Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Life Care Center Of Puyallup during CMS and state inspections, most recent first.
Failure to Protect Residents from Resident-to-Resident Abuse: A resident with vascular dementia, severe cognitive impairment, poor impulse control, and a history of aggression was involved in three physical altercations with three other residents within a 24-hour period. The resident knocked snacks from one resident’s hands and hit and kicked them, kicked another resident near the nurses’ station, and struck a third resident in the leg/ankle while agitated. One resident said the aggressor scared them and another said they did not feel safe around the aggressor; staff later stated the incidents constituted abuse.
A facility failed to provide adequate PU/PI prevention and wound care for multiple residents. Care plans and Kardex entries lacked person-centered pressure offloading interventions, and staff observations showed residents lying with heels on the mattress or foot pedals without heel protection. One resident developed a right heel PU that worsened from Stage II to unstageable, and staff were observed not following the ordered wound treatment during dressing care.
Infection control deficiencies were identified when the facility did not track all infectious organisms for two months, despite UTI lab results being available, and staff did not follow posted contact precautions in a resident room. An LPN entered a contact precautions room without hand hygiene, gown, or gloves, and another LPN was observed in the room without PPE. During wound care for a resident, an LPN/Treatment Nurse removed a soiled bandage and used the same gloves to cleanse the wound and apply a new dressing without hand hygiene or glove changes.
Failure to Implement Antibiotic Stewardship Program: The facility did not complete required antibiotic reassessments for two residents receiving antibiotics for suspected UTIs. One resident with Parkinson's disease received multiple antibiotic courses, including treatment based on delayed lab susceptibility results, but the record showed no documented UTI signs or symptoms and no McGeers assessment or antibiotic reassessment. Another resident with a broken leg received Macrobid for a UTI, but no lab results were reviewed and no antibiotic reassessment was completed; progress notes also showed no UTI symptoms.
A resident switched to Medicare A, but when Medicare coverage ended, the facility did not issue the required SNFABN. The BOM stated the resident was discharged as private pay and acknowledged that the SNFABN should have been completed.
Unnecessary AP use without documented behaviors. A resident with cognitive impairment, depression, and non-Alzheimer’s dementia received Seroquel 12.5 mg nightly even though the MDS showed no behaviors, delirium, or rejection of care. The chart listed dementia without behavioral, psychotic, mood, or anxiety disturbance as the indication, while the AP care plan referenced behavior management and target behaviors such as agitation, anxiety, delusions, and hitting/kicking. Target behavior documentation showed no behaviors, and the SS Director stated dementia was not an appropriate indication for AP use and the medication should have been evaluated and/or discontinued.
Failure to Offer Bed Holds and Provide Transfer Notices: The facility did not offer bed holds or provide written transfer notices to the resident or Ombudsman for multiple residents sent to the hospital or ER. Residents with COPD, CHF, diabetes, kidney disease, heart disease, and hypothyroidism were transferred and returned, but the EHR lacked documentation that bed holds were offered or that transfer/discharge forms were completed and provided as required.
Inaccurate resident assessments were identified for three residents. One resident receiving hospice services was coded as not on hospice in the MDS, another resident with an indwelling urinary catheter had inconsistent catheter indications and no matching MDS diagnosis or indication, and a third resident was coded as edentulous despite records and observation showing some natural teeth present. Staff acknowledged the MDS and nursing assessments did not accurately reflect the residents’ status.
Care plan not updated after a resident fall. A resident with COPD, DM, and hypothyroidism had two falls related to transfers and slipping on the floor, including a fall during self-transfer from the commode to the bed. The fall investigation noted the resident needed extensive assist with transfers and had forgotten nonskid socks, but the fall care plan was not updated with new interventions after the incident, and the Regional RN stated it should have been updated.
Failure to provide oral care assistance: A resident with respiratory failure, pneumonia, asthma, and COPD required help with ADLs but reported not brushing their teeth in the facility and not having oral care supplies. Observations showed no supplies at the sink, and later a toothbrush and toothpaste were found unopened in a box out of the resident’s reach. Staff interviews indicated the assigned CNA did not remember assisting with oral care, while the LPN, DNS, and Administrator stated staff were expected to assist with oral care and that it should be done daily per resident preferences.
A resident with respiratory failure, pneumonia, asthma, and COPD was observed receiving O2 by nasal cannula at 4 L/min and later at 3 L/min, despite a provider order for 2 L/min. The resident said they could not reach or adjust the O2 settings. An RN confirmed the higher flow rate had been used after desaturation was discussed in report, and the Administrator and Regional RN stated the expectation was to follow O2 orders.
A resident with HTN, DM, and arthritis received PRN oxycodone, but the pharmacist’s MRR noted that NPIs were not linked to the order and should be attempted before administration. The MAR showed pain was documented and oxycodone was given, but no NPI was documented with the PRN pain med order, and staff acknowledged the pharmacy recommendation was not followed.
Medication administration errors exceeded the allowed rate when an LPN gave a resident gabapentin from a card that did not match the MAR, removed and reapplied a lidocaine patch on the wrong schedule, gave PEG despite loose stool being documented, and administered plain senna instead of senna-docusate to another resident. The errors involved residents with cognitive impairment, incontinence, and dependence for care, and included mismatched medication labels, incorrect patch timing, failure to check bowel status, and wrong-drug administration.
IV antibiotic and saline bags were observed hanging for multiple residents without required labeling such as the resident’s name, medication name when applicable, infusion rate, date and time hung, discard information, or nurse initials. MAR review showed ordered IV antibiotics and flushes, but the bags at the bedside were not properly labeled, and an RN stated labeling was not necessary if the same nurse hung and administered the medication.
