify a physician's order for a resident with a feeding tube, leading to incorrect medication administration. Another resident's medication was signed off before administration, contrary to policy. Additionally, insulin injection sites were not documented for a resident with diabetes, violating best practices.
A resident with severe cognitive impairment and muscle weakness did not receive scheduled bathing and personal hygiene care as per their care plan. Observations showed the resident had long, untrimmed fingernails with debris, and documentation revealed missed bathing sessions without records of refusal. Staff interviews confirmed lapses in care and documentation, with the DON emphasizing the need for adherence to care plans.
A facility failed to manage enteral tube feeding properly for a resident with dysphagia and gastrostomy status, who relied on tube feeding for over 51% of their nutritional intake. Observations revealed multiple opened and undated syringes at the resident's bedside, contrary to the facility's policy of daily syringe changes and dating. Staff interviews confirmed the protocol was not followed, placing the resident at risk for infection.
A resident with anxiety, depression, and opioid dependence experienced a decline in cognition and behavior, yet the facility failed to conduct a social services assessment or provide necessary behavioral health services. Despite documented behavioral episodes and observations of the resident's distress, staff interviews revealed a lack of awareness and action regarding the need for psychological consultation or counseling.
The facility exceeded the acceptable medication error rate, reaching 6.45%, due to incorrect administration of medications to two residents. One resident received enteric-coated aspirin instead of chewable, and another received levothyroxine via g-tube instead of orally. Staff acknowledged the errors and the importance of following the correct medication orders.
The facility failed to follow Enhanced Barrier Precautions and proper hand hygiene practices, placing residents at risk. A resident with a feeding tube did not receive care with the required PPE, and staff did not consistently perform hand hygiene or use gloves correctly. These deficiencies were confirmed by staff interviews and observations.
The facility failed to maintain residents' dignity by not covering urinary catheter drainage bags for three residents. The bags were visible from the hallway and to visitors, and staff provided inconsistent information about the need for privacy covers.
A resident with moderately impaired cognition reported that a large man grabbed and squeezed their arm, causing a significant skin tear. Despite the facility's policy requiring such incidents to be reported, the Director of Nursing Services did not report the incident to the State Agency or law enforcement. The resident's representative and staff members attempted to follow up, but the incident remained unreported.
A resident with moderately impaired cognition reported being grabbed and squeezed by a large man, resulting in a skin tear. The facility failed to thoroughly investigate the allegation, did not interview relevant staff or the resident's representative, and did not report the incident to the state. The DNS did not consider the incident as abuse and did not conduct staff training on proper transfer techniques.
The facility failed to ensure proper skin care and treatments for three residents, resulting in undocumented and untreated skin tears. Staff did not follow protocols for notifying providers, completing thorough skin assessments, and obtaining treatment orders.
The facility failed to ensure urinary catheters were positioned off the floor for two residents, placing them at risk for infections. Staff confirmed that the drainage bags should be hooked on the bed frame, as per the facility's policy.
The facility failed to designate a qualified Infection Preventionist (IP) to oversee the infection prevention and control program. During a COVID-19 outbreak, 42 residents and 17 staff tested positive. The Executive Director confirmed that the interim IP was not certified, and the certified staff member was not acting as the IP. Infection control responsibilities were managed as a team effort.
The facility failed to ensure proper hand hygiene, disinfection of medical equipment, and appropriate use and disposal of PPE. Staff members were observed not following protocols, including not performing hand hygiene, not disinfecting vital sign equipment, and not changing N95 masks or disinfecting face shields after exiting COVID-19 isolation rooms. Additionally, 13 out of 18 staff members were not fit tested for N95 masks.
A facility failed to provide adequate nutritional care for a resident, resulting in significant weight loss. Despite policies for weekly reviews, the resident's weight loss was not discussed, and no nutritional supplements were ordered. The weight loss was not communicated to the medical provider, the resident, or their representative.
Failure to Report Alleged Neglect to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of neglect to the State Agency within the required timeframe. A grievance form dated 02/01/2026 documented that Resident 1 reported being left in a wet brief from morning until approximately 5:00 PM, and the February 2026 incident log recorded this concern as alleged neglect. The facility’s own policy on Abuse, Neglect and Exploitation required that all alleged violations of mistreatment, exploitation, neglect, or abuse, including injuries of unknown origin and misappropriation of resident property, be reported to proper authorities within prescribed timeframes, and the Nursing Home Guidelines (Purple Book) defined neglect as a pattern of conduct or inaction, or an act or omission, that fails to maintain a vulnerable adult’s physical or mental health or avoid harm. Resident 1 later stated in an interview that on weekends there were fewer staff members, that they needed to be changed, and that the CNA did not come the whole day despite being asked a couple of times; the resident reported that the CNA said she was busy and needed to take her break and later apologized. Staff C, the Assistant DON, acknowledged receiving the grievance, speaking with the resident, and documenting the incident as alleged neglect in the incident log, but did not report the allegation to the State Agency, citing inconsistency between the grievance form and the resident’s follow-up statement and the belief that the resident had been seen during a 2:30 PM round, for which there was no documentation. Staff B, the DON, and Staff A, the Executive Director, both stated that the allegation of neglect should have been reported to the State Agency, confirming that the required reporting did not occur.
Expired Food and Dishwashing Test Strips Found in Storage and Use
Penalty
Summary
Expired food and sanitation supplies were found in the kitchen dry storage and dishwashing area during observation and interview. In the kitchen dry storage room, a bottle of cooking wine with an expiration date of 11/24/2024 was observed, and a cook stated that it was expired and should have been discarded. The Food Services Director later stated that food items were expected to be discarded by their expiration date and that the expired bottle of cooking wine should have been discarded. Expired chlorine test paper strips used to check the low-temperature dishwasher rinsing phase were also observed. The container in use had an expiration date of 05/01/2025, and three additional containers with the same expiration date were found. The Food Services Director and Dietary Aide stated that all four chlorine test strip containers were expired, and record review showed the facility’s low-temperature dishwashing logs were completed three times daily from May through November using these expired test strips. The Executive Director stated that staff were expected to monitor food expiration dates and discard expired food items, and that expired chlorine test strips should not have been used.
Incomplete Daily Nurse Staffing Posting
Penalty
Summary
The facility failed to ensure that the posted daily nurse staffing information included the actual hours worked by registered and licensed nursing staff directly responsible for resident care per shift for 4 of 7 days reviewed. The report states that the facility’s policy required the actual hours worked by RNs, LPNs, and CNAs to be posted daily at the beginning of each shift, but observations on 11/21/2025, 11/24/2025, 11/25/2025, and 11/26/2025 showed the posting titled, "Posting of Licensed and Unlicensed Direct Care Staff," did not include the actual nursing staff hours worked for the shift. During interview, the Staffing Coordinator stated the posting was completed with actual worked hours at the end of each shift. The DON stated the daily nurse staffing posting was supposed to be updated at the beginning of each shift and that the actual hours worked had not been completed at that time, although they should have been. The Executive Director stated the daily nurse staffing posting must be updated every morning and that the actual hours worked must be completed at the end of each shift.
