Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Linden Grove Health Care Center during CMS and state inspections, most recent first.
Two residents did not receive showers/bathing as scheduled and preferred, with staff reporting shower aides were often pulled to the floor and showers were commonly reduced to about once weekly. In addition, an LPN/RCM confirmed that a trazodone dose increase approved by the in-house provider was not entered into the EHR, although a new naltrexone order was.
Failure to inform residents of Medicare coverage changes: The facility changed several residents from Medicare Advantage/Managed Medicare to Traditional Medicare after IDT review and Social Services discussions, but did not provide written material or documented oral-and-written explanations of the impact of the change. Several residents were cognitively intact, one had moderate cognitive impairment, and one POA said she was unaware the insurance had been changed. One resident reported difficulty seeing her usual doctor after the switch and others said they received no written explanation.
Failure to Protect Residents from Physical Abuse: Two residents with severe cognitive impairment and dementia were involved in a resident-to-resident altercation when one resident threatened and struck the other in the arm after a dispute over seating in the activity room. Staff separated the residents after the incident, and the assaulted resident was assessed with no visible injury or pain noted.
Failure to Investigate New Skin Impairments and Implement Wound Orders: A resident with Alzheimer’s disease and severe cognitive impairment developed multiple new skin impairments, including redness and blisters, MASD with penile ulceration, and stage 3 PUs. The facility did not complete accurate incident investigations or rule out abuse/neglect for several findings, did not obtain or implement a recommended arterial duplex, and delayed or omitted treatment orders and care plan updates. UWH notes documented new wounds and recommendations, but the eTAR and incident logs did not consistently reflect the identified conditions.
The facility failed to prevent multiple resident-to-resident physical altercations despite policies prohibiting abuse. In one case, a moderately cognitively impaired resident with Alzheimer’s took food from a used tray in the dining room, and a cognitively intact resident verbally objected, leading the first resident to strike the second in the face and cause a fall. In another case, two severely cognitively impaired roommates with dementia pushed each other during a dispute over a wheelchair, resulting in one resident falling and reporting head and back impact, while the other reported pushing too hard when trying to protect her wheelchair.
Insufficient nursing staff and nonfunctional call light systems led to delayed response times and unmet resident care needs. Call light boards were observed disconnected or not audible, and residents reported waits of more than an hour for help, long delays for meds, prolonged time in wet briefs, and delays in showers and linen changes. Staff reported ongoing call outs, short staffing, and being pulled from restorative and shower duties to cover the floor.
Failure to complete annual CNA performance evaluations. The facility had no documentation of yearly performance evaluations for 5 of 5 CNAs reviewed. HR/Payroll acknowledged the evaluations were due but had not been completed, and the Administrator stated staff changes contributed to the missed evaluations.
Residents repeatedly reported that meals were bland, cold, greasy, mushy, undercooked, or missing items, and that tray tickets often did not match what was served. Several residents said they had to request substitutions, extra food, or microwaved meals, while others complained that requested alternatives were not provided and portions were too small. Resident council minutes and grievances documented ongoing concerns about poor food quality, temperature, presentation, and accuracy of meal delivery.
Failure to maintain a full-time qualified social worker in a 130-bed LTC facility. The Social Services Director was on leave, and a Social Services Assistant without formal social work education was covering the duties. The Administrator stated a qualified social worker was available by phone or email, but no one was serving in the required full-time role.
Unapproved bedside medications left with residents. A resident with respiratory failure, schizophrenia, and PTSD had vitamins, Prevagen, and Preparation H at the bedside or in the bathroom even though the self-med eval showed the resident was not approved to self-administer meds. Another resident with DM, gastritis, and HTN had OTC Tums and Visine at the bedside without a care plan, provider order, or approved self-med eval. A third resident with CVA, HTN, and weakness had Aspercreme Lidocaine on the overbed table without an order or approval for self-administration.
A facility failed to provide written bed hold notices for multiple residents when they were transferred to the hospital, with records showing incomplete or unsigned bed hold forms, incorrect transfer documentation, and missing written notice to residents or representatives. The facility also failed to document discharge details and provide recapitulation of stay for residents who were discharged, including one resident whose chart lacked a completed discharge summary.
MDS assessments were not accurately coded for three residents. One resident with left ear deafness was coded as having minimal hearing difficulty instead of moderate difficulty, and two residents with documented level 2 PASSAR status related to serious mental illness were not coded correctly on their MDSs. Staff acknowledged the coding errors and stated the assessments were inaccurate.
Care plans were not reviewed and revised for several residents with changed conditions and orders. A resident with a wander guard had not been reassessed despite no recent exit-seeking, another resident’s restorative program remained on the CP after therapy began, a resident’s Foley catheter care remained listed after the catheter was removed, a resident’s psychotropic-drug risk focus stayed on the CP after those meds and behavior monitors were discontinued, and another resident’s oxygen order and Covid-related focus were not updated to match current status.
A facility failed to consistently provide bathing and personal hygiene assistance for three residents who needed help with ADLs. One resident with obesity and a knee replacement said showers were not reliably given despite requests, another resident with HF, DM, and weakness said they had only received one shower since admission, and a third resident with chronic pain and depression reported no shower or bed bath for months and lacked help with oral care, hair care, and face washing. Records, shower schedules, and staff interviews showed bathing was not consistently offered, provided, or documented as required.
Three residents with COPD, respiratory failure, and other cardiopulmonary conditions had oxygen therapy issues. One resident’s O2 concentrator was observed not in use despite an order for continuous O2, and the record lacked an order to clean the concentrator filter. Two other residents had O2 orders and documentation of sats, but the orders did not include parameters for when to notify the provider, and one resident’s ordered post-treatment assessments were not consistently documented.
Unnecessary PRN pain medication use and failure to follow medication parameters: The facility did not follow provider orders for PRN pain meds and BP med hold parameters for several residents. An LPN and the DON/DNS confirmed that NPI were not offered or documented before multiple PRN doses of opioids, acetaminophen, ibuprofen, and a muscle relaxant, and one resident received antihypertensives despite a low HR. Another resident’s Tylenol dose was documented without the required NPI notation.
Unsafe food storage was found in two resident refrigerators. Numerous items were unlabeled, expired, or spoiled, including food past use-by or sell-by dates, opened formula with visible contamination, and items with no resident name or date. Temperature logs showed the refrigerators ranged from 36 to 46 F, and the Dietary Manager stated food should be discarded after 48 hours and kept at 41 F or below, while also noting the posted acceptable temperature range was inaccurate.
Infection control surveillance was not tracked or analyzed for several months, and no documented trend review or intervention was completed. Staff also did not follow posted TBP directions in two rooms: an RN entered a room on aerosol/contact precautions without eye protection, and staff provided high-contact care under enhanced barrier precautions without wearing a gown.
Failure to Administer and Educate on Pneumococcal Vaccinations: The facility failed to ensure pneumococcal vaccines were administered to three residents who had consented, and failed to document VIS delivery or education on risks and benefits for three residents who declined. Review of records showed the residents had been assessed or offered the vaccine, but the vaccine was not documented as given for the consenting residents, and education was not documented for the residents who declined. The LPN/ADON acting as infection preventionist and the DON stated the residents did not meet expectations.
A resident with MS, DM, and anxiety received citalopram, alprazolam, and methylphenidate, but the EHR did not show risks/benefits were provided or consent was obtained before the psychotropic meds were given. An LPN initially said consent was documented on a form but later could not locate it, and the DON stated the missing consent forms for the resident's multiple psychotropics did not meet expectations.
Failure to Accommodate a Resident’s Haircut Request: A resident with DM, CHF, and depression repeatedly asked for a haircut, but the facility had no hairdresser available after salon services stopped. Staff confirmed grooming appointments had not been available for about 1.5 years, and resident council minutes showed ongoing concerns about when hair services would resume. The DON stated residents who wanted haircuts should have been accommodated.
A facility failed to ensure SNF ABNs were timely provided and completed for two residents reviewed for beneficiary notification. One resident received the ABN after the last covered Medicare skilled day had ended, and another resident’s ABN was not signed by the resident or representative. Staff stated the ABNs should have been provided with the NOMNC and signed as required.
A resident with a brain stem hemorrhage, depression, anxiety, and cognitive communication deficit was observed in a room with a bed frame that had exposed metal and no mattress or covers. On multiple observations, a second bed near the resident also had no mattress or covers. An ADON/LPN stated the bed should be made and have a mattress and that the condition was not a homelike environment.
A resident with dementia, asthma, HTN, and malnutrition was using a Wander Guard daily, but the facility did not complete the required follow-up assessment within the expected timeframe. The resident said they wanted to go outside and pointed to the bracelet, while an LPN was unsure how often residents should be reassessed and the DON stated the reassessment should have been done sooner.
Two residents received psychotropic medications without the expected documented clinical indication. One resident with dementia was given Seroquel for agitation despite no behaviors on the MDS, and the record lacked behavior monitoring, adverse effect monitoring, and a care plan for antipsychotic use. Another resident received citalopram hydrobromide and methylphenidate even though the diagnosis list did not include depression, and staff acknowledged the documentation did not meet expectations.
A resident with heart failure, bipolar disorder, and respiratory failure reported being singled out and shamed over sexual orientation during religious activities, but the facility did not identify the situation as possible mental abuse or log an incident. The facility also could not locate reference checks for five staff and completed late criminal background checks for two CNAs, despite expectations that screening be done upon hire.
Failure to report allegation of abuse: A resident with HF, bipolar disorder, and respiratory failure reported being singled out for being gay during religious discussions with volunteers and activities staff. The resident said the interactions left them upset and unable to sleep, but no incident report was logged and the complaint was treated as a religion preference grievance rather than a reportable abuse allegation.
