Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Life Care Center Of Skagit Valley during CMS and state inspections, most recent first.
Resident Council concerns were not properly acted on, documented, or resolved. Meeting minutes showed repeated complaints about late meal trays, shower frequency, tough meats, missing condiments, and food requests not being followed, but the grievance log had no entries for these issues and no grievance forms were completed. The Activity Director stated grievances were not done for Resident Council as a whole, and residents reported the concerns had not improved.
A facility failed to ensure several residents were free from unnecessary psychotropic meds. Records showed antipsychotics and other psychotropics were used without adequate documentation of indication, monitoring, GDRs, or timely consent. For some residents, MDSs showed no hallucinations, delusions, or behaviors to match the medication orders, while staff acknowledged missing behavior monitoring, incomplete psychotropic documentation, and diagnoses that did not support the meds.
A facility failed to provide bathing and grooming assistance for multiple dependent residents whose care plans and MDS assessments showed they needed substantial or extensive help with ADLs. Several residents were supposed to receive showers one or two times weekly, but records showed missed, blank, or inconsistent bathing documentation, and residents reported not getting showers, missing grooming care, or going long periods without bathing. Staff also acknowledged ongoing showering problems, staffing issues, and documentation gaps.
A resident with severe edema did not receive ordered ace wraps on multiple observed days, with the wraps found left in a chair while the resident wore tight socks and had marked lower-extremity swelling. Another resident with dementia and pain medication use went 5 1/2 days without a bowel movement, and the record showed no bowel assessment, bowel meds, refusal documentation, or provider notification despite the facility’s bowel protocol. A third resident with edema had inconsistent daily weight documentation, and staff interviews showed the omissions were not recognized.
Failure to Provide Ordered Restorative Nursing Programs: The facility did not consistently provide or document restorative nursing services for three residents with mobility and ROM limitations. One resident with falls, hemiplegia, arthritis, and limited ankle ROM had no RNP, no contracture management, and stated they were not receiving exercises. A second resident with spinal degeneration and bilateral knee replacements had ordered restorative programs, but services were inconsistent and there was no evidence of periodic RN/LPN evaluation. A third resident with weakness and bilateral LE impairment had restorative AROM interventions that were system-cancelled, with limited documentation and restorative aides frequently pulled to the floor.
A facility failed to protect a resident’s privacy during personal care when a privacy curtain was missing and the resident’s unclothed body was visible from the hallway. The facility also failed to determine preferences for another resident with severe cognitive impairment while window replacement work exposed the room to outside air, loud noise, and worker traffic; the POA was not notified and the resident could not read or understand the posted notice.
The facility failed to complete required NOTD and Ombudsman notifications for two residents who were emergently transferred to the hospital. EMR review showed no documentation of the transfer/discharge notice or Ombudsman notification, and staff interviews revealed confusion about who was responsible for the process for hospital transfers.
Failure to Provide Individualized Activities: A resident with severely impaired cognition had documented activity preferences including books, music, news, group activities, and going outside, but the care plan did not include any of those preferences. Observations showed the resident in the room without TV, music, books, magazines, or other stimulation, and the AD stated no music or other activity items had been provided and did not know why the resident's preferred activities were not implemented.
Two residents were not free from significant medication errors when ordered BP and pulse hold parameters were not followed. One resident with heart disease and HTN received antihypertensives and Tylenol despite low pulse, low SBP, and a daily acetaminophen limit, and the MAR lacked a place to document VS before evening Hydralazine doses. Another resident with cardiac diagnoses received Losartan on multiple occasions even though the pulse was below the ordered hold parameter. Staff stated they were unaware of the parameter issues and that MARs were not being audited.
Staff failed to follow infection control precautions for two residents and failed to disinfect reusable equipment as required. One resident with RSV was observed with staff entering the room without masks or face shields while another resident with a catheter and feeding tube was transferred by two CNAs without the gown and gloves required for EBP. A CNA also stated the mechanical lift was not disinfected after each use unless it had been used for someone with an infectious disease.
PASRR Not Obtained Before Admission: A resident with depression and Prader-Willi syndrome was admitted without a PASRR in place. The Level I PASRR indicated DDA involvement and adaptive functioning impairments, with instructions for DDA PASRR Team follow-up before admission. The record showed the PASRR and DDA Level 2 determination were not uploaded until after admission, and staff stated admissions was responsible for obtaining the PASRR before the resident entered the facility.
A resident with impaired mobility and multiple comorbidities was admitted with blanchable redness to the buttocks and was identified as at risk for PU development, but the care plan contained only minimal interventions such as weekly skin checks and incontinence care, without individualized measures for the existing redness or documented education on repositioning or support surfaces. Despite facility policies requiring pressure redistribution mattresses, wheelchair cushions, and regular repositioning for at‑risk residents, there were no orders for a pressure‑reducing mattress or wheelchair cushion even after an outside wound care provider diagnosed an unstageable sacral PU and recommended such support surfaces. Wound care orders for cleansing, Santyl application, and foam dressings every three days were not reliably implemented, as evidenced by a dressing observed eight days after its date with moderate drainage, conflicting TAR entries, and an RN who could not recall performing the documented dressing changes or explain the outdated dressing. CNAs reported inconsistent repositioning practices and no specific documentation of repositioning, and a family member learned of the PU only after the resident complained of sacral pain, while staff interviews showed limited awareness of the PU and lack of a system to document positioning, resulting in an avoidable unstageable PU that caused pain and discomfort.
The facility did not ensure that window locks and screens were properly maintained in multiple resident rooms. A family member reported that a resident’s room had a broken window lock and no screen, and that the facility used a screw and later a wooden dowel instead of repairing the locking mechanism, while still communicating that the window was secured. Surveyor observations confirmed one room with no screens, no functional lock on one window panel, and a dowel between windows; another room with intact locks and screens; and a third room with a missing lock knob on one window and a screen with a hole. The Maintenance Director acknowledged using a screw in place of a proper lock, confirmed the window could still be tilted to bypass it, and reported there were no documented maintenance requests, only verbal reports.
A resident with severe cognitive impairment and complex medical needs did not receive adequate social services or advocacy regarding advanced directives. Facility staff failed to document discussions about the resident's wishes, did not facilitate communication with the resident's contacts, and did not provide sufficient assistance in obtaining legal support for a POA, resulting in the resident's preferences not being properly addressed.
A resident's care plans were not updated to reflect their current urinary status and discharge goals, resulting in outdated interventions such as continued catheter care instructions after the catheter had been removed. Staff interviews and documentation confirmed the care plans did not accurately represent the resident's needs.
Two residents with wounds experienced significant gaps and inconsistencies in their clinical records, including missing or delayed weekly skin assessments and incomplete wound documentation. Staff interviews confirmed that required documentation was not consistently completed, leading to records that did not accurately reflect the residents' conditions or care provided.
Multiple areas, including shared bathrooms, a community shower room, and the main dining room, were found to be unclean, poorly maintained, and lacking a homelike atmosphere. Bathrooms had strong odors, broken and stained tiles, and poor lighting, while the shower room had missing tiles, an uneven floor, and was dirty and disorganized. The dining room lacked decor, music, and staff engagement, leaving residents sitting alone and unassisted during meals. Staff and residents confirmed these conditions, which did not meet the facility's policy for a clean and homelike environment.
Several residents who required staff assistance for ADLs, including showering, were observed with poor hygiene such as greasy hair, and records showed they did not consistently receive showers as scheduled. Staff interviews revealed that aides responsible for showers were often reassigned to other duties, leading to missed care, and that lack of documentation indicated showers were not provided. Residents had varying cognitive and physical needs, but all were dependent on staff for hygiene support.
Multiple residents reported dissatisfaction with meal quality, taste, and temperature, citing issues such as tough meats, lack of variety, and cold or unappetizing food. Observations confirmed that meals were served below recommended temperatures and were not visually appealing. Grievances about food quality and temperature were not fully addressed, and staff confirmed limitations in reheating and food preparation due to equipment and menu constraints.
Several residents with intact cognition and specific dietary needs were denied the ability to have outside food items, such as frozen meals and microwave popcorn, heated by staff after the facility changed its policy. The administration cited concerns about food safety, staff workload, and storage limitations, resulting in residents losing the ability to choose and enjoy their preferred meals and snacks. Staff confirmed the directive to stop heating food, and residents and families expressed dissatisfaction with the loss of choice.
The facility did not follow its policy for handling and storing food brought in by family and visitors, as staff were instructed not to heat up food items for residents and only limited storage was provided. The Administrator and DON confirmed these restrictions, which were not consistent with the facility's written procedures for safe food handling.
A resident with severe cognitive impairment was found with a bruise and abrasion on the forehead, but the facility's investigation was limited to a single LPN statement, basic notifications, and a skin check. No neurological assessment or witness interviews were conducted, and the DON acknowledged the investigation was incomplete.
A resident was discharged without the required MDS discharge assessment being completed or transmitted to CMS within the mandated timeframe. The omission was identified after the CMS system flagged the absence of any assessment for over 120 days, and the MDS Coordinator acknowledged the assessment was missed despite daily audit procedures.
A resident with hemiplegia and hemiparesis did not consistently receive prescribed splint and brace interventions to maintain range of motion, as staff only applied splints during restorative therapy sessions and not daily as ordered. Staff interviews revealed confusion about responsibility for splint application when restorative aides were unavailable, and documentation showed minimal evidence of splint use or monitoring.
A resident with malnutrition and dysphagia, who had documented allergies and food dislikes, was served meals containing gluten, mayonnaise, and tomato products despite these being listed as allergies or dislikes. Staff interviews confirmed that limited gluten-free options and lack of alternatives led to the resident receiving inappropriate food items, contrary to facility policy.
Surveyors observed that expired food items were not removed from a nourishment refrigerator, and a cook failed to follow proper hand hygiene and glove use during meal preparation, including handling clean plates and food with bare hands. These lapses in food safety and sanitation were acknowledged by staff and management.
Staff did not follow infection control protocols for three residents requiring different levels of precautions. One resident with a Foley catheter did not receive proper Enhanced Barrier Precautions, as a nursing assistant failed to wear a gown during catheter care. Another resident receiving pericare was assisted by a nursing assistant who did not change gloves between tasks, leading to potential cross-contamination. Additionally, a resident under investigation for C. Diff was not placed on the correct Contact Enteric precautions due to incorrect signage, resulting in staff not using the required PPE or hand hygiene methods.