Expired Medications Found in Medication Carts and Central Supply Room
Penalty
Summary
Expired medications were found stored in multiple medication storage areas during observation, interview, and record review. The facility’s policy titled, Storage and Expiration Dating of Medications, revised 06/30/2025, states that medications and biologicals with an expired date on the label, retained longer than recommended by manufacturer or supplier guidelines, or contaminated or deteriorated are to be stored separate from other medications until destroyed or returned to the pharmacy or supplier. On the Cascade Medication Cart, an opened mupirocin ointment tube with an expiration date of 10/2025 was observed, and the RN stated it had expired last month and should have been discarded. On the Olympic Medication Cart, an opened fiber powder bottle with an expiration date of July 2025 was observed, and the RN stated it was expired and would be discarded. In the Central Supply Room, 18 packages of bisacodyl 10 mg suppositories expired in June 2025 and four packages expired in July 2025 were observed, and the Nurse Unit Manager stated the medications had expired and should have been discarded. The DON stated the expectation was that expired medication should be discarded.
Improper Linen Transport and Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to ensure proper transport of clean linens for one laundry aide. During observation, the laundry aide placed clean folded towels into a rolling wired laundry basket up to its brim and covered the top with an unfolded bath towel, leaving the sides of the basket not fully covered. The aide then pushed the basket and stocked towels in the shower room and clean utility room in Cascade Hall. In interview, the aide stated this was their process for transporting clean towels, while the Environmental Services Director and the DON stated clean linen carts should be fully covered and clean linens should not be exposed during transport. The facility also failed to ensure hand hygiene practices and proper glove use during medication administration for two nurses. One RN put on gloves and a gown before entering a resident's room, closed the room window blinds with gloved hands, and then administered medication through the resident's feeding tube without changing gloves. Another LPN administered medication to one resident, touched and moved the resident's meal tray, left the room without performing hand hygiene, continued working on the medication cart without hand hygiene, and then prepared and administered medication to another resident without performing hand hygiene before entering the room. The Infection Preventionist and DON stated staff were expected to perform hand hygiene before and after medication administration and to change gloves after contact with objects and surfaces in the resident's environment.
Failure to Assess for Infection Before Starting Antibiotic
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship Program for one resident who was prescribed Augmentin for a right toe infection. The facility policy stated that the program includes a system of monitoring to improve resident outcomes and reduce antibiotic resistance, and that antibiotics should be prescribed for the correct indication, dose, and duration, with assessment of residents suspected of having an infection. A physician order dated 11/02/2025 showed Augmentin, one tablet by mouth twice a day for 10 days for right toe infection, and the November 2025 MAR showed the antibiotic was administered from 11/02/2025 to 11/12/2025. Review of the resident’s EHR did not show that the resident had been assessed or evaluated for the right toe infection before the antibiotic was started. During a joint record review, the Infection Preventionist stated that residents are assessed for symptoms of infection prior to antibiotic initiation and that findings are documented in progress notes, but after reviewing the EHR they stated there was no documentation showing the resident was assessed or evaluated before the antibiotic began. The DON stated that staff are expected to follow infection control policies and that residents should have had an assessment for presence of infection prior to initiation of the antibiotic.
Advance Directive Not Obtained or Documented
Penalty
Summary
The facility failed to ensure that a copy of Resident 21’s advance directive was obtained and documented in the medical record. The facility policy titled, Advanced Directives, revised on 11/19/2024, required staff to ask residents about advance directives, document their wishes, provide written information about facility policies and applicable state law, and review the document during admission, quarterly, and with any change in condition. Review of Resident 21’s admission packet showed the resident stated, “Prior to admission, I have executed an Advance Directive and will provide the facility with a copy,” but the Electronic Health Record contained no copy of an advance directive and no documentation that the resident was asked to provide one or offered assistance with completing one. Resident 21 stated they could not remember whether staff asked for a copy of the advance directive and believed the paperwork completed at admission was accurate. The Social Services Director confirmed there was no documentation in the EHR showing that an advance directive was requested, offered, or obtained, and stated a copy should have been requested during admission with follow-up documented in social work notes. The DON also stated Social Services was responsible for requesting a copy of the DPOA during admission and that, if a resident reported having an advance directive, it should be uploaded to the EHR and the face sheet updated; the record review showed no copy and no documentation that one was requested, offered, or refused.
Failure to Provide SNF ABN for Two Residents
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) for 2 of 3 residents reviewed for liability notices, Residents 104 and 105. The facility policy titled, Notice of Charges, revised on 05/06/2025, stated that an SNF ABN is issued when the beneficiary intends to continue services and the SNF believes the services may not be covered under Medicare, and that the facility is responsible for informing the beneficiary about potential non-coverage and the option to continue services with financial liability for those services. For Resident 104, the record showed a NOMNC was issued and signed on 05/02/2025 with a last covered date of 05/05/2025, and the resident was discharged on 05/16/2025. The EHR did not show that an SNF ABN was provided after the resident remained in the facility. For Resident 105, the record showed a NOMNC was issued and signed on 07/09/2025 with a last covered date of 07/11/2025, and the resident was discharged on 08/08/2025. The EHR also did not show that an SNF ABN was provided after the resident chose to remain in the facility. Staff P, Social Services Director, stated that an SNF ABN should be issued if residents were no longer covered by Medicare but wished to remain in the facility, and Staff A, Executive Director, stated they expected staff to issue the SNF ABN forms to Residents 104 and 105.
Failure to Provide Bed Hold and Transfer Notices
Penalty
Summary
The facility failed to provide written bed hold and transfer notices to two residents and/or their representatives when they were transferred to the hospital, and it also failed to ensure that a copy of the transfer notice was sent timely to the State Long Term Care Ombudsman office with the reason for the transfer and/or the location. The report cites facility policies requiring written bed hold information before and upon hospital transfer, and requiring written transfer or discharge notice to the resident, representative, and Ombudsman office in a language and manner they understand. Resident 69 had an unplanned discharge to a short-term general hospital in July 2025. A nursing progress note documented that the resident discharged to the hospital for further evaluation, but the record did not show that a written bed hold or transfer notice was provided. The EHR did not contain a completed Transfer or Discharge Notice (DSHS 10-237) form, and the July 2025 discharge list sent to the Ombudsman on 11/14/2025 did not include the resident’s discharge location or reason. The resident stated on 09/29/2025 that they did not receive a copy of a bed hold and/or transfer notice. Resident 94 transferred to the hospital for further evaluation in July 2025, and the discharge MDS showed an unplanned discharge to a short-term general hospital. The EHR did not show documentation that a bed hold notice was provided to the resident and/or representative, and the Transfer or Discharge Notice form was not completed. The July 2025 discharge list was sent to the Ombudsman on 11/14/2025, 135 days after the transfer, and it did not include the resident’s discharge location or reason. Staff interviews confirmed that the notices were not provided or were not documented as required.