Incomplete care plans and failure to follow required care instructions. One resident with a brain stem hemorrhage, gastrostomy, and cognitive communication deficit was NPO and receiving tube feeding, but the care plan for dehydration did not include instructions for how fluids were to be given. Another resident’s care plan required two staff for all interactions, yet a CNA provided brief care and hygiene alone and did not recognize the pair-care requirement.
Failure to Apply Ordered Foam Boot for Heel Protection: A resident with CVA, HTN, and PAD was assessed as at risk for skin breakdown and had a provider order for a foam boot to the left foot every shift for heel protection. However, repeated observations showed the resident in bed without the boot, staff could not locate it, the care plan did not include the intervention, and the TAR documented the boot as applied even though staff acknowledged it was not.
A facility failed to monitor a resident’s significant weight loss, failed to document or treat several days without bowel movements for two residents, and failed to provide ordered compression wrap treatment for a resident with edema and bilateral leg ulcers. Staff also identified duplicate Bumetanide orders that needed clarification, and the resident’s legs were observed wrapped in gauze instead of the ordered two-layer compression wraps.
A resident with CVA, HTN, weakness, and an above-knee amputation had repeated bathroom falls while trying to transfer between the toilet and wheelchair. The fall investigations did not document last toileting or last observation times, did not include aide interviews or witness statements, and misidentified the root cause as self-transferring to prepare for meals or to the toilet. The new interventions were not specific enough and were not initiated promptly.
Failure to monitor significant weight loss and nutrition: A resident with bipolar disorder and adult failure to thrive lost weight from 147 to 123 pounds, but the record showed no reweighing or additional weights after a weight warning was documented. Meal intake was not fully documented, the provider and dietitian were not contacted within the expected timeframe, and no new weight-related interventions were added to the care plan.
Enteral nutrition was not administered and documented in accordance with provider orders for a resident with a G-tube. The resident had diagnoses including brain stem hemorrhage, major depression, anxiety, and cognitive communication deficit, and was observed receiving tube feeding in the room. The order called for Jevity at 60 ml/hr with scheduled water flushes, but the MAR showed only 80 ml provided daily, and the DON stated the enteral nutrition documentation did not meet expectations.
Two residents did not receive pain management consistent with provider orders. One resident with diabetes, chronic venous hypertension with bilateral leg ulcers, and fibromyalgia had pain ratings documented without consistent NPI use or PRN Tylenol administration within ordered parameters, and staff noted pain above the ordered range should have prompted provider notification. Another resident with chronic pain syndrome reported severe pain and, despite hydromorphone orders for 2 tablets when pain was 7-10, was repeatedly given only 1 tablet when pain ratings were 7, 8, and 9.
Medication administration errors exceeded the allowed rate when two errors occurred in twenty-seven opportunities. An LPN gave one resident vitamin C instead of the ordered vitamin B12, and another LPN gave a resident duplicate folic acid doses while the ordered prenatal vitamin with ferrous fumarate-folic acid was not administered. The DON stated licensed nurses were expected to follow provider orders.
Unlocked Medication and Treatment Carts: The facility failed to keep 1 treatment cart and 1 medication cart locked during medication storage observations. An LPN left a treatment cart unlocked while on break coverage, and an LPN left a medication cart unlocked and out of visual supervision while administering meds; the medication cart was also later observed unlocked for several minutes. The DON stated the carts should have been locked when nurses were not next to them.
Failure to administer consented COVID-19 vaccines to two residents. The facility’s policy required residents to be offered the vaccine and, if they consented, to receive it at the facility or through an outside service. Two residents, including one with diabetes and one with a skin infection, consented to the COVID-19 vaccine, but the EHR had no documentation that either vaccine was administered. An LPN/IP and the DON stated residents should be educated, given the VIS, and vaccinated after consent.
A resident with a Foley catheter did not receive necessary care or monitoring, as there were no documented orders, care plans, or staff tasks addressing catheter care or securement. The resident developed severe pain and a mucosal membrane pressure injury at the catheter site, requiring hospital transfer and intervention. Facility staff confirmed that expected protocols for catheter care were not implemented.
A resident with cognitive impairment and a history of stroke and dementia, who required staff assistance for daily living, was able to leave the facility unsupervised due to failures in risk assessment, monitoring, and staff communication. The resident was later found by bystanders on a freeway ramp after a fall and was transported to the hospital, with facility staff unaware of the resident's absence until notified by the hospital. The facility's investigation revealed deficiencies in elopement risk evaluation, delayed response in searching for the resident, and lack of familiarity among reception staff with residents.
The facility failed to obtain informed consent for psychotropic medications for three residents. A resident received Zolpidem Tartrate and Escitalopram Oxalate without proper consent documentation, another was given risperidone without consent, and a third received Trazodone without verbal or written consent. Staff interviews confirmed the lack of documentation and the failure to meet expected procedures.
The facility failed to obtain necessary consent, assessment, and physician orders for the use of low beds, considered a form of physical restraint, for three residents. These residents, who were assessed as fall risks and required staff assistance, were observed in low beds without the required documentation. The Director of Nursing acknowledged this did not meet expectations, and this issue was previously cited.
The facility failed to investigate multiple allegations of abuse and neglect, including a resident left in a wheelchair for three nights, another resident's electric wheelchair removed without proper documentation, and unaddressed medication issues. Staff interviews revealed a lack of communication and failure to recognize these situations as neglect, leading to potential risks for continued abuse and diminished quality of life.
The facility failed to monitor and correctly set Low Air Loss Mattresses (LALM) for three residents, leading to a deficiency in pressure ulcer care. A resident with multiple health issues had an LALM incorrectly set at 200 lbs, despite weighing 126.8 lbs. Similar issues were found with two other residents, whose LALM settings did not match their weights. Maintenance staff set up the LALM based on estimated weight ranges, and licensed nurses were responsible for monitoring, which was not documented.
The facility did not maintain the required minimum RN coverage of eight hours daily for 60 out of 92 days. Nursing schedules for July, August, and September 2024 revealed significant gaps in RN coverage. The Staffing Coordinator admitted to the shortage of available RNs, and the DON confirmed that the facility's expectations were not met.
The facility failed to provide non-pharmacological interventions (NPI) before administering PRN pain medications to several residents, despite orders to do so. Residents with various medical conditions received pain medications without prior NPI, as documented in their medication administration records. Interviews with staff confirmed that the facility's expectations for documenting NPI were not met.
The facility's QAPI program failed to identify and address deficiencies, leading to repeated issues. Key deficiencies included failure to report abuse allegations, improper use of pressure ulcer prevention interventions, and lack of psychotropic medication consents. The QAPI committee was often unaware of these issues, resulting in unresolved deficiencies.
A facility failed to review and update the AD for a resident with dementia, missing required reviews and lacking documentation of court-appointed guardianship. Staff interviews revealed a lack of follow-up and documentation efforts, placing the resident at risk of not having an established decision maker.
A resident's personal wheelchair had armrests in disrepair, with cracked vinyl exposing uncleanable surfaces. The resident, diagnosed with cancer and depression, reported the issue, and staff confirmed the need for repair or replacement. The condition did not meet the facility's expectations.
A resident with palliative care needs was left in a power wheelchair for three nights due to missing transfer equipment, preventing proper wound care and causing distress. Despite staff being informed, the issue was not promptly addressed, leading to an allegation of neglect.
The facility failed to provide written transfer notifications to two residents or their representatives, as well as the Ombudsman program. One resident with encephalopathy and diabetes and another with heart failure and COPD were transferred to the hospital without receiving the required written notices. Staff acknowledged the oversight, admitting that only verbal notifications were given.
Failure to Provide Ordered Showers and Enter a Medication Order
Penalty
Summary
The facility failed to provide showers and bathing according to resident preferences and care plans for 2 of 5 sampled residents. One resident, admitted in 2014 with multiple sclerosis and documented as cognitively intact, was care planned for two evening showers a week with a preference for a female caregiver, but stated she was only getting one shower a week and sometimes went 8 or more days without a shower when shower aides were pulled to the floor. She reported that she had repeatedly told staff she wanted at least two showers a week and said she had just received her first shower in 8 days the night before the interview. A second resident, admitted with type 2 diabetes mellitus and documented as cognitively intact, was care planned for a tub bath on evening shift and preferred two tub baths a week. He stated that at times he received a weekly shower, but sometimes it was closer to every other week, and that he wanted two showers a week every week, especially as the weather was getting warmer. A CNA/shower aide stated that residents generally got 1 or 2 showers a week but that it was honestly closer to 1 shower a week, and that shower aides were often pulled to the floor, which caused showers not to get done. The facility also failed to implement a medication order for 1 of 3 sampled residents. A resident admitted with type 1 diabetes mellitus with foot ulcer returned from an outside provider visit with a reported increase in trazodone from 100 mg to 150 mg and a new naltrexone order. The SBAR documented the medication changes and the nurse practitioner noted the trazodone increase would be reviewed with the resident and meds updated. The physician orders were updated for naltrexone 50 mg daily, but the trazodone order for 150 mg was not located in the physician orders. The LPN/RCM stated that the trazodone increase had been approved by the in-house provider and should have been entered into PCC, but it was not.