A resident with COPD and diabetes reported dentures that did not fit and said they had seen a dentist for new dentures but had not heard anything further. Records showed a dental note recommending new upper and lower dentures and extractions, and another note stating the resident needed referral out for x-rays and extractions for all lower teeth. Staff interviews showed the transportation specialist had not seen the denture recommendation and believed only a recall exam was scheduled, while the unit care coordinator had not received notice that the follow-up was completed.
A resident's allegation of neglect, including being left in soiled briefs, developing open sores, receiving incorrect skin treatment, and having stroke-like symptoms ignored, was not reported to the State Agency as required. The administrator received the complaint but did not log or report the incident.
A resident with diabetes and heart disease, admitted after a surgical amputation, had provider orders for CRP and ESR blood tests following wound care for a dehisced surgical site. The facility transcribed the orders but did not complete the lab work until 40 days later due to lack of a phlebotomist and limited nursing staff trained in blood draws, resulting in the resident's lab work being missed.
A resident with a Stage 4 pressure ulcer did not have weekly wound assessments documented in a timely manner. Instead, several weeks of wound documentation were entered into the electronic medical record retrospectively, and the DNS could not provide consistent source data for these entries.
Two residents with documented urinary incontinence did not have this condition addressed in their care plans until late or not at all, despite assessments indicating the need. The DON confirmed that care plans should have been implemented promptly based on assessment findings.
The facility did not consistently monitor or assess the skin impairments of two residents with pressure injuries and moisture-associated skin damage. Despite initial identification and documentation, there were no ongoing measurements, treatment or monitoring orders, or follow-up assessments to track the status or healing of these wounds, as confirmed by the DON.
Two residents admitted with significant skin impairments, including a sutured leg laceration and multiple bruises, did not receive timely treatment or monitoring orders as required. Orders for wound care and monitoring were delayed by 11 and 14 days, respectively, despite facility expectations for immediate assessment and provider notification.
A resident with hemiplegia and mobility issues reported to an SLP that a staff member refused to provide their bed remote and pushed them, but the allegation was only documented on a grievance form and not immediately reported. The incident was not logged or reported to the State Agency until over a day later, exceeding required reporting timeframes.
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in their care. One resident with a pressure ulcer lacked a care plan focus area for the ulcer, while another resident's care plan inaccurately reflected their diet and NPO status. Facility staff confirmed these issues did not meet expectations.
The facility failed to follow professional standards of care for several residents, including improper medication administration and inadequate monitoring. A resident did not receive orthostatic blood pressure monitoring, and their medication was administered outside prescribed parameters. Another resident had a foley catheter of the incorrect size, and two residents did not have complete orthostatic blood pressure monitoring or required tests for medication side effects. Staff interviews confirmed these actions did not meet expectations.
The facility failed to provide necessary grooming services for two residents, leading to deficiencies in personal hygiene. One resident, with a right humerus fracture and diabetes, was not assisted with shaving despite expressing a desire for it. Another resident, with rheumatoid arthritis and heart failure, had long, thick toenails and was not referred to a podiatrist as needed. Staff interviews revealed confusion about responsibilities and unmet expectations for care.
A facility failed to ensure proper care for a resident with a fractured humerus by not applying a PRN sling as ordered, and did not consistently monitor or document bowel movements for two residents, leading to missed administration of constipation medication. Staff interviews revealed lapses in following care protocols and documentation procedures.
A resident at high risk for falls did not have fall mats in place as required by their care plan, despite previous falls and multiple diagnoses including stroke and dementia. Staff interviews revealed the mats were removed due to being frayed, and new ones were ordered, but not yet in place.
A resident with diabetes, paraplegia, and anxiety experienced inadequate pain management due to the facility's failure to provide clear parameters for PRN pain medications. The resident reported that the pain relief was insufficient, and staff confirmed the lack of guidance on medication administration. This deficiency risked the resident's quality of life.
The facility failed to maintain safe and functional wheelchairs for two residents, resulting in cracked and torn armrests that were not logged for maintenance. Despite residents' ability to communicate their needs, the issues were not addressed, and staff interviews confirmed the need for repairs.
The facility failed to make survey results easily accessible to residents and did not post notices about their availability in prominent areas. Two cognitively alert residents were unaware of the survey results' location. The binder was found in a conference room, with no notices throughout resident areas. Staff interviews revealed inconsistent knowledge about the binder's location.
The facility failed to provide written transfer notices to three residents, who were only informed verbally about their hospital transfers. An LPN confirmed the lack of written notices, and the Administrator acknowledged the expectation for written documentation, which was not met.
Failure to Protect Residents from Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure freedom from abuse during resident-to-resident altercations involving one resident with vascular dementia and severe cognitive impairment who was able to communicate needs and independently propel a wheelchair. The resident had a care plan noting potential verbal or physical aggression, poor impulse control, and a history of altercations with other residents, with interventions including redirection, activities, and calm intervention before agitation escalated. A discharge plan had also been developed for transition to a higher level of care due to increasing cognitive and behavioral needs. Within a 24-hour period, the resident was involved in three separate physical altercations with three different residents. In one incident, the resident cornered another resident in a room with a vending machine, knocked snacks from that resident’s hands, kicked the resident, and then struck the resident on the left chest with pointed straight fingers. In another incident, the resident became agitated near the nurses’ station, kicked a wheelchair-bound resident’s leg out of the way, and used profanities. In the third incident, while agitated over staff attempting to collect a urine sample and while verbally abusive toward staff, the resident wheeled down the hall, approached another resident seated in a wheelchair, and hit that resident in the right leg/ankle. The other residents involved had varying levels of impairment and mobility. One resident was alert, oriented, and able to walk with a walker; another had severe cognitive impairment, used a wheelchair, and depended on staff for mobility and daily care; and the third had memory problems and could recognize room location and staff names and faces. During interview, one victimized resident stated the aggressor scared them and that staff warned them when the aggressor was nearby so they could avoid them. Another resident indicated they did not feel safe around the aggressor. Staff later stated the physical altercations constituted abuse.