Inaccurate MDS Medication Assessment
Penalty
Summary
The facility failed to accurately assess 1 of 21 residents, Resident 5, on the admission MDS. Section N0415, High-Risk Drug Classes: Use of Indication, was marked to indicate anticoagulant use during the assessment period, even though review of the August 2025 MAR showed the resident did not receive an anticoagulant medication during that time. Resident 5 was admitted to the facility on [DATE], and the inaccurate MDS entry involved the medication section of the assessment tool. During a joint record review and interview on 11/25/2025, the MDS Coordinator stated the facility follows the RAI manual and reviews residents’ MARs to complete Section N of the MDS. After reviewing Resident 5’s admission MDS and MAR, the MDS Coordinator acknowledged that the resident did not receive anticoagulant medication during the assessment period and stated the MDS would be modified. The DON also stated that the facility follows the RAI manual and expected MDS assessments to be completed accurately.
Missing Dialysis Details in Care Plan
Penalty
Summary
The facility failed to include Resident 31’s dialysis days, transportation arrangement, and contact information for the dialysis center in the resident’s comprehensive care plan. Resident 31 was admitted to the facility and had an admission MDS completed on 09/22/2025. A physician order summary dated 11/21/2025 showed the resident had scheduled offsite hemodialysis every Monday and Thursday from 8:45 AM to 12:45 PM. The hemodialysis comprehensive care plan initiated on 09/13/2025 did not include the resident’s scheduled dialysis days, transportation arrangement, or dialysis center contact information. During a joint record review, Staff F, the Nurse Unit Manager, stated that dialysis residents had prior transportation arrangements and that the facility kept a binder with dialysis center contact information, but acknowledged that these details were not in Resident 31’s care plan. The DON stated that the comprehensive care plan should have included the scheduled dialysis days, transportation arrangements, and contact information for the dialysis center.
Unsafe Storage of Hazardous Items in Resident Room
Penalty
Summary
The facility failed to ensure that Resident 13’s room was free from accident hazards when a lighter and a box cutter were found on top of the resident’s bedside table. Resident 13’s quarterly MDS dated 07/14/2025 showed intact cognition, and the behavior/mood care plan initiated on 05/29/2025 noted that the resident keeps items in the room that he is aware are against facility policy. The facility policy titled, Area of Focus: Incident and Reportable Event Management, stated that the resident environment must remain as free of accident hazards as possible and that each resident must receive adequate supervision to prevent accidents. During an observation on 09/28/2025, a lighter and an object later described as a box cutter were seen on Resident 13’s bedside table while the resident was not in the room. Later that day, the lighter and box cutter were again observed next to the resident’s meal tray on the bedside table, and Resident 13 stated he used the lighter for burning strings sometimes and that his collateral contact brought him a model kit and used the box cutter as a tool. Staff O, RN, stated residents were not allowed to have lighters or dangerous items in their room and that such items should be kept and reported for proper storage. Staff P, Social Service Director, stated that Resident 13 cannot have lighters or anything sharp and that these items should be locked in storage. Staff B, DON, stated that residents were not allowed to have a lighter or box cutter in their room because they were safety hazards.
Failure to Document Non-Pharmacological Pain Interventions Before PRN Oxycodone
Penalty
Summary
The facility failed to provide safe, appropriate pain management for a resident with left knee osteoarthritis by not documenting non-pharmacological interventions before giving PRN pain medication. Resident 21 was admitted with a diagnosis that included left knee osteoarthritis and had physician orders for acetaminophen PRN for pain and/or fever, with instructions for staff to attempt resting/immobilizing and repositioning before administering PRN pain medications. A later physician order also included oxycodone every four hours PRN for moderate to severe pain. Review of the September 2025 MAR showed Resident 21 received PRN oxycodone on multiple dates without documented evidence that non-pharmacological interventions were attempted, including on 09/01/2025 through 09/29/2025 on the dates listed in the report. During interview and record review, the Nurse Unit Manager stated staff should follow physician orders and that non-pharmacological interventions should be tried before PRN pain medication administration. The DON also stated it was the expectation that staff followed physician orders and that non-pharmacological interventions should have been offered before administering the resident’s PRN pain medication.
Controlled Medication Count Not Reconciled
Penalty
Summary
The facility failed to ensure controlled medications were accurately reconciled for 1 of 3 medication carts reviewed, the Olympic Medication Cart. During a joint observation and interview, the controlled medications book for the cart showed one remaining tablet of oxycodone on page 114, but there was no oxycodone medication for that page remaining in the locked controlled medication box. Staff L, RN, stated that the controlled medications had been counted at the beginning of the shift and that the oxycodone had been administered by night shift staff but was not signed out on the controlled medication book. The facility policy titled, Management of Controlled Substances, stated that controlled medications must be accounted for in sufficient detail to allow accurate reconciliation and that incoming and outgoing staff must count controlled substances at each shift change. Staff B, DON, stated that whenever controlled medications were removed for administration, they should be signed out on the controlled medication book, and any discrepancy in the controlled medication count should be reported immediately. Staff B also stated that controlled medications were expected to be counted and reconciled every shift.
Failure to Document Offering Annual Influenza Vaccines
Penalty
Summary
The facility failed to ensure influenza vaccines were offered to 2 of 5 residents reviewed for immunizations, Residents 6 and 10. The facility policy titled, Influenza Vaccine Policy for Residents, stated that each resident is to be offered an influenza immunization annually from October 1 through March 31 unless medically contraindicated or already immunized, and that the medical record should document whether the resident received the vaccine or did not receive it due to contraindication or refusal. Resident 6 was admitted to the facility and later discharged on 10/23/2025. Their immunization record showed an influenza vaccine received on 10/22/2019, and the EHR immunization tab showed "Influenza not eligible." Review of the EHR found no documentation that Resident 6 was offered the annual influenza vaccine or informed about the risks and benefits. Resident 10 was admitted to the facility and later discharged on 11/24/2025. Their EHR showed an influenza vaccine received on 10/15/2018, but there was no documentation that Resident 10 was offered the annual influenza vaccine or informed about the risks and benefits. During interviews and joint record reviews, the Infection Preventionist and the DON stated that influenza vaccine should have been offered to all residents at the start of flu season and that refusals should be documented, but the records for Residents 6 and 10 showed no documentation that the vaccine was offered or refused.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that necessary interventions to manage existing pressure ulcers and prevent additional ones were not consistently carried out for affected residents.