Failure to Inform Residents of Medicare Coverage Changes
Penalty
Summary
The facility failed to ensure that residents were fully informed and understood their health status, care, and treatments when their insurance coverage was changed from a Medicare Advantage plan to Traditional Medicare. The report states that 6 of 6 residents reviewed for insurance disenrollment were not informed of the risks, benefits, options, and alternative changes in their insurance in a way that was easy for the residents and/or their representatives to understand. The facility also failed to develop written policies and procedures for assisting beneficiaries with changing health care coverage, including obtaining a signed document acknowledging that the specific information about the impact of the coverage change was provided orally and in writing and understood. The Skilled Nursing Facility admission agreement showed the facility was an in-network provider for some Medicare Advantage plans and that, for residents covered by Managed Medicare, skilled nursing care was managed through the insurance company. The CMS memo dated October 2021 stated that only the beneficiary, the beneficiary's authorized or designated representative, or a party authorized under state law can request enrollment or voluntary disenrollment from a Medicare health or drug plan, and that facilities must explain orally and in writing the impact of changing coverage and develop written policies and procedures for the process. Resident 4 was cognitively intact and had diagnoses including hemiplegia and hemiparesis following cerebral infarction. The record showed the resident was transferred from Medicaid to a managed Medicare plan and then to Traditional Medicare effective 05/01/2026, but there was no documentation that the resident or POA was explained orally and in writing the impact of changing coverage. Resident 4 said she did not handle her finances and to call her daughter, who was her POA; the resident denied receiving anything in writing. The POA said she had not been aware the insurance had been changed to Medicare A. Resident 5 was cognitively intact and had a diagnosis of an unspecified fracture of the upper end of the right humerus. The record showed the resident was admitted on a Medicare Advantage plan and transferred to Traditional Medicare effective 05/01/2026, with no documentation that the resident or POA was explained orally and in writing the impact of changing coverage. A social services note documented discussion of insurance coverage options and that Resident 5 agreed to enroll in Traditional Medicare A and B and disenroll from the Medicare Advantage plan. The resident later stated the change was explained as allowing more therapy and helping her get home faster, but she had not received anything in writing and was having difficulty getting an appointment with her usual doctor because of the insurance change. Resident 6 was cognitively intact and had diagnoses including chronic combined systolic and diastolic CHF. The record showed the resident was originally admitted on a Managed Medicare plan, then re-admitted and transferred to Traditional Medicare effective 05/01/2026, with no documentation that the resident or POA was explained orally and in writing the impact of changing coverage. A social services note documented discussion of insurance coverage options and agreement to enroll in Traditional Medicare A and B and disenroll from the Medicare Advantage plan. The resident could not be interviewed because of repeated declinations. Resident 7 was cognitively intact and had a diagnosis of unspecified atrial fibrillation. The record showed the resident was originally admitted on a Managed Medicare plan and transferred to Traditional Medicare effective 05/01/2026, with no documentation that the resident or POA was explained orally and in writing the impact of changing coverage. A social services note documented discussion of insurance coverage options and agreement to enroll in Traditional Medicare A and B and disenroll from the Medicare Advantage plan. Resident 7 was discharged from the facility and had not returned calls. Resident 8 had diagnoses including spondylosis without myelopathy or radiculopathy in the lumbosacral region, and the MDS documented moderate cognitive impairment. The record showed the resident was originally admitted on a Managed Medicare plan and transferred to Traditional Medicare effective 05/01/2026, with no documentation that the resident or POA was explained orally and in writing the impact of changing coverage. The resident stated he switched to Medicare at the beginning of the month because he wanted more therapy and said he was glad he switched, but he had not been provided anything in writing explaining either disenrolling from the old plan or enrolling in the new plan. Resident 9 had diagnoses including cerebral edema and was documented as moderately cognitively impaired. The record showed the resident was originally admitted on a Managed Medicare plan and transferred to Traditional Medicare effective 05/01/2026, with no documentation that the resident or POA was explained orally and in writing the impact of changing coverage. The resident had been sent to the ER and admitted to the hospital and could not be interviewed. Staff A, Executive Director, stated the IDT identified residents as possibly benefiting by changing insurance to Medicare so they might improve beyond baseline, Social Services discussed insurance options with the identified residents, and those who wanted to change were processed. Staff A also stated oral discussion was provided, no written material was given, and there was no policy addressing the issue.
Failure to Protect Residents from Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse during a resident-to-resident altercation involving two residents with severe cognitive impairment and diagnoses of unspecified dementia with behavioral disturbances. Resident 1 was sitting in the activity room when Resident 2 told her she was in the wrong seat, threatened to hit her, and then struck her on the right arm. The incident was documented as an alleged resident-to-resident altercation, and Resident 1 was later assessed with no pain, discoloration, or skin tear noted. Record review documented that staff separated the residents and placed Resident 2 on 1:1 supervision after the incident. Resident 2 was described as verbally aggressive during interview, stating, "I'm going to kick her mother fucking ass!" Resident 2 was assessed with no injuries noted, police responded, and Resident 2 was transported to the hospital. The report states the facility failed to protect Resident 1's right to be free from physical abuse in this event.
Failure to investigate new skin impairments and implement wound care orders
Penalty
Summary
The facility failed to provide necessary care and services for Resident 3, who was admitted with multiple diagnoses including Alzheimer’s disease and was documented as severely cognitively impaired on the quarterly MDS. A UWH note dated 03/06/2026 documented that the resident would benefit from a formal vascular assessment with arterial duplex based on prior ABI results, but the electronic medical record did not show that an order was received, implemented, or that results were available. On 04/01/2026, a progress note documented a new right knee wound, redness, and strips of blisters on the right shoulder and hip, with discomfort noted and a new zinc oxide order entered. The incident log for April 2026 did not include an investigation for the skin impairment involving redness and strips of blisters on the right shoulder and hip, and abuse/neglect was not ruled out. A Skin Alteration packet dated 04/08/2026 documented a reddened area on the right hip concerning for early pressure injury formation, but the notes section described a small skin tear in the groin area and did not address the right hip finding. A UWH note dated 04/10/2026 documented new maceration and ulceration on the ventral penis, most likely caused by incontinence, with a recommendation for aggressive zinc oxide application to the buttocks, groin, and around the penis; the incident log did not include an investigation for this ulceration. A Skin Alteration packet dated 04/24/2026 documented a new stage 3 pressure ulcer to the left posterior thigh, but the investigation conclusion repeated the earlier groin skin tear description and did not address the identified pressure ulcer, and abuse/neglect was not ruled out. The UWH note the same day documented the new stage 3 pressure ulcer on the left posterior thigh and sharp debridement. The eTAR for April 2026 showed zinc oxide orders for the right shoulder and right hip, but no provider treatment order was documented for the MASD, ventral penis ulceration, or the stage 3 pressure ulcer to the left posterior thigh. On 05/01/2026, UWH documented additional wounds, including a right buttocks stage 3 pressure ulcer and a left buttock stage 3 pressure ulcer, while the incident log for May 2026 did not include an investigation for Resident 3, and the care plan had not been updated to reflect several identified skin impairments.
Failure to Prevent Resident-to-Resident Physical Altercations
Penalty
Summary
The facility failed to protect residents’ right to be free from physical abuse in multiple resident-to-resident altercations. Facility policy dated April 2021 required policies to prohibit and prevent resident abuse, neglect, and exploitation, including prevention measures. Despite this, one incident involved a moderately cognitively impaired resident with late-onset Alzheimer’s disease taking food from a used tray in the main dining room near the end of a meal. Another cognitively intact resident told him he could not take food from trays, after which the first resident hit the second resident in the face, causing the second resident to fall to the ground. Both residents later described the event as beginning when the first resident took cornbread from a used tray and the second resident verbally intervened, leading to tempers flaring and the physical strike. In a separate incident, two severely cognitively impaired residents with Alzheimer’s disease or unspecified dementia with behavioral disturbances were involved in a physical altercation over a wheelchair in their shared room. One resident attempted to take or touch the other resident’s wheelchair, and both residents pushed each other, resulting in one resident falling to the ground and reporting she hit her head and back. Progress notes documented that the resident who fell reported being pushed down by her roommate, while the other resident reported pushing her roommate away from the wheelchair and accidentally pushing too hard, causing the fall. Both residents later did not remember the incident. These events occurred despite the facility’s stated policies to prevent abuse and resident-to-resident altercations.
Insufficient Nursing Staff and Nonfunctional Call Light Systems
Penalty
Summary
The facility failed to provide sufficient nursing staff and functional call light systems across multiple units and shifts to meet residents’ basic care needs. Observation on 01/07/2026 at 10:47 PM showed the 100 and 200 Hall call light boards disconnected with blue screens stating “Disconnected: click to configure connection” and constant beeping. Observation on 01/13/2026 at 8:26 AM showed the [NAME] Care call light system at the North and South nursing stations displaying resident room call lights on the screen, but the audible feature was not working, with an X shown through the audible display. Residents and staff described delayed responses and short staffing. One resident stated call lights sometimes took more than an hour to be answered and staff would turn the light off without meeting the need. Another resident reported an hour wait on day shift and one night spent four hours in a wet brief before help arrived. Other residents reported half-hour waits, long delays for medications, and waiting over a week for showers and sheet changes. Resident Council Minutes from multiple months documented long call wait times on night shift, lack of staff to assist residents to activities, call lights being turned off before needs were met, and difficulty finding nursing aides after breakfast. Staff reported ongoing call outs, working short staffed, not being able to provide all necessary care, restorative staff being pulled to the floor, and shower aide positions not being filled.
Failure to Complete Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to conduct annual performance evaluations for 5 of 5 Certified Nursing Assistants (Staff D, F, GG, EE, and PP) within the last 12 months. Review of the employee files for these CNAs found no documentation that the required performance evaluations had been completed. During interview, the Human Resources/Payroll staff member stated they were aware the CNAs needed yearly performance evaluations, but they had not been completed. The Administrator later stated that due to staff changes, the performance evaluations were not completed and that this did not meet expectations.