Failure to Prevent and Treat Pressure Injuries
Penalty
Summary
The facility failed to provide necessary treatment and services consistent with professional standards of practice to prevent the development and/or promote healing of pressure ulcers/pressure injuries for Residents 11, 128, 13, and 134. The report states the facility’s pressure injury prevention and care policies required assessment of resident risk factors, implementation of resident-centered interventions, monitoring of the impact of interventions, and revision of the care plan as needed. The facility also used Braden Scale assessments to identify risk, but the care plans and Kardex entries reviewed for these residents did not include resident-centered interventions that addressed the pressure-related risks identified in the assessments. Resident 11 was admitted with no unhealed pressure injuries, had limited lower-extremity range of motion, was dependent for toileting, bed mobility, and transfers, and was incontinent of bladder. The Braden assessment identified moisture, bed confinement, very limited mobility, and friction/shear concerns, along with clinical risk factors including incontinence, pain affecting movement, chronic disease, hip fracture, diabetes, and anticoagulant use. The skin integrity care plan and Kardex did not include pressure-offloading interventions. After admission, Resident 11 developed a right heel Stage II pressure injury that later became unstageable. The wound care consultant recommended cleansing, skin prep, medical honey, a bordered dressing, and floating the heels with pillows or a wedge heel lift device. During observations, Resident 11 was repeatedly found with heels resting directly on the mattress or on wheelchair foot pedals, without heel lift boots or pillows in place, and the resident reported severe heel pain. Staff also did not follow the physician’s wound care order during one observed dressing change and initially applied the wrong treatment. Resident 134 was admitted at risk for pressure injuries, was incontinent of bowel and bladder, and required staff assistance for bed mobility, toileting, and transfers. The Braden assessment identified problems with activity, friction/shear, pain affecting movement or mood, acute illness, PVD, and diabetes. The baseline care plan only addressed cleaning and drying skin after incontinence and weekly skin checks, without person-centered interventions for pressure relief. The resident was repeatedly observed lying in bed with heels directly on the mattress, reported heel pain, and later had both heels noted to be red, with the right heel boggy. Resident 128 was admitted with a Stage I pressure injury to the sacrum/buttocks and was also at risk due to moisture, chairfast status, very limited mobility, and friction/shear. The care plan and Kardex did not identify the existing pressure injury or direct staff on how often to reposition or how to relieve pressure, and the resident was repeatedly observed lying flat on the back without side-lying support or heel offloading. Resident 13 was admitted with multiple pressure injuries, including wounds to the right foot, right heel, left inner ankle, left foot, and left heel, but the care plan and Kardex did not provide sufficient person-centered interventions or clear directives for staff to prevent further pressure or promote healing.
Infection Control Program, Contact Precautions, and Wound Care Deficiencies
Penalty
Summary
The facility failed to implement an infection control program to track all infectious organisms present in the facility for January and February 2026. Review of the infection control line listings for January, February, and March 2026 showed no documentation that the organisms present for residents with a diagnosis of urinary tract infection were identified and tracked for the months of January and February 2026. During interview, the RN/Infection Preventionist stated they were aware the organisms were missing from the monthly tracking for those two months and stated the laboratory results should have been reviewed for all infections but were not. The facility also failed to implement transmission-based precautions for one hall and failed to follow infection control practices during wound care for Resident 11. Observation showed a room with a contact precautions sign posted, but an unidentified staff member entered without performing hand hygiene or putting on a gown or gloves and did not perform hand hygiene when exiting. In another observation, an LPN was standing in the resident’s room next to the resident without a gown or gloves despite the posted contact precautions sign. During wound care for Resident 11, an LPN/Treatment Nurse removed the soiled bandage and used the same gloves to cleanse the wound and apply a new bandage, with no hand hygiene or glove changes during the bandage change.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective Antibiotic Stewardship Program for 2 of 2 sampled residents reviewed for antibiotic stewardship. The facility policy titled Antibiotic Stewardship stated that antibiotic reassessment should occur two to three days after empiric antibiotic initiation or the first dose in the facility, with laboratory results, response to therapy, and resident condition considered at that time. For Resident 80, who was admitted with Parkinson's disease and was able to make needs known, the EHR showed multiple antibiotic courses, including Macrobid for a UTI, Cephalexin for a skin infection, and later Cephalexin for a UTI based on a provider note referencing E. coli susceptibility. Progress notes between 01/22/2026 and 03/12/2026 showed no documented signs or symptoms of a UTI, and Staff C stated the resident should have been assessed using McGeers criteria and had an antibiotic reassessment, but this was not done. For Resident 52, who was admitted with a broken leg and was able to make needs known, the EHR showed an order for Macrobid for a UTI with a four-day course. The record showed no laboratory results were received or reviewed and no antibiotic reassessment was completed. Progress notes between 03/18/2026 and 03/22/2026 showed no reports of UTI symptoms. Staff C stated the lab results should have been requested and reviewed and an antibiotic reassessment completed, and Staff E stated it was the Infection Preventionist's expectation to review infection-associated lab results and follow up with antibiotic reassessments, but this did not happen for Residents 80 and 52.