Failure to Conduct Thorough Investigation of Missing Resident Property
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of missing money for one resident with moderately impaired cognition. According to the investigation report, a collateral contact reported that $1,000 was missing from the resident's wallet, which had not been checked for three months. Immediate actions taken included initiating an investigation, contacting the police, searching the resident's room, reviewing the belongings list, and reporting the incident to the state agency. However, the investigation report did not include interviews with other residents or staff members who may have had information about the incident. Multiple staff members, including certified nursing assistants and registered nurses who were assigned to the resident, confirmed in interviews that they were not interviewed regarding the missing money. The Assistant Director of Nursing acknowledged that, although the facility's policy and the Purple Book guidelines require thorough investigations—including interviews with staff and residents—these steps were not documented or completed. The Director of Nursing also confirmed that the investigation lacked evidence of such interviews, indicating the investigation was not thorough as required by facility policy and regulatory guidelines.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Provide Written Baseline Care Plan Summaries to Residents and Representatives
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan to residents and/or their representatives for four residents reviewed. Record reviews for each resident showed no evidence that a written summary of the baseline care plan was given or documented as received by the resident or their representative. Interviews with staff, including the Assistant Director of Nursing, Director of Nursing, Interim Executive Director, and Social Services Director, confirmed that there was no documentation or signatures indicating that the baseline care plans had been provided or discussed with the residents or their representatives. The facility's policy required staff to review the baseline care plan and physician orders with the resident or representative, provide copies, and obtain signatures, but these steps were not documented as completed for the residents in question. Collateral contacts and residents interviewed did not recall receiving a written summary of the baseline care plan. Nursing progress notes and assessments for each resident lacked evidence of the required documentation. Staff acknowledged the importance of the baseline care plan in informing both staff and residents or representatives about the care to be provided, but confirmed that the process was not followed or documented for the affected residents.
Failure to Ensure Proper N95 Mask Use, Fit-Testing, and Enhanced Barrier Precautions
Penalty
Summary
Staff failed to use N95 masks correctly and did not receive timely fit-testing, as observed with four staff members. Staff were seen wearing N95 masks with both straps below the ears, with twisted straps, or with only one strap, and some staff reported not being trained on proper mask application. Two staff members, including an agency occupational therapist and a physical therapy intern, confirmed they had not been fit-tested at the facility before using N95 masks, despite working directly with residents. The facility's own policy required fit-testing before use and annually, but this was not followed for these staff. Additionally, the facility did not ensure Enhanced Barrier Precautions (EBP) were followed for a resident with a peripherally inserted central catheter (PICC) and wounds. There was no EBP signage or PPE cart outside the resident's room, and a certified nursing assistant assisted the resident with a transfer without wearing a gown and gloves, resulting in direct contact between the staff's clothing and the resident's gown. The staff member later acknowledged missing the requirement to use PPE for this resident, and the order for EBP had been in place for several days prior to the observation. Interviews with facility leadership confirmed that the expected practices were not followed. The infection preventionist and director of nursing both stated that staff should be fit-tested before using N95 masks and that EBP signage and PPE should be present and used for residents requiring these precautions. The failures were identified during a period when the facility had recently experienced a COVID-19 outbreak affecting residents and staff.
Failure to Provide and Document Required Toileting Assistance
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADL), specifically toileting, for one resident who was dependent on staff for this care. The resident had diagnoses including dementia, muscle weakness, and required assistance with personal care. According to the resident's care plan and assessment, the resident was frequently incontinent of urine and dependent on staff for toileting hygiene and transfers. Documentation from the electronic charting system showed that toileting assistance was either not provided or not documented on multiple shifts over a one-week period. In several instances, the activity was marked as 'did not occur,' and on other shifts, there was no documentation of toileting assistance at all. Interviews with staff, including a CNA, Unit Care Coordinator, and DON, confirmed that the expectation was for residents to be offered toileting assistance at least every two hours and for this care to be documented at least once per shift. Staff acknowledged that documentation of 'activity did not occur' meant the care was not provided, and there was no evidence that the required assistance was given or properly documented on the specified dates. The resident's representative also reported an incident where the resident was changed only once in an eight-hour period, resulting in urine soaking through their briefs.
Failure to Initiate Resident-Centered Discharge Plan
Penalty
Summary
The facility failed to ensure a resident-centered discharge plan was in place for a resident reviewed for discharge planning. The facility's policy required that the discharge planning process begin upon or shortly after admission, with Social Services or Care Management associates completing the initial discharge plan evaluation form within 48 hours of admission. However, for the resident in question, the baseline care plan did not have the discharge plan marked, and the Initial Discharge Planning Evaluation form was left blank. Interviews with various staff members, including LPNs, Social Services, and the Assistant Director of Nursing, revealed that while the discharge process was supposed to start at admission, the necessary documentation was not completed for the resident. Staff D, responsible for filling out the initial discharge planning evaluation, admitted to not completing the form, acknowledging it was opened but not filled out. This oversight placed the resident at risk for unmet care needs and a diminished quality of life, as the discharge planning process was not properly initiated or documented.
Failure to Timely Report Allegation of Neglect
Penalty
Summary
The facility failed to report an allegation of neglect involving a resident in a timely manner to the State Agency. The resident, who had intact cognition, was admitted to the facility and reported feeling neglected after not being changed for an extended period. The incident occurred when the resident was left unchanged from 8:30 AM to 2:30 PM, resulting in the resident being found in a soiled state by a visitor. The visitor reported the situation to a registered nurse, but the nurse did not report it as an allegation of neglect, believing it did not sound like one. Other staff members, including a CNA, were aware of the situation but assumed it would be handled by the nurse they informed. The facility's policy required that allegations of neglect be reported within 24 hours if they did not result in serious bodily injury. However, the incident was not logged until several days later, and the staff involved did not report the situation to the State Agency within the required timeframe. The Executive Director confirmed that the staff should have reported the allegation within two hours, but the delay in reporting was due to a lack of communication among the staff members. This failure to report the incident promptly placed the resident at risk for potential ongoing neglect.