Food Quality and Meal Service Deficiencies
Penalty
Summary
The facility failed to ensure food and drinks were palatable, attractive, and served at an acceptable temperature. Multiple residents reported that meals were bland, greasy, mushy, cold, undercooked, or otherwise unappetizing. Residents also stated that they frequently could not identify the food served, that menu items did not match what was delivered, that requested alternatives were not provided, and that portion sizes were too small. Several residents described having to ask staff to microwave meals, request sandwiches or substitutions, or send trays back to the kitchen because the food was not edible. Resident interviews reflected ongoing dissatisfaction across the facility. Residents reported receiving pork despite not eating pork, missing items from meal trays, breakfast items that were bland or absent, and meals that were not the same as the menu. Some residents stated they did not get enough to eat and had to request more food from the kitchen. Others described the food as terrible, disgusting, or not fit to eat, and one resident stated they would not feed the facility’s food to a pet. The dietary manager acknowledged awareness of concerns about food quality and missing requested items, and the administrator stated they were aware of resident concerns and working with the regional group, while also stating the residents’ complaints and grievances did not meet expectations. Resident Council minutes and grievance reports documented repeated concerns over several months about watery scrambled eggs, undercooked French toast, burnt or overcooked vegetables, cold coffee and breakfast, sour scrambled eggs, meals with missing or substituted items, and poor presentation on trays. Grievances also described cold meals with warm liquids, no silverware, missed dinner trays, not receiving ordered items, and food that was tasteless or not edible. The record shows these concerns were recurring and widespread, affecting multiple residents and meal periods.
Failure to Maintain a Full-Time Qualified Social Worker
Penalty
Summary
The facility failed to maintain a full-time qualified social worker in a building licensed for 130 beds. During interview, the Social Services Assistant stated the Social Services Director had been on maternity leave for two weeks and that they were covering the qualified social worker duties despite not having formal education in social work. The Administrator stated the Social Services Director had been on leave since about 12/19/2025 and would remain on leave for at least two more weeks, and that although the facility employed a qualified social worker and one was available by phone or email, no one was serving as the full-time qualified social worker at that time. The deficiency was cited under WAC 388-97-0960(2)(a)(b).
Unapproved bedside medications left with residents
Penalty
Summary
The facility failed to ensure safe and appropriate medication practices by leaving medications at the bedside for residents who were not assessed or approved to self-administer them. The report states that the facility’s policy required medications found at the bedside to be turned over to the nurse in charge unless the interdisciplinary team determined self-administration was clinically appropriate and safe. In this case, the interdisciplinary team assessments and care plans did not support bedside medication storage or self-administration for the residents involved. Resident 40 was readmitted with diagnoses including respiratory failure, schizophrenia, and PTSD, and was able to make needs known. During observation, multiple vitamins with minerals and Prevagen were found at the bedside, and Preparation H medicated cream was found in the bathroom. The resident stated they gave the vitamins and Prevagen to themself and that the nurses were aware, but the medication self-administration evaluation dated 12/29/2025 showed the resident was not approved to self-administer medications and that a licensed nurse was to administer medications. The order summary also showed an order stating the resident may not administer own meds, and staff stated the resident should not have had medications at the bedside or in the bathroom. Resident 15, who had diagnoses including diabetes, gastritis, and high blood pressure, was observed with chewable Tums and Visine on the nightstand and overbed table. The resident stated they used the items without telling the nurse because they were over-the-counter medications. The care plan did not include self-administration, the self-medication evaluation showed the resident was not approved to self-administer medications, and the order summary stated the resident may not administer own meds. Resident 114, admitted with cerebral infarction, high blood pressure, and muscle weakness, was observed with Aspercreme Lidocaine roll-on on the overbed table and stated it was a gift from a friend that they used once or twice a day for pain. The resident had no care plan or provider order for self-administration or bedside medication, and the self-medication evaluation showed the resident was not approved to self-administer medications.
Failure to Provide Bed Hold and Discharge Documentation
Penalty
Summary
The facility failed to provide written bed hold notice at the time of hospital transfer for 4 of 4 sampled residents. Resident 1 was admitted with diabetes and respiratory failure and was able to make needs known, but when transferred to the hospital there was no documentation that a bed hold was offered. Staff B, the DNS, stated bed holds should be offered and include the price per night when a resident is transferred to the hospital. Resident 40 was readmitted with respiratory failure, schizophrenia, and high blood pressure and was able to make needs known. The record showed an unplanned hospital discharge with return anticipated, but the bed hold policy notice and authorization form was incomplete, missing the year, the cost to hold the bed, and the resident or representative signature. The SNF/NF hospital transfer form was inaccurately completed with an incorrect transfer date and no documentation that it was sent with the resident, and the DSHS Nursing Home Transfer or Discharge Notice was not signed by the resident or representative. The record also lacked documentation that the resident received written notice of the reason for transfer or that required information was conveyed to the receiving hospital. Resident 7 had diagnoses including stroke and muscle weakness and was able to make needs known, but the EHR showed an incomplete bed hold after hospitalization. Resident 8 had diagnoses including hemorrhage in the brain stem, gastrostomy, depression, anxiety, and cognitive communication deficit and was not always able to communicate needs; the record contained a bed hold policy notice and authorization form that was not signed and had no verbal notification documented. The facility also failed to provide written notice of transfer/discharge and recapitulation of stay for 2 of 4 sampled residents. Resident 111 was discharged from the facility, but the EHR did not contain documentation detailing the discharge, and staff were unable to locate a completed discharge summary or documentation that it was provided to the resident or representative.
MDS Assessments Were Not Accurately Coded for Hearing and PASSAR Status
Penalty
Summary
The facility failed to ensure the minimum data set (MDS) assessments accurately reflected the status of 3 of 27 sampled residents reviewed for assessment accuracy. Resident 10 was admitted with diagnoses including schizoaffective disorder, depression, and anxiety, and was able to make needs known. During interview, the resident stated they could not hear anything in the left ear and preferred staff speak on the right side. The care plan documented impaired communication due to left ear deafness, but the quarterly MDS coded hearing as minimal difficulty. Staff later stated that a complete hearing deficit in one ear should have been coded as moderate difficulty and acknowledged the MDS was coded incorrectly. Resident 8 was admitted and readmitted with diagnoses including hemorrhage in the brain stem, gastrostomy, major depression, anxiety, psychotic disorder with delusions, and cognitive communication deficit, and was not always able to communicate needs. The record showed a level 2 PASSAR completed in 2024, and the annual MDS indicated the resident was receiving antipsychotic and antianxiety medications, but the annual MDS did not assess the resident as having level 2 PASSAR. Resident 40 was readmitted with diagnoses including personality disorder, schizophrenia, and PTSD, and the care plan stated the resident met PASSAR level 2 determination related to serious mental illness. However, the admission MDS coded section A1500 as No for having a PASSAR level 2 with serious mental illness, and staff stated this should have been coded Yes and that the admission MDS needed to be modified.
Care plans not updated to reflect current resident needs and orders
Penalty
Summary
The facility failed to ensure care plans were reviewed and revised for 5 of 22 residents reviewed for care plan review. The report identified that the comprehensive care plans were not kept current with resident conditions, provider orders, or services being provided, and that the care plans were not prepared, reviewed, and revised by a team of health professionals as required. Resident 12 had diagnoses including diabetes, high blood pressure, and muscle weakness, and was observed with a wander guard device on the left wrist while asleep in bed on multiple occasions. The resident stated they did not know what the device was for. The most recent elopement risk assessment in the record was completed on 06/06/2025. Staff stated the device evaluation had not been completed, even though it should have been, and the DNS stated the resident had no exit-seeking incidents in over a year and should have been reassessed to determine whether the wander guard remained appropriate and whether the care plan should have been revised. Resident 8’s record showed a restorative program care plan that remained in place even though collateral contact stated the resident was no longer on restorative and was receiving therapy instead. Resident 2’s care plan still reflected an indwelling Foley catheter even though the catheter had been removed in December 2025 and a provider note stated the resident was urinating fine without it. Resident 37’s care plan continued to address risk for complications related to psychotropic drugs even though all psychotropic medications and behavior monitors had been discontinued. Resident 51’s care plan listed oxygen at 3 liters continuous and a risk for respiratory complications related to Covid, while the provider order required oxygen at 4 liters continuous and the record did not show active Covid; staff and the DNS stated the care plan needed revision to reflect the current orders and condition.
Failure to Provide Scheduled Bathing and Personal Hygiene Assistance
Penalty
Summary
The facility failed to provide necessary care and services to maintain personal hygiene for three residents who needed assistance with bathing and daily care. Resident 117 was admitted with obesity, a history of falling, and a left artificial knee joint, and was able to make needs known. The resident stated they had asked for showers but did not always receive them, had only one shower since admission, and had not been offered a bed bath or other shower despite needing staff assistance. The care plan identified one staff assistance with bathing/showering, and the shower schedule showed the resident was assigned one shower per week, but the resident’s bathing documentation in the EHR showed no information available at the time of review. Resident 99 was admitted with heart failure, diabetes, and muscle weakness, and was also able to make needs known. The resident stated they had been asking for a shower since admission and had only received one shower, despite being told they could have showers once or twice a week. The care plan identified two staff assistance with bathing/showering, and the shower schedule showed the resident was assigned a weekly shower. Point of care documentation showed showers on several dates in the prior 30 days, including one documented as provided by a CNA; however, during interview both the resident and the CNA stated the CNA had not provided that shower, and the DNS stated showers were not consistently offered, provided, or documented as required. Resident 17 was admitted with chronic pain syndrome and major depressive disorder and was able to make needs known. During interview and observation, the resident stated they had not had a shower or bed bath since May and that staff did not help with washing the face, brushing hair, or brushing teeth unless the resident called for help. The resident had visible oral and hair hygiene concerns at the time of observation. The care plan identified maximum assistance with bed baths, personal hygiene, and oral care. Staff interviews showed one CNA did not wash hair during bed baths and did not offer oral care or hair brushing unless asked, another CNA stated showers or bed baths were only given if a resident requested them, and the DNS stated the expectation was that assigned CNAs should provide showers or bed baths when no shower aide was available and that morning care should include assistance with face washing and brushing hair and teeth.