Failure to Issue SNFABN for Medicare Coverage End
Penalty
Summary
The facility failed to accurately complete a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) for Resident 136, who was admitted to the facility and later switched insurance to Medicare A on 11/01/2025. Review of the electronic health record showed the resident’s Medicare coverage ended on 11/13/2025, and no SNFABN form was issued. During an interview, the Business Office Manager stated that Resident 136 discharged from the facility on 11/14/2025 and that the previous Business Office Manager discharged the resident as private pay, and also stated that a SNFABN form should have been completed.
Unnecessary Antipsychotic Use Without Documented Behaviors
Penalty
Summary
The facility failed to ensure one resident was free from unnecessary psychotropic medication use. Resident 125 was admitted with some cognitive impairment and diagnoses that included an infection, depression, and non-Alzheimer’s dementia. The resident’s MDS showed the resident could understand and be understood and had no behaviors, symptoms of delirium, or rejection of care. Despite this, the resident received an antipsychotic medication, Seroquel 12.5 mg at bedtime, with the indication documented as unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety. The resident’s AP care plan stated the medication was being used for behavior management and dementia with behavior and psychosis, with target behaviors listed as agitation, anxiety, delusions, and hitting/kicking. The record also included non-medication interventions such as redirection, reassurance, problem-solving, encouraging activities, and returning the resident to the room. However, the target behavior documentation showed the resident had no behaviors, and the medication was administered every night. During interview, the Social Services Director stated dementia was never an appropriate indication for antipsychotic use and that the resident should have been evaluated for the medication and/or it should have been discontinued, but was not.
Failure to Offer Bed Holds and Provide Transfer Notices
Penalty
Summary
The facility failed to offer bed holds and failed to provide written notice of transfer to the resident or the Ombudsman at the time of transfer for 3 of 4 sampled residents reviewed for hospitalization. Resident 20 was admitted with COPD, diabetes, and hypothyroidism, was able to communicate needs, and stated they were sent to the hospital and had to wait three days before returning to their room. The EHR showed Resident 20 was transferred to the hospital with new onset weakness on one side, but there was no written nursing home transfer/discharge form or bed hold documentation. Staff B, the DNS, could not locate documentation related to the discharge, and Staff A, the Administrator, stated they would look for the discharge documentation but none was provided. Resident 12 was admitted with diabetes, kidney disease, and heart disease and was able to make needs known. The EHR showed the resident was sent to the ER and later returned to the facility, but there was no documentation that a bed hold was offered at the time of transfer and no record that a notice of transfer was completed and provided to the resident, their representative, or the Ombudsman. Resident 3 was admitted with CHF, COPD, and diabetes and was able to make needs known. The EHR showed Resident 3 was transferred to the ER from a doctor's appointment on two occasions and returned to the facility, but there was no documentation that a bed hold was offered or that a notice of transfer was provided to the Ombudsman for either transfer. Staff D, the SSD, and Staff E, the Regional RN, stated it was their expectation that bed holds would be offered and transfer notices completed and provided, but this did not happen for Resident 12 or Resident 3.
Inaccurate Resident Assessments
Penalty
Summary
The facility failed to ensure the accuracy of assessments for 3 residents reviewed for assessment accuracy. Resident 56 was readmitted with diagnoses including heart failure, diabetes, and respiratory failure, and was able to make needs known. The significant change MDS coded the resident as not receiving hospice care, even though the EHR showed an order to admit to hospice services and documentation that hospice staff visited the resident from 11/22/2025 through 03/19/2026. Staff L, RN/MDSC, stated the MDS should have been coded yes for hospice care, and Staff A, Administrator, stated the MDS was coded no when it was supposed to be coded yes and needed to be modified. Resident 62’s admission MDS showed an indwelling urinary catheter, but it did not show a corresponding diagnosis or indication for the catheter. Records showed a standard urinary catheter due to urinary retention, while the MAR listed the catheter indication as related to a tear in the aorta and cancer. Staff Z, RN/MDS Coordinator, stated the indication for the urinary catheter should have been clarified and assessed accurately on the MDS but was not. For Resident 11, the admission/5-day MDS coded the resident as edentulous, while the nursing admission assessment documented missing natural teeth but not edentulous, and an observation showed some natural teeth present. Staff P, LPN/Unit Care Coordinator, stated the assessment should accurately reflect the resident’s current status but did not.
Care Plan Not Updated After Resident Fall
Penalty
Summary
The facility failed to initiate new interventions and update the care plan for Resident 20 after a fall on 01/01/2026. Resident 20 was admitted with diagnoses including COPD, diabetes, and hypothyroidism and was able to communicate needs. On 04/08/2026, the resident was observed sitting in bed with a commode next to the bed and stated they had two falls because they slipped on the floor during transfers. Review of the second fall investigation showed the resident fell due to self-transferring from the commode to the bed, needed extensive assistance with transferring, and had forgotten to put on nonskid socks. The fall investigation also showed the resident had previously used interventions in the summary of the fall. Review of the fall care plan, initiated on 10/30/2025 and revised on 12/26/2025 and 12/30/2025, showed no new interventions were added after the 01/01/2026 fall. During interview, Staff E, Regional RN, stated the care plan should have been updated and that it did not meet expectations.