Failure to Investigate Allegation of Neglect
Penalty
Summary
The facility failed to thoroughly investigate an allegation of neglect involving a resident who was cognitively intact. The incident was reported on October 12, 2024, when the resident was found to have not been changed for an extended period, resulting in them being soaked in urine and having a bowel movement (BM). The investigation lacked statements from key staff members involved in the incident, including the Certified Nursing Assistant (CNA) who changed and showered the resident after the neglect was reported. Additionally, the Registered Nurse (RN) who continued to work with the resident after the allegation was not removed from their duties, contrary to the facility's policy. The facility's policy on abuse and neglect investigations requires prompt and thorough investigation, including interviews with all relevant parties and the removal of the alleged perpetrator from resident care areas. However, the investigation into this incident did not include statements from the staff who first responded to the situation or those who assisted with the resident's shower. Furthermore, the RN involved continued to work with the resident for several days following the report of neglect, which was against the policy that mandates suspension of the accused staff pending investigation. Interviews with staff revealed inconsistencies in the care provided to the resident. Staff D reported that the resident was visibly upset and had not been changed since the morning, while Staff E claimed the resident was checked on multiple times and did not report being wet. The Executive Director acknowledged the lack of documentation regarding regular checks on the resident and the omission of critical details in the investigation. This failure to conduct a comprehensive investigation placed the resident at risk for further neglect and compromised their quality of life.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision for a resident at risk for elopement, resulting in the resident leaving the facility unnoticed. The resident, who had severe cognitive impairment due to dementia, was known to wander and had a history of attempting to leave the facility. Despite being identified as at risk for elopement, the resident managed to exit the facility without triggering alarms, suggesting they left with a visitor. This incident occurred on September 10, 2024, when the resident was last seen by staff at 6:00 PM and was later found by police at 6:48 PM outside the facility. The resident's care plan, initiated in April 2023, acknowledged their tendency to wander and included goals to prevent them from leaving the facility unattended. However, the care plan interventions, such as offering walks, providing frequent safety checks, and reducing noise, were insufficient to prevent the elopement. On the day of the incident, the facility's reporting log indicated that the resident was exit-seeking multiple times, yet they were still able to leave the premises unnoticed. Interviews with facility staff, including the Director of Nursing and the Executive Director, confirmed the resident's risk for elopement and acknowledged the failure to prevent the resident from leaving unsupervised. The staff concluded that the resident likely exited with a visitor, as the alarms did not activate. Signage was placed on exit doors to remind visitors and staff to ensure residents do not leave with them, but this measure was not effective in preventing the incident.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for five residents, leading to unmet care needs and potential complications. Resident 9 was admitted with nutritional concerns and developed a pressure ulcer, yet their care plan lacked provisions for both nutrition and wound care. Despite being identified as at risk for nutritional issues, no care plan was initiated, and the pressure ulcer was not addressed in the care plan, as confirmed by multiple staff members. Resident 65, who required CPAP therapy for obstructive sleep apnea, did not have a care plan for CPAP use, despite using the device nightly. Staff interviews revealed an expectation for a care plan to be in place, but it was not documented. Similarly, Resident 68, who was on antiplatelet medication, lacked a care plan for monitoring bleeding risks, even though a pharmacy consultation recommended such monitoring. Resident 3, with communication difficulties due to aphasia and dementia, had a care plan that included using interpretation services and communication tools, but these were not effectively implemented. Staff were observed not utilizing available resources, and interpretation service information was not accessible in the resident's room. Lastly, Resident 54, who used oxygen therapy, did not have a care plan for its use, despite having the necessary equipment and a physician's order. Staff interviews confirmed the absence of a care plan for oxygen therapy.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to properly label and store medications and biologicals, as observed in two medication carts. During an inspection of the Cascade medication cart, an opened insulin lispro pen was found without a resident's name label, although it was placed in a plastic bag labeled with Resident 68's name. Staff FF, a Registered Nurse, acknowledged that the insulin pen should have been labeled with the resident's name. Similarly, the [NAME] medication cart contained an opened insulin lispro pen without a resident's name, two expired heparin syringes, and an unlabeled opened saline nasal spray. Staff L, another Registered Nurse, confirmed that the insulin pen should have been labeled and discarded, and acknowledged the expired heparin syringes and the infection risk posed by the unlabeled nasal spray. Interviews with facility staff, including the Licensed Practical Nurse Unit Care Coordinator and the Director of Nursing, revealed that there was an expectation for opened insulin pens to be labeled with residents' names and for expired medications to be removed from medication carts. The Director of Nursing also stated that nasal sprays should not be used for multiple residents and should be labeled with a resident's name if opened. These lapses in medication labeling and storage practices placed residents at risk of receiving compromised, incorrect, or ineffective medications.
Food Safety and Hygiene Deficiencies in Kitchen and Dining Room
Penalty
Summary
The facility failed to adhere to professional standards of food safety, as observed in both the kitchen and the Baker Dining Room. In the kitchen's dry storage room, five unlabeled bags of vanilla wafers were found in a bin labeled for Cheerios, and in the walk-in refrigerator, three trays of banana pudding were stored without labels or dates. Staff C, the Dietary Manager, acknowledged that these items should have been labeled with the name and date received, and expected food items to be labeled and dated. In terms of hand hygiene, Staff I, a cook, was observed not performing hand hygiene between glove changes while handling food and cleaning containers. Similarly, Staff J, another cook, did not perform hand hygiene between glove changes while preparing residents' lunch trays. Both staff members acknowledged that they should have performed hand hygiene after removing used gloves, and Staff C confirmed the expectation for staff to perform hand hygiene between glove use. In the Baker Dining Room, Staff K, a Restorative Certified Nursing Assistant, was seen assisting a resident with their meal by touching the resident's bread with bare hands, despite acknowledging that they were not supposed to do so. Staff K stated they had washed their hands before assisting the resident, but the Infection Preventionist and the Director of Nursing both stated that staff should use utensils or gloves when touching residents' food. The Executive Director also confirmed that staff should not touch residents' food with bare hands and that food items should be labeled correctly.
Resident's Call Light Not Accessible
Penalty
Summary
The facility failed to ensure that a call light was within reach for a resident, identified as Resident 3, which placed the resident at risk for delayed care and diminished quality of life. Resident 3, who was readmitted to the facility with diagnoses including aphasia, vascular dementia with psychotic disturbance, and unsteadiness on feet, was dependent on staff assistance for various activities of daily living. The resident's care plan indicated the need for a soft touch call light to be within reach, yet observations on multiple occasions revealed that the call light was not visible or accessible to the resident. Staff members, including the Activities Director and Registered Nurse Unit Care Coordinator, were unable to locate the call light, and it was noted that maintenance was in the process of obtaining a new one. Further observations showed that even after attempts to address the issue, the call light remained out of reach, clipped to the wrong side of the bed, and the resident was observed calling out for help without response from passing staff. Interviews with staff, including the Director of Nursing, confirmed awareness of the issue and the expectation that residents should have a call light or a soft touch call light if unable to use a standard one. Despite this, the resident continued to be without a properly positioned call light, as evidenced by multiple observations and staff interviews.