The facility administration failed to manage resources effectively, leading to deficiencies in care planning, resident environment, and staffing. A resident with chronic pain experienced severe discomfort due to delayed medication administration. Staff interviews revealed issues with medication pass timing and lack of a restorative program. Additionally, the facility struggled with infection control and tuberculosis testing.
The facility did not initiate a grievance process for concerns raised by the Resident Council about call light wait times. Despite residents voicing these issues, the facility failed to log or investigate the grievances, preventing trend identification and resolution. Staff directed residents to submit forms but did not assist, and the administrator noted challenges in addressing grievances without resident participation.
The facility failed to develop comprehensive care plans for several residents, including those with amputations, smoking cessation needs, and nephrostomy care. Observations showed residents without access to call lights and unaddressed pain issues. Staff interviews revealed a lack of awareness and time constraints affecting care plan completion.
The facility failed to update care plans for several residents, leading to discrepancies in care. A resident's care plan was not updated after transitioning to restorative services, another's did not reflect hospice care, and a third's did not address smoking risks. Additionally, a resident was observed using a straw despite care plan restrictions, with staff unaware of this precaution.
The facility failed to provide adequate assistance with ADLs for several residents, particularly in bathing and toileting. A resident with a fracture and chronic conditions was not assisted with toileting due to equipment limitations. Other residents, dependent on staff for bathing, did not receive showers as per their preferences due to staffing issues. Documentation and staff interviews revealed systemic issues in scheduling and providing showers, with the DON and Administrator unaware of the missed care.
The facility experienced significant staffing shortages, resulting in delayed assistance with activities of daily living and medication administration. Residents reported long wait times for help, particularly during nights and weekends. A resident with chronic pain did not receive timely pain medication, and another resident missed scheduled showers due to staff being reassigned to cover floor duties.
The facility failed to administer scheduled medications on time for several residents, resulting in significant delays. A resident with chronic pain reported severe pain due to not receiving their morning medications, while others received essential medications, such as antipsychotic and anticoagulant drugs, hours after the scheduled time. Staff interviews indicated that the medication pass took longer than expected.
The facility failed to maintain sanitary conditions in the kitchen, as staff were observed not wearing required hair and beard restraints. This non-compliance with the facility's policy placed residents at risk of food contamination.
The facility failed to ensure proper infection control practices, as observed with a NAC not performing hand hygiene during meal service and another NAC not changing gloves or washing hands after peri-care. Additionally, incorrect transmission-based precautions were in place for a resident with c. diff, with signage instructing the use of ABHR instead of soap and water. These lapses in protocol were not recognized by the Infection Preventionist or DON.
A facility failed to obtain and maintain Advance Directives for a resident with multiple health conditions, despite the care plan indicating a Power of Attorney (POA) for healthcare. The electronic medical record lacked POA documentation, confirmed by staff interviews. The Admissions Director did not obtain the POA documents at admission, and the Medical Records Director confirmed the absence of the document. An RN-Staff Development Coordinator also could not locate the document, although the resident's daughter had signed the POLST as the POA.
The facility failed to provide a homelike environment and maintain cleanliness for three residents and the conference room. A resident with severe cognitive impairment had a stark room lacking personal decor, while another resident reported unclean windows that had not been addressed despite requests. A third resident's window and TV screen were observed to be dusty and streaked. The conference room also had dirty windows and screens, indicating a broader issue with maintaining a clean environment.
A facility failed to conduct a Significant Change in Status Assessment (SCSA) for a resident who elected Hospice services, as required by the Resident Assessment Instrument (RAI) guidelines. The resident elected Hospice on a specific date, but no SCSA was completed within the required 14-day period. An LPN/MDS Nurse was unaware that the election of Hospice services alone required a SCSA.
A resident was discharged without a complete discharge summary, missing essential components such as a recapitulation of their stay and a final status summary. The facility's policy requires both social services and nursing staff to contribute to the discharge summary, but interviews revealed that the summary was incomplete, and staff were unclear about the resident's post-discharge needs.
The facility failed to provide adequate care for three residents with limited ROM and mobility issues. A resident with rheumatoid arthritis wore a sling without an order, and no follow-up on ROM assessment was conducted. Another resident, at risk for skin breakdown, was left in a wheelchair for hours without repositioning. A third resident with contractures did not consistently receive prescribed brace and splint applications, with documentation gaps and confusion over program oversight.
A resident with malnutrition and bipolar disorder experienced significant weight loss due to the facility's failure to implement nutritional interventions and monitor weight changes. Despite the care plan identifying a risk for weight loss, the facility did not consistently obtain weights or notify appropriate parties. Staff interviews revealed a lack of awareness and communication regarding the resident's weight loss and refusal to be weighed.
A resident with a PEG tube experienced a deficiency in enteral tube feeding management due to the facility's failure to label, date, and replace feeding supplies as required. Observations showed that feeding bags and syringes were not properly managed, and interviews with staff revealed a lack of physician orders and care plan directives for these tasks. This oversight placed the resident at risk for infection and complications.
The facility failed to provide appropriate respiratory care for two residents. One resident with COPD and other conditions was not using prescribed oxygen therapy and CPAP, as observed multiple times, with the concentrator set to zero liters. Another resident used oxygen without a documented physician's order, despite stating its use for sleep apnea. Staff interviews confirmed these deficiencies, highlighting a failure to adhere to professional standards of practice.
A resident with chronic pain syndrome did not receive their scheduled morning pain medications, including Gabapentin, Acetaminophen, and Suboxone, due to delays in the medication pass. The resident reported severe pain levels, and staff confirmed the delay in administering medications, leading to avoidable pain and diminished quality of life.
A resident with Parkinson's disease and moderate cognitive impairment was not provided with care planning meetings to address their care preferences, including bathing frequency and wheelchair comfort. The facility failed to conduct required quarterly care conferences, and staff were unaware of the resident's concerns due to the lack of meetings and documentation.
A facility failed to implement its Antibiotic Stewardship Program effectively, leading to continuous antibiotic administration for a resident without proper documentation or communication with the infectious disease provider. The resident, with a history of kidney stones and antibiotic-resistant infection, received antibiotics without a documented stop date. Staff interviews revealed a lack of awareness and follow-up, indicating a failure in the facility's ASP.
A resident with a history of recurrent UTIs was not adequately monitored or assessed, leading to a lack of a care plan addressing their condition. Despite showing symptoms of a UTI, such as dark amber urine and confusion, vital signs were not consistently documented, and the resident's representative or provider was not notified. The resident's condition escalated to a UTI with sepsis, resulting in hospitalization.
The facility failed to provide timely pharmaceutical services for three residents upon admission, resulting in missed medications. A resident with Bipolar Disorder and Seizure Disorder did not receive prescribed medications due to a lack of verification and notification processes. Another resident with a recent fall and cardiac issues did not receive several medications, including pain ointment, due to pending delivery. A third resident with encephalopathy and psoriasis also missed medications that were on order. There was no documentation of provider notification for any of these cases.
The facility failed to ensure proper nail care for three residents, leading to discomfort and potential injury. One resident with contractures experienced significant pain due to long nails digging into their palms, while two other residents had long, dirty, and jagged nails despite expressing a preference for having them cut. Staff interviews revealed inconsistencies in understanding and executing nail care responsibilities.
Resident Council Grievances Not Acted On or Logged
Penalty
Summary
The facility failed to act, respond, and resolve concerns raised by the organized Resident Council group for 1 of 1 resident council groups. Review of the facility’s grievance policy showed the facility was responsible for ensuring grievances were reviewed and addressed in a timely and appropriate manner, with resolution communicated and maintained, and for keeping records of complaints. However, review of Resident Council meeting minutes from January 2026 through April 2026 documented repeated concerns about meal trays arriving late, shower frequency, meat being hard to cut, not receiving condiments with meals, food requests not being followed, and wanting more fresh fruit options. The minutes also documented that residents were reminded to complete blue card grievance forms when experiencing issues. Review of the grievance log from January 2026 through April 2026 showed no entries for the Resident Council concerns, and no grievance forms were completed for those issues as required by the facility’s grievance policy. In interview, the Resident Council group stated the shower concerns had not improved and the food concerns with late meal trays, tough meats, and missing condiments had also not improved. Staff W, Activity Director, stated they did not do grievances for Resident Council as a whole, sometimes completed grievance cards for individuals, and sometimes residents said they would do it themselves; Staff W also stated the concerns were brought to the following month’s QAPI meeting. The Administrator stated the Activity Director had been educated on the grievance process for Resident Council, and later stated resident council grievances had been started with the most recent month and would go back as needed, but an updated grievance log was not provided.
Unnecessary psychotropic medication use and inadequate monitoring
Penalty
Summary
The facility failed to ensure that 5 of 5 sampled residents were free from unnecessary psychotropic medications. The report states the facility did not comprehensively assess the risks, benefits, and parameters of use, did not ensure least restrictive alternatives were attempted, did not obtain consent prior to administration in all cases, and did not ensure appropriate indication and monitoring of psychotropic medications. The deficiency involved antipsychotic and other psychotropic medications used for residents with diagnoses including dementia, depression, agitation, and psychotic symptoms. Resident 20 had diagnoses including Alzheimer’s disease, dementia with agitation, and major depressive disorder. The record showed quetiapine orders for terminal agitation and Depakote Sprinkles for major depressive disorder, while MDS assessments documented no hallucinations, delusions, or physical or behavioral symptoms. Pharmacy recommendations later advised changing the diagnosis for quetiapine and Depakote from dementia with behaviors to agitation associated with dementia due to Alzheimer’s disease, and staff stated the diagnosis change was completed but not attached to the medications. Staff also stated the resident had been doing better and did not have many behaviors anymore. Resident 13 had diagnoses including major depressive disorder with psychotic symptoms and adjustment disorder with depressed mood. The resident received bupropion and aripiprazole, but the quarterly MDS showed no hallucinations or delusions, and progress notes from the prior year showed no documentation of psychosis. The record did not contain psychoactive medication evaluations or documentation of GDR meetings, and there were no pharmacist recommendations in the past six months. Resident 44 was receiving quetiapine for dementia without behavioral disturbance, mood disturbance, and anxiety, yet the record showed no adequate monitoring for delusions and no documentation of psychoactive medication evaluations or GDR meetings. The resident had a history of delusions, had failed a prior GDR, and staff acknowledged the lack of delusion monitoring and documentation. Resident 11 had an antipsychotic order with an indication of hallucinations related to major depressive disorder, but the behavior monitoring tracked negative statements and self-isolation instead of hallucinations. Staff stated they did not believe the resident had ever exhibited hallucinations and that the medication appeared to have been ordered on admission. Resident 59 had quetiapine ordered for agitation and dementia, but the admission MDS documented severe cognitive impairment with no behaviors. The medication consent was dated after the medication had already started, the behavior monitoring was not in place until several days later, and no behaviors were documented until later still. Staff stated the consent was not in the medical record timely, the diagnosis was not an appropriate indication for the antipsychotic, and the care plan did not support the reason for administering the medication.