Failure to Provide Oral Care Assistance
Penalty
Summary
The facility failed to ensure oral care was provided for Resident 91, who was admitted with respiratory failure, pneumonia, asthma, and COPD and was able to communicate needs but required assistance with ADLs. During observation and interview, Resident 91 stated they had not brushed their teeth in the facility and did not have oral care supplies. On a later observation, the resident still reported not having oral supplies, and the sink area had no oral care supplies present. On a subsequent observation, a gray box on a nightstand out of the resident’s reach contained a new, unopened toothbrush and travel-sized toothpaste that had not been opened. Staff interviews showed the CNA assigned to the resident did not remember assisting with oral care, another CNA was not assigned to the resident, and the LPN stated oral care supplies should be easily available and staff were expected to assist residents with oral care. The DNS and Administrator stated the expectation was for staff to assist with oral care and for oral care to be done every day per resident preferences.
Failure to Follow Ordered Oxygen Rate
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for one resident who was admitted with respiratory failure, pneumonia, asthma, and COPD. The resident was able to communicate needs and was observed in bed receiving oxygen through a nasal cannula connected to an oxygen concentrator. On one observation, the oxygen was set at 4 L per minute, and on a later observation it was set at 3 L per minute. The resident stated they were unable to reach and adjust the oxygen delivery settings. Review of the provider's orders showed the resident had an order for oxygen at 2 L per minute via nasal cannula. During interview, an RN verified the oxygen was being delivered at 3 L per minute and stated the nursing report from two days earlier discussed the resident desaturating and the oxygen rate being increased. The RN stated the expectation was for nurses to notify the provider and obtain new orders. In a joint interview, the Administrator and Regional RN stated the expectation was to follow oxygen orders.
Failure to Follow Pharmacist Recommendation for PRN Oxycodone
Penalty
Summary
The facility failed to act on and/or follow the consultant pharmacist’s medication regimen review recommendation in a timely manner for one resident reviewed for unnecessary medication use. The resident was admitted with diagnoses including high blood pressure, diabetes, and arthritis, and was able to make needs known. A pharmacist consultation report dated 03/23/2026 stated that the resident received as needed oxycodone one to three times a day, but nonpharmacological interventions were not linked to the as needed oxycodone order, with the recommendation to ensure nonpharmacological therapies were attempted prior to prn oxycodone administration. Review of the resident’s April 2026 MAR showed an order dated 01/08/2026 to monitor and document pain level every shift and to attempt non-medication interventions prior to administering as needed pain medication with NPI interventions listed. The resident’s pain level was documented, but NPI was not. The record also showed an order with a start date of 03/27/2026 for oxycodone one tablet every eight hours as needed for moderate to severe pain; pain levels were documented and oxycodone was given, but there was no NPI linked to the order to show that nonpharmacological interventions were provided before the medication. Staff stated during interview that the pharmacy recommendation was not followed up on and that the specific NPIs should have been linked to the oxycodone order.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure its medication error rate remained below 5%, with a cited error rate of 12% for 2 of 5 residents reviewed. The deficiency involved Resident 43, who had some cognitive problems, was hard of hearing, vision impaired, incontinent of bowel and bladder, and required maximum assistance for toileting, bed mobility, and transfers. During medication administration, an LPN showed a MAR order for gabapentin 100 mg three times daily, but the medication card label read gabapentin 100 mg one time daily, and the discrepancy had not been clarified or noted on the card before the medication was given. For Resident 43, the same observation showed a lidocaine 4% patch was removed from the lower back and a new patch was applied to the same area. The MAR transcription listed the patch to be applied in the morning and removed at 7:59 AM, while the original physician order stated the patch was to be removed at night. The record showed that from 04/01/2026 through 04/10/2026, the nurse documented both removal of the old patch and placement of the new patch during the morning medication pass, and the LPN stated the patch should have been removed in the evening but was not. Resident 43 also received polyethylene glycol 3350 despite the order to hold it for loose stools. The LPN asked whether the resident had pooped, but did not ask about loose stool or review the bowel record, even though the PCC task record showed a loose stool earlier that morning. For Resident 98, who had short- and long-term memory problems, cerebral palsy, and dependence for toileting, bed mobility, and transfers, an LPN administered senna 8.6 mg from a bottle labeled only "Senna 8.6 mg" instead of the ordered senna-docusate sodium 8.6 mg-50 mg tablet, and the nurse recognized the wrong medication only after re-reading the MAR.
IV medications and fluids were left unlabeled during administration
Penalty
Summary
Drugs and biologicals used in the facility were not labeled in accordance with accepted professional principles during IV medication administration for Residents 14, 104, and 125. Observations and record review showed IV antibiotic bags and saline bags hanging at the residents’ IV poles without the resident’s name, the medication name when applicable, the date and time the dose was hung, the infusion rate, when to discard unused solution, or the initials of the nurse who hung the bag. In multiple observations, empty antibiotic bags and separate saline bags remained in place without the required labeling information. For Resident 104, the April 2026 MAR showed orders for cefepime every 8 hours, daptomycin every 24 hours, and saline flushes before and after antibiotic administration. During observations, an empty saline bag labeled for cefepime and a separate 250 ml saline bag were seen without the required date, time, rate, or nurse identification. When daptomycin was administered, the IV bag also lacked the date and time the dose was hung, the infusion rate, and the nurse’s initials. Staff Q stated they were unsure of the facility policy for labeling IV medications and believed labeling was not necessary if the nurse who hung the medication was the same nurse administering it. For Resident 14, the April 2026 MAR showed cefazolin ordered every 8 hours with saline flushes. Observations showed an empty cefazolin bag and a separate 250 ml saline bag hanging without the resident’s name, infusion rate, date and time hung, discard information, or nurse initials. For Resident 125, the April 2026 MAR showed cefazolin every 8 hours with saline flushes, and observations showed both the antibiotic bag and saline bag were not dated, timed, or initialed by the nurse; the saline bag also lacked the resident’s name and infusion details. Staff P stated that professional standards required IV fluids and medications to be properly labeled with the resident’s name, medication name if applicable, infusion rate, date and time hung, and nurse initials.