Failure to Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to report suspected allegations of abuse and/or neglect to the State Agency for one resident, which placed residents at risk for potential unidentified and ongoing abuse/neglect. The facility's policy requires reporting alleged violations related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown sources and misappropriation of resident property, to the proper authorities within a prescribed time frame. However, the facility did not adhere to this policy in the case of a resident who alleged that a staff member was stealing their medication and attempting to poison them. The resident, who had moderately impaired cognition, reported these allegations to the police and provided a handwritten statement to the facility staff. Despite the resident's report and the awareness of several staff members, including the Activities Director and the Director of Social Services, the allegations were not logged in the facility's incident reporting log for the relevant months, nor were they reported to the State Agency. The Executive Director and the Director of Nursing were unaware of the allegations, indicating a breakdown in communication and reporting procedures within the facility.
Failure to Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse and/or neglect for a resident, which placed the resident at risk for unidentified abuse and/or neglect. The resident, who was moderately cognitively impaired, reported that a registered nurse was stealing their medication and attempting to poison them. The resident provided a handwritten statement detailing these allegations, which was given to the Activities Director and subsequently reported to the Executive Director. Despite these reports, no investigation was conducted into the allegations. Interviews with various staff members revealed a lack of awareness and action regarding the resident's allegations. The Director of Social Services was aware of the resident's call to 911 to report the alleged poisoning but did not ensure an investigation was conducted. The Director of Nursing was unaware of the allegations, and the Executive Director only knew of a report regarding medication refusal, not the full extent of the allegations. This lack of communication and failure to investigate violated the facility's policy and state regulations, as no incident investigation was completed.
Failure to Provide Written Transfer/Discharge Notice
Penalty
Summary
The facility failed to provide a written transfer or discharge notice to a resident and their representative, which is a requirement under their policy. This deficiency was identified during a review of the case of a resident who was hospitalized. The facility's policy, revised in August 2024, mandates that residents and their representatives be notified in writing about transfers or discharges, including the reasons for such moves, in a language and manner they understand. However, the review of the resident's electronic health record, including assessments and nursing progress notes, did not show any documentation that a written notice was provided. Interviews with facility staff revealed gaps in the process of issuing transfer or discharge notices. The Director of Social Services mentioned that the usual procedure involves filling out a notice form and mailing it to the resident's address. However, they could not find any documentation confirming that this was done for the resident in question. The Executive Director also acknowledged that residents should receive a copy of the written notice. This oversight placed the resident at risk of not being able to make informed decisions regarding their transfer or discharge.
Failure to Complete SCSA MDS for Resident with Significant Health Changes
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) for a resident who experienced significant changes in their health status. According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, a SCSA is required when a resident undergoes a major decline or improvement affecting more than one area of their health. In this case, the resident experienced a 6.83% weight loss in less than 30 days and developed a new facility-acquired Deep Tissue Injury (DTI) on their left buttock, both of which are conditions that necessitate a SCSA. Despite these significant changes, the facility did not complete the required SCSA MDS for the resident. During interviews, both the MDS Coordinator and the Director of Nursing acknowledged that the SCSA MDS should have been completed in accordance with the RAI manual guidelines. The failure to conduct this assessment placed the resident at risk for delayed care planning and unmet care needs.
Delayed MDS Assessment for a Resident
Penalty
Summary
The facility failed to complete a quarterly Minimum Data Set (MDS) assessment within the required timeframe for one resident, identified as Resident 32. According to the Resident Assessment Instrument (RAI) 3.0 User's Manual, a quarterly assessment is considered timely if completed within 14 days after the Assessment Reference Date (ARD). For Resident 32, the ARD was 10/08/2023, but the MDS was not completed until 11/01/2023, making it 10 days late. During an interview and record review, the MDS Coordinator, Staff G, acknowledged the delay and confirmed that the assessment should have been completed within the specified timeframe. The Director of Nursing, Staff B, also stated that the expectation was for the quarterly MDS to be completed on time. This delay in completing the assessment placed the resident at risk for delayed and/or unidentified care needs.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to accurately assess four residents using the Minimum Data Set (MDS) assessment tool, which is crucial for identifying and meeting residents' care needs. Resident 11's significant change of status MDS was incorrectly coded as N/A for a change in behavior, despite having a prior MDS assessment. This error was acknowledged by the MDS Coordinator, who admitted it was a coding mistake. The Director of Nursing also confirmed the expectation for accurate coding. Resident 3's annual MDS inaccurately reflected their bladder and bowel continence status. The MDS was marked as frequently incontinent, while the resident was actually always incontinent and dependent. Both the MDS Coordinator and the Director of Nursing confirmed the inaccuracy during joint record reviews and interviews. Resident 95's discharge status was incorrectly recorded as discharged to a short-term general hospital, while nursing progress notes indicated the resident was discharged home with home health services. Additionally, Resident 8's annual MDS inaccurately recorded the number of days insulin injections were received as zero, despite daily administration documented in the Medication Administration Record. These inaccuracies were confirmed by the MDS Coordinator and the Director of Nursing.
Failure to Conduct Proper PASRR Evaluations
Penalty
Summary
The facility failed to ensure that a Level I Pre-Admission Screening and Resident Review (PASRR) was properly conducted for a resident with a diagnosis of generalized anxiety disorder. The resident was admitted to the facility with this diagnosis, and the Level I PASRR dated 05/17/2024 indicated an anxiety disorder but did not include a referral for a Level II evaluation. This oversight meant that the necessary comprehensive evaluation to confirm the diagnosis and determine the appropriateness of the resident's placement was not conducted. Additionally, the facility did not complete a new PASRR Level I when the resident experienced a significant change in condition, as evidenced by a significant change in status Minimum Data Set (MDS). The resident was discharged to the hospital and readmitted with additional diagnoses of depression and anxiety, for which they were receiving medication. Despite these changes, no new PASRR Level I was completed, and no referral for a Level II evaluation was made, as confirmed by the Director of Social Services and the Executive Director during interviews.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to clarify a physician's order for a resident with a feeding tube, leading to the incorrect administration of medication. Resident 55, who had a feeding tube for supplemental nutrition, was prescribed levothyroxine to be given by mouth. However, the medication was crushed and administered via the g-tube by an LPN, contrary to the physician's order. The staff member acknowledged the discrepancy and admitted that the order should have been clarified to reflect the correct route of administration. Another deficiency was observed in the documentation of medication administration for Resident 2. An LPN was seen signing off on the Medication Administration Record (MAR) before actually administering the medications. This practice was contrary to the facility's policy, which requires staff to document medication administration only after the medication has been given to the resident. The LPN admitted to signing the MAR prematurely, which was confirmed by the Unit Care Coordinator and the Director of Nursing, who both stated that the MAR should be signed as medications are administered. Additionally, the facility failed to document insulin injection sites for Resident 3, who was receiving daily insulin injections for type 2 diabetes. The MAR for several months, including September 2024, lacked documentation of the injection sites, which is necessary to prevent complications such as hard lumps or fatty deposits. Staff members, including an RN Unit Care Coordinator and the Director of Nursing, confirmed the absence of documentation and acknowledged that best practices for insulin administration were not followed.