Failure to Provide Scheduled Bathing and Grooming Assistance
Penalty
Summary
The facility failed to provide assistance with bathing and grooming for 6 of 7 residents reviewed who were dependent on staff for ADLs. The deficiency involved Residents 8, 13, 15, 44, 63, and 79, all of whom had care plans or Kardex instructions indicating they required substantial or extensive assistance with bathing, and several of whom preferred showers one or two times per week. The report states that the failure to provide bathing and grooming assistance placed the residents and others at risk for poor hygiene, unmet care needs, and a diminished quality of life. Resident 8 had diagnoses including stroke with impaired speech, writing, and comprehension, along with hemiplegia and hemiparesis affecting the right side. The resident’s MDS documented substantial/maximal assistance for showering, and the care plan stated a preference for showers twice weekly with substantial assistance from one staff member. Bathing records showed the resident was scheduled only once weekly despite the stated preference, with several dates showing blank documentation or activity not occurring. A collateral contact stated the resident used to shower every day at home and would like more showers, and the resident nodded yes when asked about wanting showers twice a week. Resident 79 had diagnoses including heart failure, muscle weakness, and limitation of activities due to disability, and the MDS documented substantial/maximal assistance with showering. The care plan stated a preference for showers twice weekly and substantial assistance for bathing. Bathing documentation showed multiple missed or blank entries and only limited showers recorded. Resident 13 had diagnoses including stroke with hemiplegia and hemiparesis, muscle contractures, and difficulty walking; the MDS showed extensive assistance for bathing and no refusal of care, while the Kardex stated a preference for showers twice weekly. The resident stated they were only getting one shower a week, wanted two a week, and needed a shave, and denied refusing showers. Staff later acknowledged the resident wanted two showers weekly and that there was no documentation about bed baths. Resident 15 had diagnoses including hemiplegia and hemiparesis, respiratory disease, difficulty walking, and muscle weakness. The MDS showed extensive assistance for bathing and refusals in the lookback period. The resident reported missed showers and missing lotions and turning, and on observation had greasy hair and body odor while stating they had not yet had a bath. Resident 44 had dementia, muscle weakness, and difficulty walking, with severe cognitive impairment and extensive assistance for bathing on the MDS; the Kardex stated a preference for showers twice weekly, and bathing records showed repeated refusals and intermittent bathing. Resident 63 had upper spinal degeneration, bilateral artificial knee joints, muscle weakness, and disability-related limitations; the MDS showed extensive assistance for bathing and no refusals, but the resident reported sometimes going two weeks without a shower and said shower staff left before they were ready. Staff interviews described showering as an ongoing issue, with shower aides being pulled to the floor, residents not always receiving showers when scheduled, and documentation showing that if no shower was charted then staff believed it did not occur.
Failure to Follow Edema, Weight, and Bowel Protocol Orders
Penalty
Summary
The facility failed to provide treatment and care according to physician orders and its own protocols for three residents. One resident with edema and Prader-Willi syndrome had an order for ace wraps to both lower extremities daily in the morning and removed at night, but the wraps were not applied on multiple observed days. During repeated observations, the resident’s lower extremities were severely edematous, the non-skid socks appeared tight, and the ace wraps were seen left in a chair rather than on the resident. The resident’s care plan identified lower extremity edema, but it did not include individualized goals or interventions addressing the edema. For another resident with dementia, cognitive communication deficit, pain medication use, and frequent bowel incontinence, the bowel monitoring record showed no bowel movement for 5 1/2 days. During that time, there was no bowel medication administered, no documentation that the resident was assessed for constipation, no documentation of refusal, and no notification to the provider. The resident had orders for oxycodone as needed for pain and standing bowel medications including milk of magnesia, bisacodyl, and a fleet enema if constipation persisted, but the record did not show the facility implemented the bowel protocol during the period without a bowel movement. A third resident with aortic valve stenosis, hypertension, and edema had an order for daily weights due to increasing edema. The MAR/TAR showed weights were documented on some days but not consistently across the reviewed period, and the progress notes did not show documentation of refusals or provider notification related to missed weights. Staff interviews indicated the assigned nurse and RCM were unaware of the omissions, and the DON stated periodic MAR/TAR audits were performed. The report cited the facility for failing to ensure treatment and care were provided in accordance with professional standards of practice for edema management, daily weights, and bowel protocol implementation.
Failure to Provide Ordered Restorative Nursing Programs
Penalty
Summary
The facility failed to provide necessary care and services related to restorative nursing programs for three residents reviewed for positioning, mobility, and range of motion. The deficiency was identified under WAC 388-97-1060(3)(d) and involved residents with documented mobility limitations, weakness, and reduced range of motion who either did not receive restorative nursing services as ordered or did not have the required program oversight and documentation in place. Resident 15 was re-admitted with diagnoses including repeated falls, hemiplegia and hemiparesis, degenerative joint disease, arthritis, difficulty walking, muscle weakness, and limitation of activities due to disability. Therapy records showed a hip contracture and ongoing significant assistance needs with self-care. The quarterly MDS showed limited ROM in both lower extremities and no restorative nursing program. During interviews and observations, the resident stated they did not get exercises or ROM and were not on an RNP, and demonstrated limited ROM in both ankles with inability to dorsiflex. The clinical record showed no contracture management, no orthotic device, and no RNP. Staff C stated the resident did not have an RNP but that did not mean they did not need one. Resident 63 had diagnoses including upper spinal degeneration, bilateral artificial knee joints, muscle weakness, and limitation of activities due to disability. OT discharge documentation showed an RNP had been established and that the resident’s prognosis to maintain current function was excellent with consistent staff support. The resident stated they only got restorative once or twice a week because that was all the time the restorative aide had for them, and that the aide was also busy helping on the floor. The record showed two restorative programs ordered, but documentation reflected inconsistent completion across February through May. There was no evidence in the clinical record of periodic evaluation of the RNP by a licensed nurse during the review period. Resident 79 had diagnoses including muscle weakness, difficulty walking, bilateral knee joint replacement, and limitation of activities due to disability. The MDS documented impairment on both sides of the lower extremities. The care plan included restorative AROM programs for the lower and upper extremities, but both interventions were system-cancelled. Restorative documentation showed only limited completion in March and April, with the resident also documented as out of the facility on several occasions. The facility schedule showed restorative aides were pulled from restorative duties to work the floor multiple times, and on two days no restorative aide was scheduled. Staff stated one restorative aide was on leave, the other was pulled to the floor due to call-ins, and restorative duties could not be picked up by other aides because they lacked restorative training.
Failure to Protect Resident Privacy and Honor Resident Choice During Care and Room Work
Penalty
Summary
The facility failed to maintain residents’ rights to privacy and choices for 2 residents reviewed for dignity. One resident had severe cognitive impairment and was on hospice with anticipated decline in condition. The resident’s room had space for three beds, but the privacy curtain for the resident’s bed was missing, with only metal chains hanging from the ceiling track where the curtain should have been attached. During personal care, a CNA was observed providing care while the resident’s unclothed body was visible from the hallway. Staff stated the door was kept closed and that the privacy curtain should have been pulled, but the curtain remained missing during later observation. Housekeeping stated they had not been aware the curtain was missing, and the resident care manager stated the missing curtain should have been identified during rounds and that CNAs should be pulling privacy curtains during care. A second resident had severe cognitive impairment and was totally dependent on staff for ADLs including transfers and mobility. While window installers were replacing the resident’s window, a large plastic sheet was removed, exposing the window opening to the outside, and workers were observed speaking loudly, laughing, playing music, and stepping into the room through the opening. The resident remained in bed near the open window with wind coming into the room and frequent loud banging from nail guns nearby. A paper notice in the room stated the resident could remain in the room or go to another area during the work, but the resident’s POA stated they had not been notified and that the resident would not have been able to read or comprehend the notice. The POA also stated the resident had recently moved to the room and was easily irritated by noise and commotion.
Missing Ombudsman and Transfer/Discharge Notifications After Hospital Transfers
Penalty
Summary
The facility failed to ensure notification to the Office of the State Long-Term Care Ombudsman and failed to provide written notice to the resident or resident representative, in a language and manner they understood, for 2 of 4 sampled residents reviewed for hospitalization. Resident 9 was initially admitted to the facility, then transferred emergently to the hospital and later returned to the facility. Review of Resident 9’s progress notes documented the emergent hospital transfer, but the electronic medical record contained no notice of transfer and discharge form or Ombudsman notification related to the hospital discharge. Resident 12 was also initially admitted to the facility, then transferred emergently to the hospital and had not returned to the facility at the time of review. Review of Resident 12’s progress notes documented the emergent transfer, but the electronic medical record contained no notice of transfer and discharge form or Ombudsman notification related to the hospital discharge. Staff interviews showed confusion about who was responsible for completing the notice and Ombudsman notification for hospital transfers, with the LPN, Social Services Assistant, DON, and RCM/ADON staff giving differing responses about the process.
Failure to Provide Individualized Activities
Penalty
Summary
Provide activities to meet all resident's needs. The facility failed to ensure that 1 of 1 resident reviewed for activities received an ongoing program of activities to meet the resident's physical and mental needs. Resident 1 was admitted to the facility and, according to the quarterly MDS dated 04/02/2026, had activity preferences documented as very important, including books, newspapers, magazines, music, news, doing things with groups of people, and going outside. The MDS also assessed the resident with severely impaired cognition. Record review of the activities care plan on 05/13/2026 showed that none of Resident 1's preferred activities were included. During observations on 05/11/2026, 05/12/2026, 05/13/2026, and 05/14/2026, Resident 1 was observed in their room with no TV, no music available, no books or magazines, and no forms of stimulation observed to be provided in the room. CC2 stated on 05/14/2026 that Resident 1 had a TV but it was never turned on when they visited, and that they visited about once a week. Staff W, the Activity Director, stated they conducted the activities interview for the MDS, tried to communicate with family for residents who were not interviewable, and provided one-to-one visits for residents unable to attend groups, but also stated they had not provided any music or other activity items to Resident 1 and did not know why none of the resident's stated preferred activities had been implemented.