Respiratory Care Orders and Monitoring Not Followed
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for three residents who had orders for oxygen therapy. Resident 40 had diagnoses including COPD and respiratory failure and was ordered oxygen at 3 liters per minute via nasal cannula continuously for pneumonia with pulse oximetry every shift to keep oxygen saturations at or above 90%. Multiple observations showed the oxygen concentrator in the resident’s room near the bed and not in use, and the resident stated they only used oxygen at night. The record also showed no current diagnosis of pneumonia, no order to clean the oxygen concentrator filter, and documentation that did not show the filter was being cleaned. Resident 42 had diagnoses including COPD, heart failure, and respiratory failure and was observed in bed with oxygen via nasal cannula connected to a humidifier and concentrator at 2 liters per minute. The provider order required oxygen continuously for shortness of breath and documentation of oxygen saturations every shift, but the order did not include parameters for when to notify the provider based on oxygen saturation levels. The January 2026 treatment administration record documented oxygen saturations per order, but the order itself lacked the required parameters. Resident 51 had diagnoses including COPD, heart failure, and respiratory failure and was observed in bed receiving oxygen via nasal cannula at 4 liters per minute from a concentrator. The provider order required continuous oxygen and post-treatment evaluation of heart rate, respiratory rate, pulse oximetry, skin color, and breath sounds, but the order did not include oxygen saturation parameters for provider notification. The care plan included maintaining saturations at or above 90%, and the treatment administration record documented oxygen and saturations, but it did not document the ordered post-treatment assessments consistently in the treatment record or progress notes.
Unnecessary PRN pain medication use and failure to follow medication parameters
Penalty
Summary
The facility failed to ensure residents’ drug regimens were free from unnecessary drugs by not following provider directions for PRN pain medications and by not holding blood pressure medications per ordered parameters. The deficiency involved 4 of 7 sampled residents: Residents 4, 115, 2, and 99. The report states that failure to ensure nonpharmacological interventions were used before PRN pain medications and failure to follow blood pressure medication parameters placed residents at risk of using unnecessary medications, avoidable side effects, and a diminished quality of life. Resident 4 was re-admitted with diagnoses including diabetes, CHF, and depression and could make needs known. The resident had an order for Roxicodone every 8 hours PRN for pain, with directions to document nonpharmacological interventions before administration. The MAR showed Roxicodone was given multiple times in December 2025 and January 2026, and the documentation for nonpharmacological interventions was marked N/A. An LPN stated NPI were not offered before giving the pain medication, and the DNS stated staff were expected to offer and document NPI before PRN pain medications. Resident 115 had diagnoses including MS, diabetes, and anxiety and was ordered PRN acetaminophen, ibuprofen, oxycodone, and tizanidine with instructions for staff to provide NPI before use. The January 2026 MAR showed ibuprofen, oxycodone, and tizanidine were given without NPI, and the DNS and an LPN stated this did not meet expectations. Resident 2 had diagnoses including hypertensive chronic kidney disease, diabetes, anxiety, and polyneuropathy and was ordered amlodipine and carvedilol with hold parameters for low systolic BP and low heart rate; on one date the resident received both medications despite a heart rate of 56. Resident 2 also received PRN acetaminophen and oxycodone in December 2025 and January 2026 without documented NPI. Resident 99 had diabetes, chronic venous hypertension with bilateral lower extremity ulcers, and fibromyalgia; the care plan addressed pain, and Tylenol was ordered PRN with NPI listed. The MAR showed Tylenol was given for pain level 4, but NPI was documented as NA, and the DNS stated it should have been marked for NPI provided or refused.
Unsafe Food Storage in Resident Refrigerators
Penalty
Summary
The facility failed to ensure resident refrigerators were maintained for safe food storage in the 100 Hall and 200 Hall resident refrigerators. A review of the facility policy titled, Safe Handling of Foods from Visitor, showed foods were to be labeled with the resident's name, current date, and use-by date, items were to be thrown out after 48 hours, and refrigeration temperatures were to be monitored daily at less than 41 F. Observation of the 100 Hall resident refrigerator found numerous items without required labels or with expired dates, including teriyaki, soup, fried chicken, spoiled lettuce, a half sub sandwich with a receipt from 12/23/2025, opened nutritional formula with dried substance in the spout and floating items, French onion dip past best-by date, expired yogurts, pizza, Chinese food, cornbread, an opened water bottle with frozen yellow solid inside, wrinkled grapes, sandwich makings with meat sold on 12/02/2025, pasta, unidentifiable food, and condiments with illegible or out-of-range dates. Observation of the 200 Hall resident refrigerator found similarly unlabeled or expired items, including fast food, ribs and fruit trays with sell-by dates of 12/23/2025, tartar sauce past use-by date, salad, soup without resident name or date, homemade chicken broth and an orange with a note showing placement on 12/20/2025, and a half-eaten pastry without name or date. Review of the temperature logs for both refrigerators showed temperatures ranging from 36 to 46 F. During interview, the Dietary Manager stated nursing staff was responsible for maintaining the resident refrigerators' safe food storage and that food should be thrown away after 48 hours and stored at 41 F or below. The Dietary Manager also stated the temperature log sheets used to monitor the resident refrigerators showed an acceptable range of 34 to 46 F, and this was inaccurate. The Administrator stated the observations of food outside of date range and temperature logs indicating inaccurate safe food temperatures did not meet expectations.
Infection Control Program and Transmission-Based Precautions Failures
Penalty
Summary
The facility failed to maintain an infection prevention and control program by not completing analysis of infection control data, identifying trends, or documenting follow-up activities in response to those trends for October, November, and December 2025. Review of the facility’s infection control surveillance documentation showed infections were not tracked to determine potential spread using a map or other tracking tool, and there was no documented monthly analysis of infection data to identify trends or interventions for all 3 months reviewed. The facility also failed to implement transmission-based precautions for 2 of 4 halls reviewed. Outside one room, an Aerosol/Contact precautions sign directed staff to perform hand hygiene and wear a gown, gloves, an N95 respirator, and eye protection, but an RN entered the room wearing a surgical mask and no eye protection and provided medications before exiting. Outside another room, an Enhanced Barrier Precautions sign directed staff to perform hand hygiene and wear a gown and gloves for high-contact activities, but staff entered and provided personal high-contact care without wearing a required gown.
Failure to Administer and Educate on Pneumococcal Vaccinations
Penalty
Summary
The facility failed to develop and implement policies and procedures for flu and pneumonia vaccinations. Review of the facility policy titled Pneumococcal Vaccine dated August 2025 showed the facility would assess all residents on admission for eligibility to receive the pneumococcal vaccine, provide the vaccine information sheet and education on the risks and benefits when indicated, and administer the vaccine within 30 days of admission if consented. However, record review showed that Resident 5, who was admitted with dementia and whose legal guardian consented to the pneumococcal vaccine, had no documentation that the vaccine was given. Resident 19, admitted with a skin infection and who consented to the vaccine, also had no documentation of receiving it. Resident 35, admitted with diabetes and whose responsible family member consented, likewise had no documentation that the vaccine was administered. Record review also showed that Resident 42, Resident 63, and Resident 65 were offered the pneumococcal vaccine and declined, but there was no documentation that they received the VIS or were educated on the risks and benefits of the vaccine. During interviews, the LPN/Assistant DON acting as infection preventionist stated it was expected that residents be assessed, educated, and offered the pneumococcal vaccines on admission and receive it within a week of consent. The DON stated it was expected that residents receive the VIS and education on the risks and benefits when offered the vaccines, and if they consented, the vaccine should have been ordered and given right away. The DON stated the pneumococcal vaccines for Residents 5, 19, 35, 42, 63, and 65 did not meet expectations.
Lack of Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident was provided risks and benefits and gave consent before being administered psychotropic medications. Review of the electronic health record showed the resident was admitted with diagnoses including multiple sclerosis, diabetes, and anxiety, and was able to make needs known. Provider orders showed the resident received citalopram hydrobromide, alprazolam, and methylphenidate, all psychotropic medications. Review of the electronic health record did not show that the resident was provided risks and benefits or that consent was obtained for the use of these psychotropic medications. During interviews, an LPN stated the facility provided risks and benefits and obtained consent prior to giving psychotropic medications and that this was documented on a consent form, but later stated she was unable to locate consent forms for the resident's psychotropic medications. The DON stated residents were provided risks and benefits and gave consent prior to psychotropic use, and that the lack of consent forms for this resident's multiple psychotropics did not meet expectations.
Failure to Accommodate Resident Grooming Preference
Penalty
Summary
The facility failed to reasonably accommodate a resident’s expressed preference for grooming services by not assisting the resident with accessing a haircut after onsite salon services were discontinued. Resident 4 was re-admitted to the facility with diagnoses including diabetes, congestive heart failure, and depression, and was able to make needs known. During interview, the resident stated they had been waiting for a haircut and had informed staff multiple times, and stated that the facility had previously had a hairdresser who came regularly but had not been providing services for several months. Staff interviews and record review showed the facility had not had a hairdresser available for approximately one and a half years. The receptionist stated they had previously coordinated grooming appointments by communicating resident requests to the hairdresser. Resident Council Minutes documented repeated resident concerns about when a hairdresser would be available, including that the facility was waiting to see if an offer to a hairdresser was accepted and later that the facility and hairdresser were in wage negotiations. The admission packet stated salon services were available through Social Services, but the Director of Nursing stated the facility did not currently have a hairdresser and that residents who wanted haircuts should have been accommodated.