Failure to Provide Scheduled Bathing and Hygiene Care
Penalty
Summary
The facility failed to consistently provide bathing, shower, and personal hygiene care according to the care plan for a resident with severe cognitive impairment and muscle weakness, who required substantial assistance with personal hygiene. The resident was observed multiple times with long, untrimmed fingernails and brown debris underneath them, indicating a lack of proper hygiene care. The resident's care plan specified the need for a sponge bath when a full bath or shower could not be tolerated, and the resident was scheduled for bathing twice a week. However, documentation showed that the resident received bathing only once in July and had no documented bathing in August, with no records of the resident refusing care. Interviews with staff revealed that the responsibility for providing showers and fingernail care lay with the shower aides, and any refusal of care should have been reported and documented. Staff members, including a CNA and an RN Unit Care Coordinator, acknowledged the oversight in care and documentation, noting that the resident's showers were incorrectly documented as "activity did not occur." The Director of Nursing confirmed the expectation that care should be provided according to the care plan and that refusals should be documented and addressed, emphasizing the need for the resident's fingernails to be kept short and clean.
Failure in Enteral Tube Feeding Management
Penalty
Summary
The facility failed to ensure proper management of enteral tube feeding for a resident, identified as Resident 55, who was receiving more than 51% of their nutritional intake through tube feeding due to conditions including dysphagia and gastrostomy status. The deficiency was identified through observations, interviews, and record reviews, which revealed that the facility did not adhere to its policy of changing and dating tube feeding syringes daily. Specifically, the Treatment Administration Record for August and September 2024 lacked documentation of daily syringe changes for Resident 55. During observations, multiple opened syringes were found at Resident 55's bedside, some dated several days prior and others undated, indicating they were not replaced daily as required. Interviews with staff, including a Registered Nurse and the Director of Nursing, confirmed that the facility's protocol was to change syringes every 24 hours and to date them upon opening. The failure to follow these procedures placed Resident 55 at risk for infection and related complications.
Failure to Provide Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident with a history of generalized anxiety disorder, depression, and opioid dependence. Upon readmission, the resident experienced a decline in cognition and overall medical condition, as noted in the Minimum Data Set (MDS) assessment. Despite these changes, the facility did not complete a social services assessment for the resident's change in condition. The Care Area Assessment (CAA) indicated the resident had inattention, disorganized thinking, confusion, and occasional agitation, along with little interest or pleasure in activities and verbal behavioral symptoms directed towards others. The Medication Administration Record (MAR) documented behavioral episodes for six out of eight days in August, including crying, isolation, and anxious behavior. Observations and interviews revealed that the resident was often found lying in bed with closed blinds and no lights, expressing a desire to be left alone and wanting to go home. Staff interviews indicated a lack of awareness and action regarding the resident's need for behavioral health services. The Activity Director noted the resident's long history of disinterest and refusal of activities, while the Registered Nurse Unit Care Coordinator was unaware of any referral for behavioral health services. The Director of Social Services acknowledged the resident's symptoms could indicate depression but confirmed no referral or services were provided. The Director of Nursing and Executive Director both expressed expectations that the resident should have been referred for psychological consultation or counseling, which did not occur.
Medication Error Rate Exceeds 5% Due to Incorrect Administration
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a rate of 6.45% during a medication pass observation. This deficiency involved two residents. For Resident 2, the error occurred when an LPN administered an enteric-coated aspirin instead of the prescribed chewable aspirin. The LPN acknowledged the mistake during a joint record review, stating that they should have given the chewable form as ordered. The Unit Care Coordinator confirmed the expectation that medication orders should match what is administered to residents. For Resident 55, the error involved the administration of levothyroxine via a g-tube instead of by mouth as prescribed. The LPN responsible for this administration expressed confusion over the order, expecting it to specify the g-tube route given the resident's feeding tube. The Unit Care Coordinator reiterated the importance of following the correct route as per the medication order. The Director of Nursing also emphasized the necessity of adhering to the prescribed form and route of medication administration.
Infection Control Deficiencies in PPE and Hand Hygiene Practices
Penalty
Summary
The facility failed to adhere to Enhanced Barrier Precautions (EBP) and proper hand hygiene practices, which are critical for infection control. Specifically, for Resident 55, who had a feeding tube and was on EBP, Staff AA, an LPN, did not wear the required personal protective equipment (PPE) such as a gown and mask while administering medications via the feeding tube. This oversight was acknowledged by Staff AA and confirmed by Staff F, the Assistant Director of Nursing/Infection Preventionist, who stated that PPE should be worn during high-contact care involving indwelling medical devices like feeding tubes. Additionally, the facility did not ensure proper hand hygiene and glove use among its staff. Staff EE, an LPN, failed to perform hand hygiene before and after entering resident rooms and before and after glove use, as observed during blood sugar checks and medication administration. Similarly, Staff M, a Certified Nursing Assistant, did not remove gloves after handling trash and used them inappropriately in the hallway, contrary to the facility's expectations. These lapses in infection control practices were confirmed through interviews with various staff members, including the Director of Nursing, who emphasized the importance of hand hygiene and proper glove use.
Failure to Cover Urinary Catheter Drainage Bags
Penalty
Summary
The facility failed to maintain and promote residents' dignity by not covering urinary catheter drainage bags for three residents. Resident 4's catheter drainage bag was observed with amber-colored urine and visible from the hallway without a privacy bag. Staff C, a Registered Nurse, confirmed that the drainage bag should be covered. Resident 5's catheter drainage bag was also visible to their roommate and a visitor, and it was not covered. Staff D, an LPN, incorrectly stated that the drainage bag did not need to be covered. Resident 6's catheter drainage bag was visible from the hallway and not covered when they were out of their room in a wheelchair. Resident 6 confirmed that their catheter bag was not covered, and Staff G, the Unit Care Coordinator, and Staff B, the Director of Nursing, both stated that catheter drainage bags should be covered for dignity.
Failure to Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident to the State Agency and/or law enforcement. The resident, who was usually understood but had moderately impaired cognition, was found with a significant skin tear on their right forearm. The resident reported that a large man had grabbed and squeezed their arm, causing the injury. Despite this, the incident was not reported to the appropriate authorities as required by the facility's policy. The Director of Nursing Services (DNS) was informed of the incident but did not consider it an alleged violation or abuse due to the location of the wound and did not report it. The resident's representative also attempted to follow up on the incident by contacting the DNS but received no response. Staff members who were aware of the incident and the resident's account of the event reported it to the DNS, who assured them that it would be investigated. However, the DNS did not report the incident to the State Agency or law enforcement. The facility's administrator later acknowledged that the incident should have been reported to the appropriate agencies.