Medication Orders Not Followed for Blood Pressure Parameters
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors when physician order parameters were not followed for two residents. Resident 13 had diagnoses including heart disease and high blood pressure and was ordered Amlodipine 5 mg and Lisinopril 10 mg daily, with Lisinopril to be held if SBP was less than 110 or heart rate was less than 60. The resident also had an order for Hydralazine 25 mg daily to be held if SBP was less than 140 or pulse was less than 60. Review of the MAR showed Amlodipine and Lisinopril were not held on occasions when the pulse was 57 and 52, Lisinopril was given when SBP was below 110, Hydralazine was held when BP was 142/60 and pulse was 60, and Hydralazine was administered when SBP was below 140. The March and April 2026 MARs also did not have a location to document vital signs before evening doses of Hydralazine. Resident 13 also received Tylenol 650 mg on two occasions after already receiving 3,000 mg in a day, despite a not-to-exceed daily order of 3,000 mg. Resident 44 had multiple cardiac diagnoses including high blood pressure and was ordered Losartan Potassium twice daily, to be held for SBP less than 100 or pulse less than 50. Review of the MAR showed Losartan was not held on multiple occasions when the pulse was below 50, including readings of 49, 48, 49, 49, 45, 49, and 45. In interviews, the ADON and LPN/RCM stated they were unaware of parameter issues and that MARs were not audited. An RN stated medications should be held per orders when BP or pulse was low, and the DON stated periodic MAR audits were done and nurses needed re-education on parameters.
Infection Control Failures With PPE Use and Equipment Disinfection
Penalty
Summary
The facility failed to ensure staff followed infection prevention and control guidance for residents on transmission-based precautions and enhanced barrier precautions, and failed to ensure reusable resident equipment was disinfected as required. Review of CDC guidance and facility policies showed that droplet precautions were required for a resident with RSV, enhanced barrier precautions were required for residents with certain devices during high-contact care, and non-critical reusable equipment was to be cleaned daily and before and after every use. During observation of one resident room, staff were seen entering and working in the room with gowns and gloves, but no masks or face shields, even though the resident had returned to the facility with RSV and the room had a contact isolation sign posted before it was later changed to droplet precautions. Multiple staff responded to the resident’s call light over a period of time while the resident remained in the room, and the staff present were observed without the PPE required for droplet precautions. In another room, two CNAs entered to transfer a resident with a catheter and feeding tube using a mechanical lift while wearing no PPE, despite an enhanced barrier precautions sign outside the door indicating gown and glove use for high-risk care activities including transferring. One CNA stated they would have worn gown and gloves only if providing peri care, then acknowledged they should have been wearing them for the transfer. The same CNA stated they had been told the mechanical lift only needed disinfection if used for someone with an infectious disease, rather than after each use. The IP later stated the resident had been on EBP because of the catheter and feeding tube, that staff had not been following the EBP guidance, and that the facility expectation was for reusable equipment such as mechanical lifts to be disinfected after every use.
PASRR Not Obtained Before Admission
Penalty
Summary
The facility failed to ensure that the Pre-admission Screening and Resident Review (PASRR) was completed and obtained before admission for one resident with diagnoses including depression and Prader-Willi syndrome. The resident’s Level I PASRR, dated 04/14/2026, indicated mood disorder as a mental illness indicator and showed that the resident had received services from the Developmental Disability Administration (DDA), had impairments in adaptive functioning expected to continue indefinitely, and answered yes to Section B questions 6-9. The form instructions stated that when those questions are all marked yes, the PASRR must be forwarded to the regional DDA Intellectual Disability/Related Condition PASRR Team for follow-up before the individual can be admitted to a nursing facility. The resident was admitted to the facility without a PASRR in the record at the time of admission. The Level I PASRR was not uploaded into the resident’s medical record until 04/16/2026, and the DDA PASRR Level 2 Determination was also dated 04/16/2026. A progress note documented that the resident had admitted without a PASRR, that the facility requested it from the hospital without response, and that the social services director emailed the DDA PASRR coordinators for assistance obtaining it. The social services director and administrator both stated that admissions was responsible for ensuring the PASRR was received prior to admission, and the administrator stated the DDA PASRR coordinator told them residents should not be admitted if the PASRR is not received prior to admission.
Failure to Prevent and Properly Treat an Avoidable Unstageable Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to implement adequate pressure ulcer (PU) prevention measures and to provide ordered wound treatment for a resident at risk for skin breakdown. The resident was admitted with diagnoses including history of falls, muscle weakness, osteoarthritis, and scoliosis, and the hospital discharge summary documented impaired mobility and recent falls but no skin issues. On admission, the facility’s nursing assessment noted blanchable redness to the buttocks, and the admission MDS and CAA identified the resident as at risk for PU development due to limited ability to participate in incontinence care and physical dependence on staff for position changes and offloading. The care plan documented risk for skin integrity breakdown with a goal to maintain intact skin, but interventions were limited to keeping skin clean and dry after incontinence and weekly skin checks, with no individualized interventions addressing the existing buttock redness or the resident’s identified PU risk. Over the ensuing months, Braden Scale scores consistently indicated mild risk for PU development, yet the record from admission through early January contained no documentation of education to the resident or representative regarding repositioning, mattress type, wheelchair cushion use, or other PU prevention measures. Facility policy required, at minimum, a pressure redistribution mattress, wheelchair cushion, and repositioning for residents at risk, but the resident’s medical record from mid-January through mid-February showed no physician orders for a pressure-reducing mattress or wheelchair cushion, despite an outside wound care company’s recommendation for these support surfaces. When the resident’s sacral PU was later assessed by the outside wound company, it was documented as an unstageable PU on the bilateral sacrum, and the plan included specific wound care with Santyl and foam dressings, as well as pressure-reducing support surfaces. The facility’s implementation of ordered wound care was also deficient. A weekly skin integrity assessment on a January date documented a small opening at the top of the gluteal fold, and a provider note the same day described a small, deep, painful open area with surrounding blanchable redness. Subsequent wound care orders directed cleansing with normal saline, application of skin prep and Santyl, and coverage with foam dressing every evening shift every three days. However, when surveyors observed the resident in late February, the resident was on a standard, approximately three‑inch mattress, wearing an incontinent brief, and the sacral PU dressing was wrinkled, clumped, and dated eight days earlier, with moderate red/green/brown drainage. Although the TAR showed that an RN had documented completing dressing changes on two dates after the dressing date, the RN later stated they could not remember performing the dressing changes, reported difficulty finding supplies, and could not explain why the dressing remained dated from the earlier date. Nursing staff interviews revealed inconsistent knowledge of the PU, lack of specific documentation for repositioning, and no charting system to record monitoring of the resident’s positioning, while the ADON could not provide details on the type of mattress or wheelchair cushion used prior to PU development and stated the resident’s PU was considered unavoidable. The report states that this failure resulted in the resident developing an avoidable unstageable PU that caused pain and discomfort and placed residents at risk for skin breakdown, unmet care needs, and diminished quality of life. Additional observations and interviews further illustrated the gaps in PU prevention and care. During the wound observation, the sacral PU measured 1.0 cm by 1.5 cm with 0.3 cm depth, with light pink wound bed and visible slough, and no odor or signs of infection. A bruise was also noted on the resident’s thigh. A CNA familiar with the resident’s care reported assisting with toileting and pericare, stated they had no knowledge of any PU, and indicated they did not reposition the resident when sleeping but did assist with repositioning when the resident was awake. Another CNA stated they repositioned the resident with pillows and that the resident did not refuse repositioning, but confirmed there was no specific charting for repositioning. A family member reported learning of the sacral PU only after hearing the resident complain of sacral pain while being assisted in the bathroom, and staff then attributed the pain to the PU. Overall, the documented and observed inactions included lack of individualized preventive interventions despite identified risk, absence of ordered pressure‑reducing support surfaces, failure to consistently perform and/or document ordered dressing changes, and lack of systematic documentation of repositioning and monitoring, culminating in the development and inadequate treatment of an avoidable unstageable PU. The report explicitly states that the facility failed to implement measures to prevent development of an avoidable PU and failed to provide ordered treatment for the PU for this resident. It further states that the resident experienced harm when they developed an avoidable unstageable PU that caused pain and discomfort, and that this failure placed residents at risk for skin breakdown, unmet care needs, and diminished quality of life. The findings are referenced to WAC 388‑97‑1060(3)(b).
Failure to Maintain Functional Window Locks and Screens in Resident Rooms
Penalty
Summary
The facility failed to maintain safe, functional, and comfortable resident rooms by not repairing broken window locking devices and not ensuring the presence and integrity of window screens in 2 of 3 rooms reviewed. A family member of a resident reported that upon the resident’s move-in, the left window panel in the resident’s room had a broken locking mechanism and no window screen, leaving the window unsecured. The family member stated that instead of replacing the locking mechanism, the facility initially placed a screw in the window frame to limit how far the window could open, but the window could still be tilted to bypass the screw. The family member further reported that the facility later placed a wooden dowel between the sliding windows and had communicated via email that the window lock was secured, despite the ongoing concerns. During observations of three rooms, one room was found to have a screw in the left window frame, no window screens, no locking mechanism on the left side, and a wooden dowel between the windows. Another room had window screens and functional locking mechanisms on both sides. A third room had an intact and functional locking mechanism on the left window, but the right window’s locking mechanism was missing the knob used to operate it, leaving the window in a locked position; the screens were present, but one had a hole in the bottom left corner. The Maintenance Director reported learning of the missing locking mechanism only a few weeks prior and confirmed placing a screw in the frame where the lock would engage, acknowledging that the window could still be tilted to bypass the screw. The Maintenance Director also stated there were no written maintenance requests or documentation for these issues, only verbal communications with nursing staff and the Administrator.