Failure to Provide Needed Dental Services
Penalty
Summary
The facility failed to provide needed dental services for Resident 17, who was admitted with COPD and diabetes and was able to make needs known. The resident stated during interview that their dentures did not fit and that they had seen a dentist three months earlier for new dentures but had not heard anything further. The EHR included a Dental Progress Note dated 02/05/2026 recommending new upper and lower dentures and extractions, and a progress note dated 02/12/2026 stating the resident was seen by an outside dental provider and would need a referral out for x-rays and extractions for all lower teeth. Staff interviews showed the transportation specialist had not seen the recommendation for new dentures and believed the resident was only scheduled for a recall exam in one year, while the unit care coordinator stated transportation was expected to schedule the follow-up and notify them when completed, but no notice had been received.
Failure to Report Allegation of Neglect
Penalty
Summary
The facility failed to report an allegation of neglect involving one resident, as required by regulation. A public complaint was sent to the State Agency alleging that the resident was left in soiled adult diapers for extended periods, developed open sores in the groin area, received incorrect treatment for skin impairments, and experienced symptoms such as left arm numbness, tingling, nausea, and vomiting, which were reportedly ignored by staff. The complaint was copied to the facility administrator via email. However, a review of the facility's incident report logs showed that the allegation was not logged or reported to the State Agency. During an interview, the administrator confirmed receipt of the complaint but acknowledged that the allegations were not reported to the State Agency.
Failure to Timely Complete Ordered Laboratory Tests
Penalty
Summary
The facility failed to follow provider orders for laboratory blood work for one resident who was admitted after a surgical amputation of toes and had diagnoses including diabetes and heart disease. The resident had an order for blood tests (CRP and ESR) to be drawn at the facility following a visit to an outpatient wound care center for treatment of a dehisced surgical foot wound. Although the physician's order for these labs was transcribed into the facility's records, the tests were not performed until 40 days after the order was written. According to the Director of Nursing Services, the delay occurred because the facility did not have a phlebotomist at the time and only two nurses were trained to draw blood, resulting in the resident's lab work being missed.
Failure to Maintain Timely and Accurate Wound Documentation
Penalty
Summary
The facility failed to maintain accurate and timely wound monitoring records for a resident with a Stage 4 pressure ulcer. The resident was admitted with a significant wound over the sacrum, with exposed bone and specific measurements documented at admission. Although the facility had a process in place for weekly wound documentation using a Wound Observation Tool, records showed that several weeks of wound assessments were not entered into the electronic medical record on a weekly basis as required. Instead, multiple weeks of documentation were entered retrospectively, well after the assessments should have been completed. During interviews, the Director of Nursing Services (DNS) acknowledged that the weekly wound documentation was not completed as scheduled and admitted to being behind in documentation. When asked to provide the original source data for the wound documentation, the DNS was unable to produce records consistent with what was entered into the electronic medical record. This lapse resulted in incomplete and potentially inaccurate clinical information being available to the interdisciplinary team.
Failure to Develop Comprehensive Care Plans for Urinary Incontinence
Penalty
Summary
The facility failed to develop and implement comprehensive care plans addressing urinary incontinence for two residents. For the first resident, who was admitted with diagnoses including hip fracture with surgical repair, weakness, difficulty walking, and a need for assistance with personal care, the admission MDS indicated that the resident was always incontinent of bowel and bladder. However, review of the comprehensive care plan showed that incontinence was not listed, and there were no goals or interventions documented to address this need. For the second resident, who was admitted with dementia, overactive bladder, and a need for assistance with personal care, the admission MDS and facility documentation indicated frequent bladder incontinence. Despite this, the comprehensive care plan did not include incontinence until the date of discharge. During an interview, the DNS confirmed that care plans for incontinence should have been in place as soon as the need was identified through assessments.
Failure to Monitor and Assess Pressure Injuries and Skin Impairments
Penalty
Summary
The facility failed to routinely monitor and assess the status of skin impairments for two residents who were at risk for pressure injuries. One resident was admitted with a hip fracture, weakness, and impaired mobility, and was identified as having a stage 1 pressure injury over the sacrum. Although the care plan noted the risk for pressure-related skin injury, there were no documented measurements of the injury, no treatment or monitoring orders, and no follow-up documentation to indicate whether the injury was monitored, worsened, or improved after admission. Another resident, admitted with dementia, generalized muscle weakness, and incontinence, was identified as having moisture-associated skin damage and a small open area in the gluteal cleft. Initial documentation included measurements of the wound, but subsequent records lacked ongoing measurements or descriptions of the wound's status. There was no further documentation after the initial assessment to show that the open area was monitored or that its condition was tracked over time. The Director of Nursing Services confirmed that monitoring orders and weekly assessments should have been in place for both residents.