SNF ABNs Were Not Timely Provided or Completed for Two Residents
Penalty
Summary
The facility failed to ensure that Skilled Nursing Facility Advanced Beneficiary Notices (SNF ABNs) were provided timely and/or completed as required for 2 of 3 sampled residents reviewed for Beneficiary Notification. For Resident 93, a Notice of Medicare Non-Coverage dated 07/30/2025 showed the facility informed the resident that skilled nursing services would end on 08/01/2025, and the form was signed on 07/30/2025. The resident’s SNF ABN was dated 08/04/2025 and was provided and signed three days after the last covered date of skilled services ended on 08/01/2025. Staff M, Business Office Manager, stated the SNF ABN should have been provided the same day as the NOMNC, and Staff A, Administrator, stated the ABN should have been provided no more than 48 hours when the last covered date of Part A service had been determined and the resident was to remain in the facility. For Resident 23, a NOMNC dated 09/19/2025 showed the facility informed the resident that skilled nursing services would end on 09/21/2025, and the form was signed on 09/10/2025. The resident’s SNF ABN dated 09/19/2025 was not signed by the resident or a representative. Staff M stated whoever completed the NOMNC for Resident 23 did not get a signature for the SNF ABN, and Staff A stated the SNF ABN should have been signed by the resident or representative. The report cited WAC 388-97-0300(1)(e)(5)(6).
Missing Mattress and Unmade Bed Frame
Penalty
Summary
The facility failed to provide a homelike environment for Resident 8 by not having a mattress on a bed frame and leaving the bed frame with exposed metal visible in the resident’s room. Resident 8 was admitted with diagnoses including hemorrhage in the brain stem, depression, anxiety, and cognitive communication deficit, and was not always able to communicate needs. Survey observations on multiple dates showed Resident 8 in the room with a bed frame that had no mattress and no covers, including a second bed near the resident that also had no mattress or covers. During interview, the ADON/LPN stated the bed should be made and have a mattress, and that the condition observed was not a homelike environment and did not meet expectations.
Failure to Reassess Wander Guard Use
Penalty
Summary
The facility failed to complete a follow-up assessment for Resident 13’s Wander Guard device, which was being used daily and functioned as a device that alarms and restricts movement in and out of doors. The resident was admitted with dementia, asthma, hypertension, and malnutrition, and was able to communicate needs. The annual MDS showed the Wander Guard was in use, and the facility’s policy stated physical restraint assessments were to be reviewed at least quarterly to determine reduction. An EHR document titled Restraint Evaluation/Reduction dated 02/28/2025 included a recommendation to re-evaluate in six months, but the reassessment was not completed within that timeframe. During observation and interview on 01/05/2026, Resident 13 stated they wanted to go outside and pointed to the Wander Guard bracelet on their left wrist, saying whoever took them outside needed to get a star. Staff J, an LPN, stated that residents who were actively going out of the facility got a Wander Guard and was not sure how frequently residents should be reassessed. Staff B, the DON, stated the reassessment of Resident 13’s Wander Guard should have been done sooner and did not meet the expectation.
Psychotropic medications used without documented diagnosis or monitoring
Penalty
Summary
The facility failed to ensure psychotropic medications were prescribed to treat a specific condition for 2 of 5 sampled residents, Residents 13 and 115. The cited deficiency involved the use of medications affecting the mind without the expected supporting documentation and monitoring. The facility policy stated that medications used to treat behaviors must have a clinical indication and be monitored for efficacy, risks, benefits, and adverse consequences, and that if a psychotropic medication is ordered without a diagnosis, the ordering prescriber should review the medication plan and consider a gradual dose reduction. Resident 13 was admitted with diagnoses including dementia, asthma, hypertension, and malnutrition, and was able to communicate needs. The annual MDS dated 11/18/2025 indicated no behaviors, yet the resident was receiving antipsychotic medications. The provider ordered and administered Seroquel for agitation starting 05/03/2025, but the record did not show behavior monitoring, adverse side effect monitoring, or a care plan for antipsychotic use, and the Care Area Assessment was not completed to explain the medication use. Resident 115 was admitted with diagnoses including multiple sclerosis, diabetes, and anxiety, and was able to make needs known. The current orders showed citalopram hydrobromide and methylphenidate, but the diagnosis list did not include depression. Staff stated residents should only receive psychotropic medications for specific diagnoses, and that the lack of a depression diagnosis for Resident 115 did not meet expectations.
Failure to Identify Possible Mental Abuse and Complete Required Hiring Screening
Penalty
Summary
The facility failed to implement its written abuse prohibition policy when it did not identify a potential allegation of mental abuse involving a resident who was admitted with heart failure, bipolar disorder, and respiratory failure and who was able to make needs known. The resident reported being singled out twice because of being gay, including an interaction with an outside preacher during an activity and a later interaction in the dining room when bible study was moved there. The resident stated they felt religion was being pushed on them and that a volunteer said, "I can't go along with that," which the resident perceived as shaming related to sexual orientation. The resident’s complaint/grievance was logged as a religion preference issue and marked pending, but the facility’s incident log did not show a report for the resident during the relevant period. The grievance report stated the resident was offered bible soul salvation when they did not want religion preached to them, and the resolution focused on communicating the resident’s preference not to be offered religious services or faith-based outreach. However, the report did not include the Activity Director’s interview statement that the resident had not expressed feeling shamed to them, but had said that to someone else, which was relevant to whether the situation involved possible mental abuse as defined by the facility policy. The facility also failed to complete required pre-employment screening for multiple staff. Reference checks or information from prior or current employers could not be located for five sampled staff members, including a CNA, LPN, Social Services Director, and ADON. In addition, criminal background checks were completed late for two sampled CNAs, with one check dated about four months after hire and another more than a month after hire. The Administrator stated references were expected upon hire and that the late background checks did not meet expectations.
Failure to Report Allegation of Abuse
Penalty
Summary
The facility failed to identify and report an allegation of abuse for one resident who stated they were singled out because they were gay. The resident, who had diagnoses including heart failure, bipolar disorder, and respiratory failure, was able to make needs known. During interviews, the resident described two separate incidents involving volunteers and activities staff during religious discussions, including being told, "I can't go along with that," and feeling that religion was being forced on them. The resident reported being upset and having no sleep after the events, and the grievance was logged as related to religion preference. The record review showed no incident report was logged for the resident in the facility's incident reporting log for the relevant period. The grievance was marked pending and assigned to the activities department for investigation, and the complaint/grievance report stated it was not a reportable incident. The Administrator stated that if there was potential for abuse, it should have been reported to the state hotline as soon as possible and/or within two hours, and that this situation should have been reported to the abuse hotline, the DON, and the Administrator with an incident investigation initiated at that time.
Incomplete Care Plans and Failure to Follow Required Care Instructions
Penalty
Summary
The facility failed to implement a comprehensive plan of care for Resident 8 and Resident 17. Resident 8 was admitted and later readmitted with diagnoses including hemorrhage in the brain stem, gastrostomy, major depression, anxiety, psychotic disorder with delusions, and cognitive communication deficit, and was not always able to communicate needs. The provider’s orders dated 12/31/2025 showed the resident was NPO, and an observation on 01/05/2026 showed the resident receiving tube feeding and liquids through a tube into the stomach. The care plan dated 11/22/2024 identified a focus area that the resident was at risk for dehydration, but it did not include instructions on how the resident was to receive fluids. During interview, the DNS stated residents with NPO status were expected to have a care plan and directives for staff on how they receive fluids, and stated Resident 8’s care plan did not meet expectations. Resident 17 was admitted with diagnoses of chronic pain syndrome and major depressive disorder and was able to make needs known. The plan of care dated 01/06/2026 stated the resident required two caregivers for all interactions and care in pairs. However, during observation on 01/09/2026, a CNA was providing a brief change and personal hygiene to the resident alone, and when asked if the resident required care in pairs, the CNA stated no. The DNS later stated it was the expectation that staff followed the plan of care and that if a resident required care in pairs, a second staff member should be present for all interactions.
Failure to Apply Ordered Foam Boot for Heel Protection
Penalty
Summary
The facility failed to ensure that a foam boot ordered for left heel protection was applied for Resident 114. Resident 114 was admitted with diagnoses including cerebral infarction, hypertension, and atherosclerosis of both legs, and was able to make needs known. The electronic health record showed an admission MDS indicating the resident was at risk for developing a pressure ulcer or skin wound injury. A provider order dated 10/14/2025 directed staff to apply a foam boot to the left foot every shift for left heel protection, but the resident’s focused skin breakdown care plan initiated on 09/17/2025 did not include an intervention for a foam boot to the left foot. During interview, Resident 114 stated the left heel was sensitive and that staff had said they would get a boot for the left foot, but it never arrived. Multiple observations on 01/07/2026, 01/08/2026, 01/09/2026, and 01/12/2026 showed the resident lying in bed without a boot on the left foot. Staff U stated they had never seen the resident wear a foam boot and that the care plan and Kardex did not show one. Staff R stated the boot was not in place and could not be located in the room, and acknowledged the January 2026 TAR documented the boot as applied even though it had not been. Staff B stated the provider’s order should have been followed and that the TAR documentation did not meet expectations.
Failure to Monitor Weights, Bowel Function, and Edema Treatments
Penalty
Summary
The facility failed to provide quality of care related to monitoring resident weights, bowel management/treatments, and edema management/treatment for four residents. One resident with bipolar disorder and adult failure to thrive had a documented weight decrease from 147 pounds to 123 pounds, a progress note indicating a weight warning and reweigh order, and no additional weights were taken. Meal intake was not documented for all meals, and the care plan did not include new interventions related to weight monitoring. Staff stated the provider, dietician, and guardian should have been notified and recommendations implemented when the weight loss was identified. Two residents had bowel management concerns. One resident with urinary tract infection, urinary retention, diabetes, anxiety, and polyneuropathy had no documented bowel movements for five consecutive days, and laxative medications were available but not administered. Another resident with dementia, asthma, hypertension, and malnutrition had no documented bowel movements for four consecutive days, and as-needed constipation medications were available but not given. Staff stated bowel movements were to be monitored daily, documented, and reported to the nurse, and that laxatives were to be started after two days without a bowel movement and followed until results were achieved. A resident with heart failure, diabetes, chronic venous hypertension, and bilateral lower extremity ulcers had provider-ordered two-layer compression wraps for edema and wound care, but the legs and feet were observed wrapped in gauze instead of the ordered compression wraps. The resident stated staff did not use the compression bandages, and later stated gauze had been applied because the facility ran out of compression wraps. The record also showed two Bumetanide orders for fluid retention, and a pharmacy review noted the 0.5 mg order had been entered as 1 mg and recommended clarification. Staff stated the treatment supplies should have been available, provider orders followed, and the duplicate Bumetanide orders needed clarification.