Failure to Provide Social Services and Advocacy for Advanced Directives
Penalty
Summary
The facility failed to provide medically related social services and to advocate for a cognitively impaired resident regarding the development and documentation of advanced directives. The facility's policy required review and updating of advanced directives upon admission, quarterly, and with any change in condition, with the social services director or designee responsible for documenting conversations and assisting with revisions. Despite these requirements, there was a lack of documented conversations with the resident or their collateral contacts about advanced directives, wishes, or rights, and insufficient assistance was provided in obtaining appropriate legal support for the development of a power of attorney (POA). The resident in question had a history of developmental and intellectual disability, anxiety, depression, and significant urinary tract issues, with cognitive assessments indicating severe impairment at multiple points. The resident's mental status fluctuated, and during periods of decline, they became non-communicative and unable to make informed decisions. Despite these challenges, there was minimal documented engagement by social services with the resident or their contacts regarding the resident's wishes for care, advanced directives, or the POA process. Attempts by a family friend to coordinate POA paperwork and discuss advanced directives were not adequately supported or facilitated by facility staff, and care conferences did not consistently include relevant parties or discussions about the resident's preferences. Interviews with staff and collateral contacts revealed that the resident required significant support to make decisions and that there was confusion and lack of clarity regarding who was responsible for advocating for the resident's wishes. The facility did not ensure that the resident's rights and preferences were thoroughly explored, documented, or honored, as evidenced by the absence of care conference notes addressing advanced directives and the lack of communication with the resident's contacts. This failure to provide comprehensive social services and advocacy placed the resident at risk of not having their rights and wishes respected.
Failure to Update and Revise Care Plans to Reflect Resident's Current Needs
Penalty
Summary
The facility failed to ensure that care plans were reviewed, revised, and accurately reflected the current care needs of a resident. Specifically, a resident admitted with perineal and sacral wounds, urinary incontinence, and cognitive impairment had discrepancies in their care documentation. The Quarterly Minimum Data Set (MDS) assessment indicated the resident was continent of bowel and bladder and did not have an indwelling urinary catheter. However, the resident's care plan for an indwelling urinary catheter, last revised months after the catheter was removed, still directed staff to perform catheter care every shift. Nursing assistant documentation for the last 30 days showed the resident was incontinent of bladder with no mention of a catheter, and direct observation confirmed the absence of a catheter. Interviews with staff revealed that the care plan had not been updated to reflect the resident's current status. The MDS Coordinator acknowledged that the care plan should have been updated, and the Social Service Director confirmed that the discharge care plan did not reflect the resident's current discharge goal. These failures resulted in care plans that did not accurately represent the resident's needs or status, as evidenced by outdated interventions and goals.
Inaccurate and Incomplete Wound Documentation for Residents with Skin Integrity Issues
Penalty
Summary
The facility failed to ensure that clinical records were accurate and maintained according to accepted professional standards for two residents with wounds. For one resident, there were significant gaps and inconsistencies in the documentation of weekly skin assessments and wound observations. The resident was admitted with multiple pressure ulcers and moisture-associated skin damage, but the required weekly skin assessments were either missing, marked as refused without follow-up, or left blank for extended periods. Wound observation tools were not completed at the required frequency, with some assessments delayed by several weeks. Observations and interviews confirmed that the documentation did not consistently reflect the resident's actual wound status or the care provided. Another resident with multiple chronic conditions, including multiple sclerosis and malnutrition, also had inconsistent and unclear documentation regarding skin integrity. Weekly skin checks noted open areas on the coccyx, but there was a lack of detailed wound notes or measurements for an extended period. The care plan indicated the presence of a pressure ulcer and follow-up by a wound care clinic, but the medical record did not contain corresponding wound documentation during a critical month. Staff interviews revealed that a new nurse was responsible for some of the incomplete documentation and that there was confusion and inaccuracy in the records related to the resident's skin condition. The facility's own policies required weekly head-to-toe skin inspections and timely, detailed documentation of any wounds or skin alterations. However, the records reviewed showed multiple instances where these requirements were not met, including late entries, missing assessments, and lack of clear wound descriptions. These documentation failures resulted in clinical records that did not accurately reflect the residents' conditions or the care provided, as confirmed by staff interviews and record reviews.
Failure to Maintain Clean, Comfortable, and Homelike Environment in Resident Areas
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment in multiple areas, including two shared resident bathrooms, a community shower room, and the main dining room. Observations revealed that the shared bathrooms had strong, unpleasant odors, sticky floors, broken and stained tiles, poor lighting, and damaged walls. Staff and residents confirmed these conditions, noting persistent odors, moldy or stained areas, and a lack of cleanliness and comfort. The community shower room was found to have missing tiles, no grout, an uneven and sunken floor, dust and dirt accumulation, disorganized medical equipment, overflowing trash cans, and a strong musty odor suggestive of mold or mildew. Staff interviews corroborated these findings, describing the room as dirty, in need of cleaning, and not homelike. In the main dining room, observations during multiple meal services showed that residents often sat alone at bare tables with minimal decor, no music or television, and little to no engagement from staff. Residents were observed waiting for meals in silence, with some staring at the walls or at each other, and staff either absent or standing at a distance without interacting with residents. Staff interviews indicated that music or movies were previously provided but were no longer offered, and that the dining room atmosphere was described as "dead." Residents reported difficulty obtaining assistance in the dining room due to staff inattention. The facility's own policy requires staff to provide a clean, safe, and homelike environment, but observations and interviews demonstrated that these standards were not met in the identified areas. The lack of cleanliness, maintenance, and engagement in these common areas contributed to an environment that was not comfortable or homelike for residents, as confirmed by both staff and resident statements.
Failure to Provide Consistent ADL Assistance and Hygiene Care
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs), specifically showering and personal hygiene, for four residents who required varying levels of staff support. Observations over several days revealed that these residents consistently had greasy hair, indicating a lack of proper hygiene care. Documentation in the electronic medical record showed that showers were not provided according to the residents' stated preferences, with some residents receiving fewer showers than scheduled and others having missed or refused showers without evidence of appropriate follow-up or re-approach by staff. Interviews with staff confirmed that shower aides were frequently reassigned to other duties, which contributed to missed showers, and that if care was not documented, it was likely not performed. The residents involved had different cognitive and physical abilities, ranging from cognitively intact but physically dependent to severely cognitively impaired and fully dependent on staff for showers. Despite facility policy requiring assistance with ADLs as needed, the lack of consistent showering and hygiene support was evident through both staff interviews and resident reports. One resident reported being denied a shower due to staff being busy, and another was found to have received only two showers in a 30-day period. The facility's documentation practices and staff allocation contributed to the failure to meet residents' ADL needs.
Failure to Provide Palatable and Properly Heated Meals
Penalty
Summary
The facility failed to provide meals that were palatable, attractive, and served at an appetizing temperature, as evidenced by multiple resident interviews, observations, and review of dietary grievances. Residents reported dissatisfaction with the quality, taste, and temperature of the food, noting issues such as tough meats, lack of variety, overuse of certain seasonings, and inability to access or use a microwave for reheating food. During a group meeting, all residents in attendance expressed that meals were often cold, unappetizing, and not visually appealing, with specific complaints about soggy or hard French fries, smashed buns, and excessive barbecue sauce. Observations of meal service confirmed that food items, such as burgers and fries, were served below recommended temperatures and were not palatable. Review of the facility's grievance log revealed that concerns about undercooked or cold food were not adequately addressed in the facility's responses, which focused on updating preferences or communication rather than resolving the underlying issues. Staff interviews confirmed that the kitchen does not reheat resident foods and that certain equipment, such as a toaster, was unavailable for a period. The Food Services Director acknowledged limitations in food preparation methods due to lack of equipment and noted that menus were determined by corporate, sometimes including items not suitable for the available kitchen setup. The Administrator was aware of some complaints but had not personally evaluated the food quality.
Failure to Honor Resident Food Preferences and Choices
Penalty
Summary
The facility failed to honor and facilitate resident preferences for food, specifically by not allowing residents to have food items from outside sources heated up, despite previous practices and resident requests. This change affected at least four residents, all of whom had intact cognition and specific dietary needs or preferences, such as altered taste due to stroke, diabetes, malnutrition, and personal snack choices. The facility's policy previously allowed for the safe heating of outside food using food thermometers and staff education, but this was discontinued. Residents and their families reported that the facility stopped heating up food items, including frozen meals and microwave popcorn, citing state regulations, staff workload, and concerns about food safety and potential burns. Residents expressed dissatisfaction, noting that the inability to heat up their preferred foods negatively impacted their meal enjoyment and choice. Staff interviews confirmed that management had directed them to stop heating food for residents, and staff expressed difficulty in denying these requests, acknowledging the impact on residents' quality of life. Administrative staff explained that the policy change was implemented due to an increase in outside food being brought in, lack of storage space, and concerns about staff capacity to safely heat food according to guidelines. The facility communicated this change to residents and families through a letter, stating that only small amounts of perishable food could be stored and that no food requiring heating would be accommodated. This resulted in residents losing the ability to choose their preferred meals and snacks, contrary to facility policy and resident rights.
Failure to Implement Policy for Outside Food Brought by Visitors
Penalty
Summary
The facility failed to implement its policy regarding the safe and sanitary storage, handling, and consumption of foods brought in by family and visitors for residents. The policy required that when food needed to be heated, staff should use a food thermometer and alcohol wipes to ensure proper heating, and that staff should be educated on required food temperatures and the use of thermometers. However, a letter from the Administrator to residents, staff, and family members stated that staff would no longer heat up food items for residents, including frozen foods, hot dogs, and microwave popcorn, and that only a small number of food items could be stored for residents due to limited space. In interviews, the Administrator and DON confirmed that residents were not allowed to have food heated up and cited concerns about staff being able to safely heat food and the burden it placed on staff. These actions were not in accordance with the facility's written policy.