Failure to Investigate Allegation of Abuse
Penalty
Summary
The facility failed to ensure an allegation of abuse was thoroughly investigated for one resident. The resident, who was usually understood but had moderately impaired cognition, reported that a large man grabbed and squeezed their arm, causing a skin tear. The facility's investigative report concluded that the injury likely occurred during a transfer from a wheelchair to a bed, but there was no documentation of interviews with relevant staff or the resident's representative, nor was there evidence of staff training on proper transfer techniques. The Director of Nursing Services (DNS) did not consider the incident as an alleged violation or abuse and did not report it to the state or conduct a thorough investigation. The resident's representative reported the incident to the DNS and requested a copy of the incident report but received no response. Staff members confirmed that the resident had mentioned being grabbed by a large man, and one staff member identified another staff member who fit the description. Despite this, the DNS did not take appropriate action to investigate the allegation or educate staff on proper transfer techniques. The facility administrator acknowledged that the incident should have been reported and investigated.
Failure to Ensure Proper Skin Care and Treatment
Penalty
Summary
The facility failed to ensure residents received skin care and treatments in accordance with professional standards of practice for three residents reviewed for skin conditions. Resident 1 had a skin tear on the right forearm that was not documented with measurements in the skin assessment, and there was no physician's treatment order for the skin tear. Resident 2 had a skin tear on the right knee, but there was no treatment order written for it, even though the skin tear was resolved. Resident 3 had a skin tear on the left buttock, but the dressing was incorrectly placed on the right buttock, and there was no physician's order for the left buttock skin tear. Staff E and Staff F confirmed these deficiencies during joint record reviews and interviews. The Director of Nursing (DNS) stated that staff were expected to notify the provider, DNS, and the resident's representative when new skin issues were found, complete a thorough skin assessment, and obtain treatment orders. However, this protocol was not followed for Residents 1, 2, and 3. The lack of proper documentation, assessment, and treatment orders for the skin tears placed the residents at risk for not receiving the necessary skin care treatment, unmet care needs, and a diminished quality of life.
Failure to Properly Position Urinary Catheters
Penalty
Summary
The facility failed to ensure urinary catheters were positioned off the floor for two residents, which placed them at risk for urinary tract and bladder infections. Resident 4 was observed with their urinary drainage bag lying flat on the floor while sitting on the edge of their bed. Staff C, a Registered Nurse, confirmed that the drainage bag should be hooked on the bed frame and off the floor. Similarly, Resident 5 was observed in bed with their drainage bag lying flat on the floor. Staff D, a Licensed Practical Nurse, also confirmed that the drainage bag should be off the floor. The facility's policy on Indwelling Urinary Catheter Management, reviewed on 08/24/2023, specifies that the collecting bag should always be kept below the level of the bladder and should not rest on the floor. Despite this policy, both residents' catheter bags were found on the floor during observations. Staff G, the Unit Care Coordinator, and Staff B, the Director of Nursing Services, both acknowledged that the urinary catheter drainage bags should be off the floor, indicating a lapse in adherence to the facility's policy and proper catheter care protocols.
Failure to Designate a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified staff person to serve as an Infection Preventionist (IP) to oversee the infection prevention and control program. This deficiency was identified during a review of the facility's records and interviews with staff. The facility document titled 'Care List for Positive Individuals' showed that 42 residents and 17 staff had tested positive for COVID-19 between 03/18/2024 and 04/01/2024. On 04/03/2024, the Executive Director (Staff A) confirmed that the facility did not have a certified IP, and that Staff B was serving as the interim IP without certification. Staff B also confirmed their lack of certification. Staff C, who was certified, stated they were not acting as the IP but were assisting with infection control tasks as directed by Staff B. Staff A reiterated that the infection control responsibilities were being managed as a team effort, with no single certified IP designated.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by one of the staff members, identified as Staff E. Staff E was observed exiting a COVID-19 isolation room with soiled linen and entering a non-isolation room without performing hand hygiene. This action was against the facility's hand hygiene policy, which mandates hand hygiene before and after contact with residents and contaminated surfaces. Staff E admitted to not sanitizing their hands before entering the non-isolation room, acknowledging the lapse in protocol. The facility also failed to appropriately disinfect medical equipment. Staff E was observed using vital sign equipment in a COVID-19 isolation room and exiting without disinfecting the equipment. According to the facility's policy, non-critical reusable patient care equipment should be cleaned daily and before and after reuse with an EPA-registered hospital disinfectant. Staff E admitted to not disinfecting the equipment and stated they were informed of the correct procedure only on the day of the observation. Additionally, the facility did not ensure the proper use and disinfection or disposal of personal protective equipment (PPE). Staff E and Staff F were observed exiting COVID-19 isolation rooms multiple times without changing their N95 masks or disinfecting their face shields. Staff F admitted to wearing the same N95 mask all day and only changing it if a resident seemed sicker. The facility's policy requires staff to remove and discard disposable respirators and disinfect or discard face shields after exiting isolation rooms. Furthermore, the facility failed to ensure that 13 out of 18 staff members were fit tested for N95 masks, which is required before staff can wear tight-fitting respirators. Staff E, who tested positive for COVID-19, had not been fit tested prior to the observation date, and several other staff members either had no fit testing documentation or had expired fit testing documentation.
Failure to Provide Adequate Nutritional Care
Penalty
Summary
The facility failed to provide adequate nutritional care and services for a resident, leading to significant weight loss. The resident, who was at risk for malnutrition due to dysphagia, was readmitted to the facility and initially showed no weight loss. However, subsequent records indicated a significant weight loss of 16.5 lbs. (9.9%) within a month. Despite the facility's policy to conduct weekly meetings to review residents at risk, the resident's weight loss was not discussed, and no nutritional supplements were ordered. The resident's weight dropped from 166.3 lbs. to 149.8 lbs. within a short period, and this was not communicated to the medical provider, the resident, or their representative. Interviews with staff revealed that the registered dietician was not informed of the resident's weight loss, and the weight loss was not addressed in the weekly meetings. The resident care manager confirmed the weight loss and acknowledged that it was not communicated appropriately. The facility administrator stated that the process for monitoring weights and updating nutritional assessments was not followed, leading to a lack of intervention and notification regarding the resident's significant weight loss.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 1,216 citations issued within 25 miles in the last 12 months — including the 2 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 Kirkland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cascades Of St Anne | 3.7 mi | ★★★★★ | 42 | 0 |
| Redmond Care And Rehabilitation Center | 4 mi | ★★★★★ | 1 | 0 |
| Shoreline Health And Rehabilitation | 4.6 mi | ★★★★★ | 55 | 0 |
| Corwin Center At Emerald Heights | 4.7 mi | ★★★★★ | 0 | 0 |
| Avamere Rehabilitation Of Shoreline | 5 mi | ★★★★★ | 12 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.