Incomplete fall investigations and delayed toileting-related interventions
Penalty
Summary
The facility failed to thoroughly investigate Resident 114’s falls and did not ensure new interventions were appropriately developed or timely initiated. Resident 114 was admitted with diagnoses including cerebral infarction, hypertension, muscle weakness, and acquired absence of the right leg above the knee, and was able to make needs known. The resident reported falling in the bathroom while trying to transfer from the toilet to the wheelchair, and the incident reports showed falls on 12/04/2025 and 12/17/2025. The investigation for the 12/17/2025 fall did not document when the resident was last toileted or last observed/provided care before the fall and did not show that the assigned aide was interviewed or that a witness statement was obtained. The root cause was documented as self-transferring to prepare for dinner, rather than the resident’s transfer from the toilet to the chair, and the new intervention of assisting with transfer to the wheelchair prior to meals with frequent visual safety checks did not specify how often the checks were to occur. The resident’s care plan showed the new interventions were initiated on 12/11/2025, seven days after the fall. A second incident report also did not show when the resident was last toileted or last observed/provided care before the fall and did not show that the assigned aide was interviewed or a witness statement obtained. That report documented the resident was found on the floor in front of the toilet and stated they had gone to the bathroom by themselves and fell while trying to transfer back into the chair. The root cause was documented as self-transferring to the toilet before lunch, and the new intervention was staff assistance with toileting before and after meals. Staff stated the investigation should have included the resident’s transfer status, last toileting time, and staff statements, and that the interventions should have been initiated sooner and been more specific to toileting.
Failure to Monitor Significant Weight Loss and Nutrition
Penalty
Summary
The facility failed to ensure that a resident with significant weight loss was identified, assessed, and provided with interventions related to nutrition. Resident 5 was admitted with diagnoses including bipolar disorder and adult failure to thrive and was able to make needs known. The resident weighed 147 pounds on 11/10/2025 and 123 pounds on 12/02/2025. A progress note dated 12/05/2025 documented a weight warning for a five percent change over 30 days and noted variable meal intake with an order to reweigh, but the record showed no documentation that the resident was reweighed or that any additional weights were taken. A Change of Condition Evaluation completed by Staff J, LPN, documented that the resident had a five percent weight loss within the past 30 days. The provider was notified on 01/06/2026 and recommended monitoring, but the care plan contained no new interventions related to weight monitoring. The resident’s meal intake was not documented for all meals throughout the day. During interviews, Staff J stated the provider should have been notified the same day significant weight loss was identified and that a weight variance meeting with the Dietician and DON should have been conducted, but it did not occur. Staff B, DON, stated staff were expected to contact the provider and Dietician within 24 hours when weight loss was identified and that the lack of monitoring of meal intake and weights did not meet expectations.
Enteral Nutrition Not Administered and Documented per Order
Penalty
Summary
The facility failed to ensure enteral nutrition was administered in accordance with provider orders and professional standards of practice for one resident who had a gastrostomy tube. The resident was admitted and later readmitted with diagnoses including hemorrhage in the brain stem, gastrostomy, major depression, anxiety, and cognitive communication deficit, and was not always able to communicate needs. On observation, the resident was seen in the room with a pole and machine connected to a bag of water and tube feeding formula delivering liquids into the stomach via tube. Review of the provider's orders dated 12/31/2025 showed an enteral feeding order for Jevity at 60 ml every hour for 22 hours, from 2:00 PM to 12:00 noon, with 150 ml water flushes every four hours, for a total of 1760 ml/2640 calories of formula and 2137 ml of free water. Review of the January 2026 MAR showed the resident was provided 80 ml every day. The DON stated the process for documentation of enteral nutrition was to document the amount of formula and water every shift and total for the day, and stated the resident's enteral nutrition documentation did not meet expectations.
Pain Medication Not Given Per Ordered Parameters
Penalty
Summary
The facility failed to provide pain management consistent with provider orders and documented parameters for two residents. Resident 99 was admitted with diabetes, chronic venous hypertension with bilateral lower extremity ulcers, and fibromyalgia, and was able to make needs known. The resident stated staff did not always manage pain, that Tylenol did not help enough, and that oxycodone had been discontinued. The care plan directed staff to monitor for signs of pain, provide medication as ordered, advise the resident to request pain medication before pain became severe, and monitor the frequency of breakthrough pain. For Resident 99, the provider ordered Tylenol 1000 mg every 6 hours as needed for pain rated 1 to 4 out of 10 with non-pharmacological interventions listed, and pain monitoring every shift. The MAR showed Tylenol was given on two occasions when pain was rated outside the ordered parameters, including pain levels of 6 and 5. The record also showed pain ratings ranging from 2 to 6 on six occasions when Tylenol and non-pharmacological interventions were not provided. On one occasion Tylenol was documented for pain rated 4, but non-pharmacological intervention was documented as not applicable. Staff stated the resident’s pain levels above 4 should have prompted provider notification and that pain reports should have been assessed with non-pharmacological interventions and medication offered as ordered. Resident 17 was admitted with chronic pain syndrome and was able to make needs known. During observation, the resident stated being in a lot of pain all the time and appeared guarded, curled in bed, and grimacing. The provider order for hydromorphone directed one tablet for pain levels of 4 to 6 and two tablets for pain levels of 7 to 10 every 6 hours as needed. The January 2026 MAR showed that when the resident reported pain levels of 7, 8, and 9 on multiple occasions, staff administered one tablet instead of the ordered two tablets. Staff stated it was their expectation that nursing staff follow the provider order parameters and that the resident’s pain medication administration did not meet expectations.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure a medication error rate of less than five percent, with two errors in twenty-seven opportunities for a 7.4% medication error rate during medication administration for 2 of 3 sampled residents. During observation, Staff Y, an LPN, administered vitamin C 500 mg to Resident 7 even though there was no order for vitamin C 500 mg on the January 2026 MAR, and Resident 7’s ordered cyanocobalamin (vitamin B12) 500 mcg was not administered. In a separate observation, Staff K, an LPN, administered folic acid 1000 mcg from an over-the-counter container and folic acid 1 mg from pharmacy packaging to Resident 52, even though the January 2026 MAR did not show two folic acid orders, and the ordered prenatal vitamins with ferrous fumarate-folic acid were not administered. The DON stated that licensed nurses were to follow provider orders when administering medications and that this did not meet expectations.
Unlocked Medication and Treatment Carts
Penalty
Summary
The facility failed to secure 1 of 4 treatment carts (Cart South 2) and 1 of 6 medication carts (Cart South 3) during medication storage observations. The facility policy titled, Storage of Medications, stated that drugs and biologicals used in the facility are stored in locked compartments and that only authorized persons preparing and administering medications have access to locked medications. During an observation on 01/07/2026 at 10:56 PM, Cart South 2 was found unlocked without nurse supervision for 10 minutes, and Staff X, LPN, was called to lock it. Staff X stated the nurse responsible for Cart South 2 was on break and that the cart should have been locked. During an observation on 01/09/2026 at 7:38 AM, Staff Y, LPN, was administering medication to a resident and left Cart South 3 unlocked and not in visual supervision while turning toward the resident to administer medications. During an observation on 01/12/2026 at 10:36 PM, Cart South 3 was again left unlocked for eight minutes until Staff J, LPN, was called to lock it. Staff B, DNS, stated on 01/09/2026 and again on 01/12/2026 that the medication and treatment carts should have been locked when nurses were not next to the carts and that the unlocked carts did not meet expectations.
Failure to Administer Consented COVID-19 Vaccines
Penalty
Summary
The facility failed to provide COVID-19 immunizations for 2 of 7 residents reviewed for COVID-19 immunization, identified as Residents 26 and 19. The facility policy stated that each resident would be offered the COVID-19 vaccine and, if the resident or representative consented, the facility would provide the vaccine at the facility or arrange for an outside service. Resident 26 was admitted with a diagnosis of diabetes and had consented to receive the COVID-19 vaccine, but the electronic health record contained no documentation that the vaccine was administered. Resident 19 was admitted with a diagnosis of skin infection and had also consented to receive the COVID-19 vaccine, but there was no documentation in the electronic health record that the vaccine was administered. During interviews, the LPN/Assistant DON acting as Infection Preventionist stated it was their expectation that residents are assessed, educated, and offered the COVID-19 vaccine and, if they consent, should receive it within a week of consent. The DON stated it was their expectation that residents receive the VIS form and are educated on the risks and benefits when offered vaccines, and if the resident consents, the vaccine should be ordered from the pharmacy and administered as soon as available.
Failure to Provide Foley Catheter Care and Monitoring Resulting in Pressure Injury
Penalty
Summary
The facility failed to provide necessary care and monitoring for a Foley catheter, resulting in an avoidable pressure injury at the catheter insertion site for one resident. Upon readmission, the resident had a Foley catheter in place due to obstructive uropathy and was cognitively intact. Throughout the resident's stay, there were no documented physician orders, care plans, eTAR entries, Point of Care tasks, or Kardex guidance related to Foley catheter care, monitoring, or securement. Progress notes and assessments also lacked documentation of catheter care or monitoring. The resident experienced severe, unrelieved pain at the catheter site, which was not alleviated by prescribed interventions, and exhibited signs of distress such as anxiousness, restlessness, and verbalizing discomfort. The resident was eventually transferred to the hospital, where it was noted that the catheter and surrounding area were unclean, and a significant meatal erosion was identified at the insertion site. Hospital records indicated that exchanging the Foley catheter resolved the resident's pain, and a mucosal membrane pressure injury (MMPI) was diagnosed. Interviews with facility staff confirmed that expected protocols for Foley catheter care and monitoring were not in place or followed for this resident.