Failure to Thoroughly Investigate Injury of Unknown Source
Penalty
Summary
The facility failed to conduct a thorough investigation of an injury of unknown source for one resident with severely impaired cognition, memory, and decision-making abilities. The resident was found with a bruise and small abrasion on the forehead by an LPN, who documented that the resident denied abuse or neglect but was unable to recall the incident. The investigation consisted only of a statement from the LPN, notification of the provider and the resident's son, a skin check, and monitoring of the bruise. No neurological assessment was performed despite the unwitnessed head injury, and there was no follow-up with the son regarding the time frame or circumstances of the injury. Additionally, the investigation did not include statements from potential witnesses, other staff, or residents who may have had relevant information. Interviews with facility staff revealed that the process for investigating such incidents was not fully followed, as no additional data gathering or witness statements were obtained. The Director of Nursing acknowledged that the investigation was incomplete and lacked thorough data collection as required by facility policy.
Failure to Complete and Transmit Discharge MDS Assessment
Penalty
Summary
The facility failed to ensure the timely completion and transmission of the required Minimum Data Set (MDS) discharge assessment for one resident. According to the report, a resident was admitted and later discharged, but review of the clinical record revealed that no discharge MDS assessment was completed or transmitted to CMS within the required 14-day period following discharge. The CMS system flagged the resident's file as lacking any type of assessment for over 120 days. During an interview, the MDS Coordinator stated that although daily audit reports and discussions occur during stand up meetings, this particular assessment was missed.
Failure to Provide and Document Splint Application for Resident with Limited ROM
Penalty
Summary
The facility failed to provide appropriate interventions to maintain or prevent decline in range of motion (ROM) for a resident with a history of stroke resulting in hemiplegia and hemiparesis. Physician orders specified that the resident was to wear a left wrist splint in the morning and remove it at bedtime, and a left ankle splint for six hours daily. Multiple observations over several days revealed that the resident was not wearing the prescribed splints, and the resident reported that splints were only applied during restorative therapy sessions, which occurred twice a week. The resident denied refusing the splints when offered. Interviews with nursing assistants, restorative aides, and nursing staff indicated confusion and lack of clarity regarding responsibility for applying the splints when restorative aides were reassigned to other duties. Documentation review showed that splint or brace assistance was recorded on only seven of the last thirty days, and there was no documentation of splint or brace application in the resident's Medication and Treatment Administration Records for several months. Facility leadership confirmed that nurses were supposed to apply the splints when restorative aides were unavailable, but there was no evidence of this being done or documented.
Failure to Accommodate Resident Food Allergies and Preferences
Penalty
Summary
The facility failed to ensure that a resident's menu and individual food plan met their documented nutritional needs and preferences. The resident, who had diagnoses including malnutrition and dysphagia and received extra calories via a PEG tube, was noted to have allergies and dislikes including gluten, eggs, mushrooms, mayonnaise, and tomato products. Despite this, observations showed that the resident was served a hamburger with mayonnaise and battered onion rings, which contained gluten, as well as gluten-free pasta with tomato sauce, which the resident disliked and refused to eat. The resident expressed dissatisfaction and concern about the presence of gluten and other disliked items in their meals. Interviews with staff revealed that meal tray cards listing allergies and dislikes were used to guide food preparation, but limitations in available gluten-free options from the food vendor resulted in the resident receiving inappropriate food items. The Food Services Director acknowledged that alternatives were not available for certain menu items, leading to the resident being served foods containing allergens or items they disliked. The facility's policy required accommodation of allergies and preferences, but this was not consistently implemented for the resident in question.
Failure to Maintain Sanitary Food Preparation and Storage Practices
Penalty
Summary
The facility failed to ensure that food was prepared and stored under sanitary conditions, as evidenced by multiple observations in the kitchen and nourishment areas. During an inspection of the nourishment refrigerator, an opened carton of thick and easy supplement was found with a manufacturer expiration date that had already passed, and the carton had been opened after its expiration. This indicates that expired food items were not consistently removed from storage, contrary to facility policy and food safety standards. Additionally, during meal preparation and tray line observation, a cook was seen engaging in unsanitary practices. The cook changed gloves multiple times without performing required hand hygiene between changes and was observed handling clean plates and food items with bare hands. Specifically, the cook touched a clean plate and a sandwich with bare hands and did not replace the contaminated plate. These actions were acknowledged by the staff involved and the food services manager, who noted that the staff member was working too quickly and that expired items should have been removed but were missed.
Noncompliance with Infection Control Precautions and PPE Use
Penalty
Summary
Staff failed to comply with infection prevention and control guidelines for multiple residents requiring different levels of precautions. For a resident with an indwelling Foley catheter on Enhanced Barrier Precautions (EBP), a nursing assistant emptied the catheter bag while wearing only gloves and not a gown, despite facility policy requiring both gown and gloves for high-contact activities involving indwelling devices. The staff member stated they did not believe a gown was necessary for this task, even though the EBP signage indicated otherwise. During personal care for another resident with hemiplegia and hemiparesis, a nursing assistant did not change gloves after providing pericare and continued to assist the resident with dressing and handling the resident's wheelchair with the same soiled gloves. The staff member later acknowledged that the gloves were dirty and should have been changed after pericare, but stated they typically only change gloves when visibly soiled. For a resident under investigation for Clostridium difficile (C. Diff), the room was posted with EBP signage instead of the required Contact Enteric precautions. Staff followed the posted EBP instructions, which did not require gown and glove use for all room entry or soap and water hand hygiene, as would be necessary for C. Diff. The error in signage led to staff not following the appropriate level of precautions until the signage was corrected.
Resource Mismanagement and Care Deficiencies
Penalty
Summary
The facility administration failed to effectively manage resources and maintain compliance with federal and state regulations, resulting in multiple deficiencies. These included inadequate administrative oversight and monitoring of personnel, systems, and policies related to care planning, resident environment, activities of daily living, range of motion services, respiratory care, nursing staff sufficiency, social services, pharmacy services, food service procedures, infection control, and tuberculosis testing. The administration's failure to ensure a homelike environment, proper maintenance, and timely comprehensive assessments after significant changes in residents' conditions contributed to these deficiencies. Specific incidents highlighted in the report include the failure to provide adequate care for dependent residents, such as bathing and toileting, leading to poor hygiene and unmet care needs. The facility also lacked a restorative program for residents needing range of motion and splint care, as acknowledged by the Director of Rehabilitation. Additionally, there were issues with respiratory care, where staff failed to administer oxygen as per the ordered dosage, and insufficient nursing staff led to delays in medication administration, affecting residents' pain management and overall care. One resident, admitted with chronic pain syndrome, experienced significant pain due to delayed administration of pain medications. Despite being scheduled for morning medication, the resident did not receive their pain relief until much later, resulting in severe discomfort. Interviews with staff revealed that the medication pass often extended beyond the scheduled time, affecting multiple residents. The administration also failed to ensure proper infection control practices and tuberculosis testing, further compromising resident safety and care quality.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to initiate a grievance process for concerns raised by the Resident Council, which included issues with call light wait times during nights and weekends. Despite residents voicing these concerns in meetings, the facility did not log or investigate these grievances, nor did they inform the residents of any findings or actions taken. This lack of action prevented the facility from identifying trends in grievances and addressing them effectively. Interviews revealed that staff directed residents to submit a concern or comment form, but did not assist in completing these forms, relying instead on residents to do so. The Activities Director provided resident council minutes to the administrator and director of nursing but did not ensure grievances were logged. The administrator expressed that grievances from the resident council were challenging to address if residents were not willing to participate in finding solutions, which limited the facility's ability to resolve the issues.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for six residents, leading to potential risks for these individuals. Resident 6, who had a history of amputations and used limb prosthetics, did not have these needs addressed in their care plan. Similarly, Resident 53, who was undergoing smoking cessation treatment, lacked a care plan that included their smoking history and current treatment. Staff interviews revealed that the Resident Care Managers (RCMs) were responsible for ensuring care plans were completed, but they felt overwhelmed due to staffing issues. Resident 5, who had severe cognitive impairment and required assistance for mobility, was observed multiple times without access to their call light, contrary to their care plan instructions. Resident 8, who had a nephrostomy, had a care plan that did not reflect the necessary care for this condition. Staff interviews indicated that the care plan was supposed to guide the care provided, but there was a lack of awareness and information regarding the specific needs of Resident 8's nephrostomy. Resident 49, who experienced pain in their left knee and lower back, did not have these issues documented in their care plan, which only mentioned pain related to hip surgery. Resident 168, who was prescribed antibiotics for presumed pneumonia, did not have this condition or treatment reflected in their care plan. The Director of Nursing Services (DNS) acknowledged that care plans should address all resident needs and that there were missing items in the care plans reviewed by the interdisciplinary team.
Care Plan Deficiencies in Resident Management
Penalty
Summary
The facility failed to ensure that care plans were accurately reviewed and revised to reflect the current status and needs of four residents. Resident 6, who was admitted with a history of stroke, diabetes, and bilateral below-knee amputations, had their skilled therapies discontinued and transitioned to restorative services. However, their care plan was not updated to reflect these changes. Resident 43, who elected hospice care, did not have their care plan updated to include hospice services and coordination with the hospice care team. Resident 53, with a diagnosis of tobacco use disorder and an order for nicotine patches, was found smoking outside the facility, yet their care plan did not reflect their smoking history, risk, or current treatment. Resident 2, admitted with a history of stroke, left hemiparesis, dysphagia, and Type 2 Diabetes Mellitus, was observed using a straw despite their care plan indicating they should not have one. Staff were unaware of this restriction, and no signs were posted in the resident's room to remind staff and visitors of the precaution. Interviews with staff revealed a lack of awareness and communication regarding the resident's care plan, leading to the resident being served drinks with a straw, contrary to their care plan instructions.
Deficiencies in ADL Assistance for Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for several residents, specifically in the areas of bathing and toileting. Resident 24, who was admitted with a fracture of the right femur, chronic heart failure, and kidney disease, was not provided with the necessary assistance for toileting. Despite being aware of their need to have a bowel movement, the resident was unable to be transferred to the bathroom due to the mechanical lift not fitting into the bathroom. The care plan for Resident 24 did not address their continence needs, and staff failed to offer alternative solutions such as a bedside commode. Residents 7, 8, 23, and 28, who were dependent on staff for bathing, did not receive showers or bathing assistance as per their preferences and needs. Resident 7, with moderate cognitive impairment, reported only being bathed every two or three weeks despite preferring weekly baths. Resident 28, who had a stroke and hemiplegia, was supposed to be bathed twice a week but experienced inconsistent bathing schedules due to staffing issues. Resident 8, with a history of stroke and muscle weakness, was observed with greasy, uncombed hair and reported receiving showers only once a week, although they preferred twice weekly showers. The facility's documentation and staff interviews revealed systemic issues in scheduling and providing showers. Staff members indicated that shower aides were responsible for bathing, and if they were unavailable, showers were often missed without proper documentation or follow-up. The Director of Nursing Services and the Administrator were unaware of the missed showers and the lack of adherence to residents' bathing preferences, highlighting a breakdown in communication and care planning within the facility.