Failure to Implement Timely Skin Impairment Treatment and Monitoring Orders
Penalty
Summary
The facility failed to implement treatment and monitoring orders for skin impairments for two residents upon admission. For one resident, who was admitted with a right lower leg laceration that had been sutured in the hospital, the facility did not initiate any treatment or monitoring orders for the wound until 11 days after admission, despite hospital discharge instructions to follow current wound care recommendations. The resident's initial assessment documented the presence of a significant laceration with 15 stitches, but this was not followed by timely care orders. Another resident was admitted with multiple medical diagnoses and was noted during the nursing admission evaluation to have a large bruise on the right upper shoulder and bruises on both arms. However, no treatment or monitoring orders for these bruises were implemented until 14 days after admission. The Director of Nursing Services confirmed that the expectation was for a full-body skin assessment upon admission and prompt communication with a medical provider for any skin impairments, which did not occur in these cases.
Failure to Timely Identify and Report Alleged Abuse
Penalty
Summary
A resident with hemiplegia, muscle weakness, and difficulty walking was admitted to the facility and required assistance with personal care. On the morning of 04/21/2025, the resident reported to a Speech Language Pathologist (SLP) that a staff member had refused to give them their bed remote control and pushed them on the shoulder the previous night, expressing that the staff member appeared angry. The SLP relayed the allegation to their supervisor and documented it on a grievance form, which was then placed in a grievance box near the social services office. The facility's incident report log showed that the allegation of abuse was not logged until 04/22/2025, and the State Agency was notified approximately 33 hours after the resident initially reported the incident. The Director of Nursing Services (DNS) stated they were unaware of the delay, and the Administrator acknowledged that the allegation should have been reported to the State Agency within 2 hours, rather than being handled solely through the grievance process. This delay in identifying and reporting the abuse allegation resulted in a failure to meet required reporting timeframes.
Deficiencies in Care Planning for Two Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, which led to deficiencies in their care. Resident 10, who was admitted with paraplegia, diabetes, and a pressure ulcer, did not have a care plan focus area for the pressure ulcer. Despite receiving treatment from facility staff and an outside wound provider, the care plan lacked specific interventions for the pressure ulcer. Interviews with facility staff, including a Licensed Practical Nurse/Unit Care Coordinator and the Director of Nursing Services, confirmed that the absence of a care plan focus area for the pressure ulcer did not meet the facility's expectations. Resident 80, admitted with hydrocephalus, dysphagia, and respiratory failure, also experienced a deficiency in care planning. The resident's care plan inaccurately reflected a diet intervention of nothing by mouth (NPO), despite having a provider's order for a regular diet with puree texture. The resident was observed with a feeding pump machine and reported receiving tube feeding at night. The Director of Nursing Services acknowledged that the care plan was not updated to reflect the current diet and NPO status, which did not meet the facility's expectations.
Deficiencies in Monitoring and Medication Administration
Penalty
Summary
The facility failed to adhere to professional standards of care for several residents, leading to deficiencies in monitoring and medication administration. Resident 1, diagnosed with Crohn's disease, autism, and dementia, did not receive orthostatic blood pressure monitoring as ordered, and their medication, midodrine, was administered outside the prescribed parameters multiple times over several months. Staff interviews confirmed that these actions did not meet the facility's expectations for following provider orders. Resident 75, who had a history of stroke, muscle weakness, and neurogenic bladder, was found to have a foley catheter of the incorrect size, contrary to the provider's orders. The resident's family had expressed concerns about the appearance of the resident's urine and reported abdominal pain, which was documented by a licensed nurse. However, the catheter was changed to a smaller size than ordered, and staff were unaware of this discrepancy until it was pointed out during an interview. Resident 72, with anxiety and psychotic disorders, did not have complete orthostatic blood pressure monitoring documented as required by their provider's orders. The MARs for several months showed incomplete or missing documentation of blood pressure readings in different positions. Similarly, Resident 6, who was on quetiapine, did not have the required AIMS test completed to monitor for adverse side effects, and there was no documentation of orthostatic blood pressures. Staff interviews confirmed that these monitoring processes were not conducted as expected.
Deficiencies in Grooming Services for Residents
Penalty
Summary
The facility failed to provide necessary grooming services for two residents, leading to deficiencies in personal hygiene. Resident 49, who was admitted with a right humerus fracture, diabetes, and depression, expressed a desire to shave but was not offered assistance by the facility. Observations showed that Resident 49 had facial hair about an inch long, indicating a lack of grooming. The care plan for Resident 49 required one staff assistance with personal hygiene but did not include specific instructions for shaving. Interviews with staff revealed confusion about responsibilities for shaving, with CNAs providing conflicting accounts of who should assist Resident 49. Resident 61, admitted with rheumatoid arthritis, respiratory failure, and heart failure, required substantial assistance with personal hygiene due to impairments in both upper and lower extremities. Observations showed Resident 61 had long, thick toenails and had requested to see a podiatrist, but their name was not on the referral list. Staff interviews confirmed that Resident 61's toenails should have been trimmed by a podiatrist, but this had not occurred, failing to meet the facility's expectations for care.
Deficiencies in Resident Care and Bowel Management
Penalty
Summary
The facility failed to ensure necessary interventions were in place for a resident with a history of a fractured humerus. Resident 75, who had multiple diagnoses including stroke and dementia, was observed without a sling or proper arm positioning despite a provider's order for a PRN sling for comfort when out of bed. The order was not transcribed into the medication administration record (MAR) until several days later, leading to a lack of proper care and positioning for the resident. Staff interviews revealed that the resident's daughter wanted the sling applied, but the resident frequently refused, resulting in a change to a PRN order that was not properly documented. Additionally, the facility failed to consistently monitor and document bowel movements and implement the bowel program for two residents. Resident 6 and Resident 49 both experienced multiple days without bowel movements, yet the prescribed constipation medication was not administered as per the provider's orders. Interviews with staff indicated that the system was supposed to flag when there were no documented bowel movements, but the protocol was not followed, leading to a lack of necessary interventions for these residents.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that fall mats were in place to minimize the risk of injury during a fall for one resident, identified as Resident 75, who was at high risk for falls. The resident had multiple diagnoses, including stroke, muscle weakness, cancer, dementia, anxiety, and depression, and was dependent on staff for assistance with activities of daily living. Despite the care plan indicating that the bed should be in the lowest position and floor mats should be placed at the side of the bed while the resident slept, these interventions were not observed during the survey. The resident had previously experienced falls on two occasions, and the fall scene investigation reports did not document the presence of fall mats. Interviews with facility staff revealed that the fall mats were not in place due to them being frayed and awaiting replacement. Staff members, including a Licensed Practical Nurse and a Certified Nurse Aide, acknowledged the absence of fall mats and the requirement for them as per the resident's care plan. The Director of Nursing Services confirmed that the mats had been removed earlier, and the Administrator stated that the expectation was for the interventions in the care plan to be implemented. This oversight placed the resident at risk for potential injury and negative outcomes.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide adequate pain management for a resident, identified as Resident 3, who was admitted with diagnoses including diabetes, paraplegia, and anxiety. Resident 3 reported that the pain medication provided by the facility staff sometimes did not control their pain effectively. When Resident 3 requested additional pain medication, they were informed by the staff that they could not receive more at that time. The review of Resident 3's medication administration records for January and February 2025 revealed that the resident was prescribed two over-the-counter (OTC) pain medications and one narcotic pain medication, all on an as-needed (PRN) basis. However, there were no parameters set for the nursing staff to determine which medication to administer based on the resident's pain level. Interviews with facility staff, including a Licensed Practical Nurse/Unit Care Coordinator and the Director of Nursing Services, confirmed that the PRN pain medications lacked specific parameters to guide nursing staff in medication administration. The Director of Nursing Services acknowledged that the absence of pain scale parameters for PRN medications did not meet the facility's expectations. This deficiency in pain management placed Resident 3 at risk of experiencing uncontrolled pain and a diminished quality of life.
Wheelchair Maintenance Deficiency
Penalty
Summary
The facility failed to maintain a safe and functional environment for residents, as evidenced by the condition of wheelchairs used by two residents. Resident 21's wheelchair had a left armrest with cracked and torn vinyl, exposing an uncleanable surface. Despite the resident's ability to communicate their needs, the issue was not addressed by the staff, and the problem was not logged in the maintenance binder from early January to late February. Staff interviews confirmed the armrest's condition and acknowledged that it should have been repaired or replaced. Similarly, Resident 72's wheelchair had a right armrest with cracked and torn vinyl and a left armrest that was unstable. The resident had informed staff about these issues, but they were not logged in the maintenance binder. Staff interviews corroborated the resident's account and identified the need for repairs. The facility's administrator confirmed that the process for logging equipment issues was not followed, and the condition of the wheelchairs did not meet the facility's expectations.
Survey Results Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that survey results were posted in a location easily accessible to all residents and did not provide notices regarding the availability of these survey reports in prominent areas. This deficiency was identified during a group interview with two cognitively alert residents who were unaware of the survey results' availability or location. Observations revealed that the binder labeled 'State Survey Results' was placed on a small corner table in the conference room on the 100-hall, while the facility had four hallways where residents resided. There were no notices about the binder's availability or location throughout the resident-occupied areas. Interviews with staff members, including an LPN, a receptionist, and the administrator, indicated a lack of consistent knowledge about the binder's location, with the administrator confirming its placement in the conference room but acknowledging the absence of additional signage informing residents or visitors of its location.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide written notification of the reason for transfer to the hospital to three residents, placing them at risk of not knowing their rights regarding transfer and discharge. Resident 21, who was admitted with heart failure, kidney failure, and diabetes, was transferred to the hospital twice without receiving written notice. Similarly, Resident 54, with heart failure, diabetes, and respiratory failure, was transferred once without written notification. Resident 72, with heart failure and diabetes, was also transferred twice without receiving written notice. In each case, the residents or their representatives were only informed verbally. During interviews, Staff C, an LPN/Unit Care Coordinator, confirmed that the residents or their representatives did not receive written notices for the hospital transfers. Staff A, the Administrator, stated that the expectation was for nurses to complete an interact transfer form and provide a written Nursing Home Transfer or Discharge Notice form to the resident and/or their responsible party. However, this procedure was not followed, as evidenced by the lack of documentation in the residents' electronic health records.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 729 citations issued within 25 miles in the last 12 months — including the 4 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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Puyallup
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rainier Rehabilitation | 0.5 mi | ★★★★★ | 0 | 0 |
| Puyallup Post Acute | 0.9 mi | ★★★★★ | 38 | 0 |
| Life Care Center Of South Hill | 1 mi | ★★★★★ | 18 | 1 |
| Linden Grove Health Care Center | 2 mi | ★★★★★ | 49 | 0 |
| Heartwood Extended Healthcare | 5.7 mi | ★★★★★ | 33 | 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 August 2026) and official state health department websites.