Staffing Shortages Lead to Delayed Care and Unmet Needs
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of its residents, as evidenced by multiple resident interviews and observations. Residents reported long wait times for assistance with activities of daily living, such as getting out of bed, attending activities, and receiving help with grooming and showers. Some residents expressed concerns about the lack of staff available to respond to call lights, particularly during nights and weekends, leading to delays in receiving necessary care. The report highlights specific instances where residents did not receive timely medication administration, which is critical for managing their health conditions. For example, Resident 16, who suffers from chronic pain syndrome, did not receive their morning pain medications on time, resulting in severe pain. The delay in medication administration was attributed to the heavy workload and insufficient staffing on the unit, as confirmed by staff interviews. Additionally, the facility's staffing issues affected the provision of showers and restorative services. Staff interviews revealed that shower aides were often pulled to cover floor duties due to staffing shortages, leading to missed showers for residents like Resident 28, who preferred twice-weekly showers. The facility's inability to maintain adequate staffing levels compromised the quality of care and residents' quality of life, as documented in the report.
Delayed Medication Administration
Penalty
Summary
The facility failed to ensure the timely administration of scheduled medications for four residents, resulting in significant delays in receiving essential medications. The scheduled AM Medication Pass was supposed to occur between 6:00 AM and 10:00 AM, but residents did not receive their medications until much later. Resident 16, who suffers from chronic pain syndrome, reported severe pain levels of 10/10 on two consecutive mornings due to not receiving their morning pain medications, including Gabapentin, Acetaminophen, and Suboxone, within the scheduled time. Interviews with staff revealed that the delay was due to the medication pass taking longer than expected. Other residents also experienced delays in receiving their medications. Resident 38 received seven morning medications, including pain and antipsychotic medications, over two hours after the scheduled time. Similarly, Resident 7 received their morning medications, including antidiabetic and anticoagulant medications, as late as 12:15 PM. These delays were documented in incident investigations, and the facility acknowledged the need for improvement in the efficiency of medication administration.
Failure to Ensure Sanitary Food Handling
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and served under sanitary conditions in its kitchen, as observed by surveyors. Specifically, staff members were not wearing required hair and beard restraints while working in the kitchen, which is a violation of the facility's policy. On multiple occasions, staff members, including the Dietary Manager and Dietary Aides, were observed without hair or beard restraints. The Dietary Manager acknowledged that staff were supposed to wear these restraints upon entering the kitchen but noted that a new staff member was still in training. This lack of compliance with sanitary protocols placed residents at risk of receiving contaminated food.
Infection Control Deficiencies in Hand Hygiene and Precautions
Penalty
Summary
The facility failed to ensure compliance with infection prevention and control guidelines during meal service, peri-care, and transmission-based precautions. Specifically, Staff F, a Nursing Assistant Certified (NAC), did not perform hand hygiene before and after delivering meal trays to residents' rooms. This was observed multiple times as Staff F handled meal trays and residents' personal items without washing hands or using alcohol-based hand rub (ABHR). Staff F acknowledged the responsibility to perform hand hygiene but was unaware of the lapses during the breakfast meal tray pass. Additionally, Staff P, another NAC, was observed providing peri-care to a resident without changing gloves or performing hand hygiene afterward. Staff P used the same gloves to dress the resident and then moved the bedside commode and wheelchair without washing hands or using ABHR. This failure to adhere to hand hygiene protocols was noted despite recent training sessions on proper handwashing techniques. The facility also failed to implement appropriate transmission-based precautions for a resident with Clostridium difficile (c. diff) infection. The contact isolation sign outside the resident's room incorrectly instructed staff and visitors to use ABHR instead of washing hands with soap and water, which is necessary to remove c. diff spores. Staff H followed these incorrect instructions, and the Infection Preventionist and Director of Nursing Services were unaware of the signage error. The facility's policies require handwashing with soap and water for residents with c. diff, but this was not enforced, leading to potential infection risks.
Failure to Maintain Advance Directives Documentation
Penalty
Summary
The facility failed to obtain and maintain Advance Directives (AD) for Resident 24, who was admitted with diagnoses including a fracture of the right femur, chronic heart failure, and kidney disease. The care plan indicated that Resident 24 had a Power of Attorney (POA) for healthcare, with their daughter specified as the POA. However, a review of the electronic medical record revealed no documentation of the POA paperwork. This oversight was confirmed during an interview with Staff W, a Licensed Practical Nurse, who was unable to locate the POA documentation in the resident's chart. Further interviews revealed that Staff X, the Admissions Director, did not obtain the POA documents at the time of admission, despite the presence of Resident 24's daughter. Staff X was unsure of the process to follow up if the POA paperwork was not provided. Staff Z, the Medical Records Director, confirmed that if the POA document was not in the electronic medical record, it was not given to them. Staff AA, an RN-Staff Development Coordinator, also could not locate the document and noted that Resident 24's daughter had signed the Physician's Order for Life Sustaining Treatment (POLST) as the POA. The deficiency was identified as a failure to ensure the resident's healthcare preferences and decisions were documented and honored.
Failure to Maintain Homelike and Clean Environment
Penalty
Summary
The facility failed to ensure a homelike environment for three residents and maintain cleanliness in the facility's conference room. Resident 11, who had severe cognitive impairment, was observed to have a stark room lacking personal belongings or decor, with bare walls and minimal furnishings. Staff acknowledged the lack of homelike elements in the room. Resident 28, who had no cognitive impairment, expressed dissatisfaction with the cleanliness of their room windows, which had not been cleaned in over two years despite multiple requests. The maintenance staff confirmed that windows were cleaned quarterly and attributed wall damage to improper bed placement by nursing staff. Resident 17, who was hearing impaired but able to communicate, reported that their window and TV screen were dusty and streaked, which was confirmed by observation. Additionally, the conference room windows and screens were found to have extensive dirt and debris build-up. These deficiencies indicate a failure to provide a clean and homelike environment, as required by regulations, potentially impacting the residents' quality of life and the facility's overall environment.
Failure to Conduct Significant Change in Status Assessment for Hospice Election
Penalty
Summary
The facility failed to identify a Significant Change in Status for a resident who elected Hospice services, as required by the Resident Assessment Instrument (RAI) guidelines. The resident, who was not initially receiving Hospice services, elected their Hospice benefit on August 10, 2024. According to the RAI manual, a Significant Change in Status Assessment (SCSA) should have been conducted within 14 days of this election, by August 24, 2024. However, a review of the resident's Minimum Data Set (MDS) assessments on September 10, 2024, revealed that no SCSA had been completed. During an interview on September 11, 2024, the Licensed Practical Nurse/Minimum Data Set (MDS) Nurse, identified as Staff O, stated that the only change for the resident was the initiation of Hospice services and that the care plan had not been altered. Staff O was unaware that the election of Hospice services alone constituted a Significant Change requiring a SCSA, as per the RAI manual.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to complete a discharge summary for a resident, identified as Resident 67, who was discharged to an assisted living facility. The discharge summary was missing a recapitulation of the resident's stay and a final summary of the resident's status, which are required components. The resident had been admitted with diagnoses including neutropenia, pulmonary fibrosis, and high blood pressure. The facility's policy on discharge summaries, dated May 6, 2019, requires participation from both social services and nursing staff in developing the summary, which should include a comprehensive overview of the resident's stay and status. Interviews with facility staff revealed gaps in the discharge process. Staff S, the Social Services Director, indicated that they were responsible for certain parts of the discharge summary but not for the recapitulation of the stay or physical assessment on discharge. Staff S also could not recall if any durable medical equipment or home health services were needed for Resident 67. Additionally, Staff A, the Administrator, and Staff B, the Director of Nursing Services, acknowledged that the discharge summary for Resident 67 was incomplete and should have been finalized on the day of discharge. This lack of a complete discharge summary placed residents at risk of post-discharge complications and delayed treatment.
Deficiency in ROM and Mobility Care for Residents
Penalty
Summary
The facility failed to provide necessary care and services to maintain or improve the range of motion (ROM) for three residents, leading to a deficiency in care. Resident 17, who had multiple diagnoses including rheumatoid arthritis and a history of shoulder issues, was observed wearing a sling without a corresponding order. Despite an order for occupational therapy to assess ROM, there was no follow-up, and the resident expressed interest in exercises that were not provided. The Director of Rehab acknowledged the oversight, indicating a lapse in the facility's process for monitoring and addressing potential declines in residents' activities of daily living. Resident 5, with severe cognitive impairment and limited mobility, was at risk for skin breakdown due to prolonged periods in a wheelchair without repositioning or a pressure-reducing cushion. Observations showed the resident remained in the same position for extended hours without staff intervention, contrary to the care plan that required repositioning every two hours. The lack of adherence to the care plan and absence of documentation of any refusals to reposition highlighted a significant gap in the facility's care practices. Resident 23, who had contractures and required a brace and splint for their right knee, was not consistently receiving the prescribed restorative nursing services. Documentation showed frequent refusals and incomplete application of the brace and splint, with significant gaps in the records. Staff interviews revealed that the restorative nursing program had been on hold, and there was confusion about who was responsible for overseeing the program. The lack of documentation and communication about the resident's refusals and the absence of the brace and splint during observations further underscored the facility's failure to implement and monitor necessary interventions for maintaining residents' mobility and function.
Failure to Implement Nutritional Interventions and Monitor Weight Loss
Penalty
Summary
The facility failed to develop and implement nutritional interventions and evaluate their effectiveness for a resident with nutritional needs. The resident, who was admitted with diagnoses including malnutrition, bipolar disorder, and cognitive communication deficit, experienced significant weight loss over several months. Despite the resident's care plan identifying a potential nutritional problem and risk for weight loss, the facility did not consistently obtain weights, notify appropriate parties, or implement the Registered Dietician's recommendations. The resident's medical records showed a decline in weight from 152.8 pounds to 135.6 pounds over a period of several months. The facility's policy required weekly reviews of residents at risk for nutritional issues, but there was no consistent method for weighing the resident or monitoring their weight loss. The resident frequently refused to be weighed, and there was no documentation of notification to the physician or power of attorney about these refusals or the weight loss. Interviews with staff revealed a lack of awareness and communication regarding the resident's weight loss and refusal to be weighed. Staff members indicated that they were not informed of the resident's weight loss and that the care plan was not updated to reflect the resident's refusal to be weighed. The facility's process for obtaining weights was not followed, and the care plan did not include updated interventions to address the resident's nutritional needs.
Deficiency in Enteral Tube Feeding Management
Penalty
Summary
The facility failed to ensure proper management of enteral tube feeding supplies for a resident with a PEG tube, leading to a risk of infection and complications. Resident 8, who was admitted with a history of stroke, dysphagia, and malnutrition, relied on a PEG tube for nutrition. Observations revealed that the tube feeding supplies, including bags and syringes, were not labeled or dated as required. The feeding bag was observed to be used beyond the recommended 24-hour period, and the water bag was unlabeled. These observations were made over several days, indicating a lack of adherence to proper protocols for tube feeding management. Interviews with facility staff, including a Registered Nurse, a Licensed Practical Nurse, and the Director of Nursing Services, confirmed that there were no physician orders or care plan directives for the replacement and labeling of tube feeding supplies. Staff members acknowledged that supplies should be replaced every 24 hours and properly labeled, but this was not being done. The care plan for Resident 8 was not updated to include the PEG tube until nearly a year after admission, and staff were unaware of the lack of orders for tube feeding supplies. This oversight in care planning and execution contributed to the deficiency identified by the surveyors.
Failure to Provide Ordered Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, leading to deficiencies in care. Resident 24, who was admitted with diagnoses including a fracture of the right femur, chronic heart failure, and COPD, had physician orders for oxygen therapy and CPAP use. However, observations revealed that the resident was not using the prescribed nasal cannula or CPAP mask, and the oxygen concentrator was set to zero liters and not running. Staff interviews confirmed that the resident was not receiving the ordered respiratory support, which was inconsistent with the facility's policy and physician orders. Resident 17, admitted with COPD, Reynaud's Syndrome, gangrene in the fingers, and atrial fibrillation, was observed using an oxygen concentrator without a physician's order documented in their electronic chart. The resident stated they used oxygen at night for sleep apnea, but staff were unable to provide documentation of an order for oxygen use. This lack of documentation and adherence to physician orders for oxygen therapy represents a failure to meet professional standards of practice for respiratory care.
Failure to Administer Timely Pain Management
Penalty
Summary
The facility failed to provide necessary pain management for Resident 16, who was admitted with chronic pain syndrome and was dependent on opiate medication for pain relief. The resident's Minimum Data Set assessment indicated frequent pain affecting their sleep, and they reported a pain level of 8 out of 10. On multiple occasions, the resident expressed experiencing severe pain, with a pain level of 10 out of 10, and had not received their scheduled morning pain medications, which included Gabapentin, Acetaminophen, and Suboxone. Observations and interviews revealed that the facility's medication administration schedule was not adhered to, as the resident did not receive their morning medications within the scheduled time frame of 6:00 AM to 10:00 AM. Staff interviews confirmed delays in medication administration, with staff members acknowledging that the medication pass was taking longer than expected. This failure to administer pain medications as scheduled resulted in the resident experiencing avoidable pain and a diminished quality of life.
Failure to Conduct Care Planning Meetings for Resident
Penalty
Summary
The facility failed to provide medically-related social services to help Resident 13 achieve the highest possible quality of life. Resident 13, who has Parkinson's disease and moderate cognitive impairment, expressed dissatisfaction with their bathing schedule, stating they were only able to bathe once a week instead of their preferred twice a week. Additionally, an observation revealed that Resident 13 was sitting uncomfortably in their wheelchair, with no right legrest or footrest, causing their right leg to be suspended in the air. The facility did not conduct care planning meetings for Resident 13, as required, to address their care preferences and needs. Staff S, the Social Services Director, and Staff V, the Social Services Assistant, admitted to not holding quarterly care conferences for the resident, citing the power of attorney's declination. However, they were unable to provide any information on how the resident's care was assessed without these meetings. A review of the resident's progress notes over the past year showed no documentation of any care conferences, and Resident 13 confirmed that the facility never offered a care conference to discuss their care, bathing preferences, or wheelchair comfort.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship Program (ASP) effectively for a resident, increasing the risk of developing multidrug-resistant organisms. The facility had a document titled 'Statement of Leadership Commitment for Antibiotic Stewardship in a Skilled Nursing Facility,' which was signed by key personnel, including the Medical Director and Director of Nursing Services. This document outlined the facility's commitment to the CDC's core elements of antibiotic stewardship, including leadership, accountability, and drug expertise. However, the facility did not adhere to these elements in the case of a resident who was admitted with a history of kidney stones, surgery to the urinary system, and an antibiotic-resistant bacteria infection. The resident's physician orders included an antibiotic with a note indicating a need for a stop date, but the medication was administered continuously without documented communication with the infectious disease provider regarding the stop date. Interviews with facility staff revealed a lack of awareness and follow-up regarding the resident's antibiotic use. The Director of Nursing Services was initially unaware of the status of the resident's antibiotic treatment and had to contact the infectious disease provider to obtain documentation, which was not part of the medical record until requested. The Infection Preventionist, who was responsible for overseeing the ASP, was also unaware of the lack of documentation and follow-up in the medical record. This oversight indicates a failure in the facility's ASP, as there was no proper tracking or communication regarding the antibiotic's usage and stop date, leading to potential adverse outcomes for the resident.
Failure to Monitor and Address Recurrent UTIs in Resident
Penalty
Summary
The facility failed to provide resident-focused care by not consistently monitoring, assessing, and evaluating the condition of a resident with a history of recurrent urinary tract infections (UTIs). The resident, who was readmitted to the facility with diagnoses including recurrent UTI, type two diabetes mellitus, and Parkinson's disease, did not have a care plan addressing their history of chronic UTIs or their candidacy for timed/scheduled voiding. Despite being incontinent of urine and having a history of chronic UTIs, the care plan only noted the resident's risk for skin breakdown and required assistance for peri care and brief changes. Throughout the period from 08/16/2024 to 08/19/2024, the resident exhibited symptoms indicative of a UTI, such as dark amber urine with odor, confusion, and discomfort with urination. However, there was a lack of documentation of vital signs and no notification to the resident's representative or provider about these findings. The resident's condition escalated to a UTI with sepsis, as confirmed by an emergency department encounter, where they presented with fever, tachycardia, and confusion. Interviews with facility staff revealed gaps in the care planning and monitoring processes. Staff acknowledged that the resident's recurrent UTIs were not included in their care plan or diagnosis list, and vital signs were not consistently checked during the alert status. The facility's protocol for placing a resident on alert did not necessitate provider notification, and there was a lack of communication regarding the resident's change in condition. These oversights contributed to the resident's decline and subsequent hospitalization for UTI with sepsis.
Failure to Provide Timely Pharmaceutical Services for New Admissions
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of three residents upon their admission. Resident 1, who was admitted with conditions including Bipolar Disorder and Seizure Disorder, did not receive prescribed medications such as Quetiapine, Benzatropine, and Lamotrigine on the day of admission. The Licensed Practical Nurse (LPN) documented the absence of these medications as 'new admit' without verifying their availability in the Omnicell or notifying the resident's provider. The Director of Nursing Services (DNS) confirmed that no medications were dispensed from the Omnicell for Resident 1 on the day of admission. Resident 2, admitted with conditions including a recent fall and cardiac issues, also did not receive several prescribed medications, including Memantine, Rosuvastatin, Symbicort, and Voltaren, due to pending delivery. Despite Memantine being available in the Omnicell, it was not administered. The resident expressed a need for pain ointment, which was not available until days after admission. There was no documentation indicating that the provider was notified about the unavailability of these medications. Resident 3, admitted with encephalopathy and psoriasis, did not receive Lactulose and Betamethasone as they were on order and not available in the Omnicell. Similar to the other cases, there was no documentation of provider notification regarding the unavailability of these medications. The DNS acknowledged the need to review the pharmacy delivery and admission process after receiving an updated list of medications available in the Omnicell.
Failure to Provide Adequate Nail Care
Penalty
Summary
The facility failed to ensure that three residents received proper nail care, leading to discomfort and potential injury. Resident 1, who had contractures, reported that their fingernails were so long they were digging into their palms, causing significant pain. Despite repeated requests, it took several days before the Activity Director filed the nails. Staff A confirmed that Resident 1's nails were long and causing discomfort, with reddened skin and callouses forming in their palms. Resident 2, who was dependent on staff for most activities of daily living, was observed to have long, jagged fingernails with dirty cuticles and debris under the nails. Resident 2 expressed a preference for having their nails cut, not just filed, but stated that staff did not comply with this request. Resident 3, who required maximum assistance for hygiene, also reported that staff had not been maintaining their fingernails properly. Their nails were long, with old polish and dirty cuticles, and the resident expressed a preference for having their nails cut rather than filed. Interviews with staff revealed inconsistencies in the understanding and execution of nail care responsibilities. Staff C, a Registered Nurse, stated that Nursing Assistants (NAs) were responsible for trimming nails unless the residents were diabetic or on blood thinners, in which case nurses were responsible. Staff B, a Licensed Practical Nurse, confirmed this protocol and added that nail care was usually documented in the resident's treatment administration record. However, Staff D, an NA, was unaware that NAs were responsible for trimming residents' fingernails. This lack of clarity and adherence to the facility's nail care policy resulted in inadequate care for the residents, leading to discomfort and potential injury.
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What surveyors actually found near you
We read the 197 citations issued within 25 miles in the last 12 months — including the 1 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
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Illustrative
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Nursing homes near Sedro Woolley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mira Vista Care Center | 6.6 mi | ★★★★★ | 26 | 0 |
| Life Care Center Of Mount Vernon | 7.2 mi | ★★★★★ | 9 | 0 |
| Soundview Rehabilitation And Health Care Inc | 16.5 mi | ★★★★★ | 32 | 0 |
| Highland Health And Rehabilitation Of Cascadia | 17.2 mi | ★★★★★ | 5 | 0 |
| Mt Baker Care Center | 17.9 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.