Failure to Prevent Elopement and Provide Adequate Supervision for Cognitively Impaired Resident
Penalty
Summary
The facility failed to accurately assess, identify, monitor, and supervise a resident at risk for elopement, resulting in the resident leaving the facility unsupervised and sustaining harm. The resident, who had a history of stroke, dementia, and encephalopathy, was documented as requiring staff assistance for activities of daily living and was noted in the care plan to be at risk for falls and injury due to cognitive loss and lack of safety awareness. Despite these documented risks, the resident was able to exit the facility without staff knowledge or intervention. On the day of the incident, nursing notes indicated that the resident had previously expressed a desire to leave and had shown signs of confusion and attempts to leave the facility. The resident was last checked on in their room in the early afternoon, and when staff later noticed the resident was missing, there was a delay in initiating a search. Staff were unclear about which residents were allowed to leave and did not immediately begin looking for the missing resident. Additionally, staff in the reception area did not notice the resident leaving the building. The resident was subsequently found by bystanders on a freeway ramp after having fallen and sustained injuries, including abrasions and bruising. Emergency services were called, and the resident was transported to the hospital, where it was determined that facility staff were not aware the resident was missing until contacted by the hospital. The facility's own investigation identified issues with the accuracy of the elopement risk assessment, delays in searching for the resident, and lack of familiarity among reception staff with the residents.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain and document informed consent for the administration of psychotropic medications for three residents, which is a requirement to ensure residents or their legal representatives are fully informed about their treatment. Resident 92 was prescribed Zolpidem Tartrate for insomnia and Escitalopram Oxalate for depression, but the consent for Zolpidem Tartrate lacked documentation of the medication's frequency, and no consent was found for Escitalopram Oxalate. Staff interviews confirmed the absence of proper documentation and acknowledged that the expected procedures were not followed. Resident 87 was prescribed risperidone, an antipsychotic medication, without any consent documentation on file. Similarly, Resident 2 was administered Trazodone for insomnia without obtaining verbal or written consent. Staff interviews revealed that the necessary consents were not located, and the expectation was that consents should be obtained prior to medication administration. These oversights placed residents at risk of not being fully informed about their medication use, potential side effects, and the ability to make informed decisions about their care.
Failure to Obtain Consent and Orders for Low Bed Use
Penalty
Summary
The facility failed to obtain a provider's order, assessment, and consent for the use of low beds for three residents, which is considered a form of physical restraint. The facility's policy requires that physical restraints, including low beds, should only be used upon the written order of a physician and after obtaining consent from the resident or their representative. However, for Residents 86, 74, and 89, there was no documentation of consent, order, or assessment for the use of low beds, which were observed during the survey. Resident 86, who was admitted with conditions such as intracranial hemorrhage, anxiety, depression, and aphasia, was assessed as a fall risk and required staff assistance for mobility. Despite this, there was no documentation supporting the use of a low bed. Similarly, Resident 74, diagnosed with dementia, depression, and osteopenia, and Resident 89, diagnosed with dementia, anxiety, and receiving palliative care, were also observed in low beds without the necessary documentation. The Director of Nursing Services acknowledged that the lack of consent, assessment, and order did not meet the facility's expectations. This deficiency was previously cited in a Statement of Deficiencies.
Failure to Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to identify and investigate allegations of abuse and neglect for several residents, leading to potential risks for continued abuse and diminished quality of life. Resident 78, who was dependent on staff for transfers, reported being left in a power wheelchair for three nights due to missing equipment. Despite the resident's grievance and staff awareness, no investigation was initiated, and the incident was not logged in the facility's records. Staff interviews revealed a lack of communication and failure to recognize the situation as neglect. Resident 48 experienced a safety incident involving their electric wheelchair, which was removed after being seen in the roadway. Although staff were aware of the incident, it was not documented in the incident log, and no investigation was conducted. Similarly, Resident 77 reported a resident-to-resident altercation that was not logged or investigated, despite staff acknowledging the need for such actions. The lack of documentation and follow-up on these incidents highlights a systemic issue in addressing and investigating potential neglect and abuse. Other residents, such as Resident 360 and Resident 66, also reported issues with medication administration and being left uncovered, respectively. These incidents were not logged or investigated, indicating a broader failure to adhere to facility policies and state regulations. The facility's inaction in these cases demonstrates a significant deficiency in ensuring resident safety and addressing grievances appropriately.
Failure to Monitor and Set Low Air Loss Mattress Correctly
Penalty
Summary
The facility failed to ensure that the ordered intervention of a Low Air Loss Mattress (LALM) was properly monitored and used as directed for three residents, leading to a deficiency in pressure ulcer care. Resident 73, who had diagnoses including heart and lung disease, dementia, and malnutrition, was dependent on staff for all activities of daily living and had pressure ulcers on the buttocks and heels. Despite the care plan specifying the use of an air mattress for pressure reduction, the LALM was incorrectly set at 200 lbs, while the resident's actual weight was 126.8 lbs. Staff interviews revealed that the maintenance department set up the LALM based on an estimated weight range, and licensed nurses were responsible for monitoring the settings, which were not documented in the electronic health record. Further investigation showed similar issues with Residents 83 and 18, whose LALM settings were also incorrect based on their documented weights. Resident 83, weighing 83 lbs, had the LALM set at 200 lbs, and Resident 18, weighing 90 lbs, had the LALM set at 400 lbs. The Assistant Director of Nursing stated that the expectation was for maintenance staff to set up the LALM based on residents' weights and for licensed nurses to ensure the settings were correct. This failure to implement the care plan as ordered prevented the facility from promoting wound healing and preventing further decline in the residents' conditions.
Failure to Maintain Minimum RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for a minimum of eight hours each day, as required, for 60 out of 92 days reviewed for staffing. Specifically, the nursing schedules for July, August, and September 2024 showed that there was no RN scheduled for 23, 19, and 18 days, respectively. This deficiency was identified through observation, interviews, and record reviews. During interviews, the Staffing Coordinator acknowledged the shortage of available RNs and the Director of Nursing Services confirmed that the lack of daily RN coverage did not meet the facility's expectations.
Failure to Provide Non-Pharmacological Interventions Before PRN Pain Medications
Penalty
Summary
The facility failed to provide non-pharmacological interventions (NPI) prior to administering as-needed (PRN) pain medications for six of eight sampled residents. This deficiency was identified through interviews and record reviews, revealing that residents were at risk of taking unnecessary medications, experiencing avoidable side effects, and having a diminished quality of life. The residents involved had various medical conditions, including palliative care, osteomyelitis, diabetes, heart and lung disease, fibromyalgia, quadriplegia, radiculopathy, anxiety, depression, dementia, atrial fibrillation, insomnia, kidney disease, and Crohn's disease. For Resident 78, the electronic health record showed nearly daily administration of PRN narcotic pain medication without prior NPI in December 2024 and January 2025. Similarly, Resident 48's medication administration record (MAR) for January 2025 lacked consistent documentation of NPI despite orders to attempt such interventions before administering oxycodone and acetaminophen. Resident 94's MAR also showed multiple entries of administered pain medications without consistent documentation of NPI, despite orders to document such interventions and their effectiveness. Resident 92 received narcotic pain medication 77 times in January 2025 without documented NPI, contrary to the provider's orders. Resident 360's MAR showed no order for NPI, yet the resident received acetaminophen and narcotic medications multiple times. Lastly, Resident 87's December 2024 MAR showed no documented NPI before administering acetaminophen. Interviews with staff, including the Director of Nursing Services and Assistant Director of Nursing, confirmed that the facility's expectations for documenting NPI prior to PRN medication administration were not met.
Repeated Deficiencies Due to Ineffective QAPI Program
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Performance Improvement (QAPI) program effectively identified and addressed deficiencies, leading to repeated issues and a pattern of deficiencies. During the Long Term Care survey conducted on January 29, 2025, it was found that the facility did not identify or address several areas of concern, including the failure to report and investigate allegations of abuse or neglect for six out of seven sampled residents. Additionally, the facility did not ensure the proper use and monitoring of ordered interventions, such as the Low Air Loss Mattress, for the prevention of pressure ulcers in three out of seven residents. The facility also demonstrated ineffective plans of correction for sustaining compliance in various areas, resulting in repeated deficiencies. For instance, the facility failed to complete and maintain psychotropic medication consents before administering these medications to three out of five sampled residents. Furthermore, the facility did not periodically review residents' advanced directives or maintain court-appointed guardianship documentation, affecting one out of two sampled residents. These issues were not brought to the attention of the QAPI committee, indicating a lack of awareness and oversight. Additional deficiencies included the failure to provide a safe, sanitary, and homelike environment, obtain necessary consents for the use of physical restraints, and provide written notifications for transfers or bed hold policies. The facility also failed to accurately assess residents' conditions, develop comprehensive care plans, and ensure professional standards of practice were met. Despite some awareness of certain issues, such as staffing shortages, the QAPI committee was generally unaware of many concerns, leading to repeated citations and unresolved deficiencies.
Failure to Review Advanced Directive and Obtain Guardianship Documentation
Penalty
Summary
The facility failed to periodically review and update the advanced directive (AD) for Resident 77, who was admitted with diagnoses including dementia, depression, and osteoarthritis. Despite being unable to sign AD documentation due to cognitive issues, the facility did not conduct the required reviews in August and November 2024. This oversight was acknowledged by Staff F, who confirmed that the reviews were missed. Additionally, there was a lack of documentation regarding the court-appointed guardianship, which was supposed to be obtained and maintained in the resident's medical records. Interviews with facility staff revealed that there was a breakdown in communication and follow-up regarding the guardianship documentation. Staff D, the Business Office Manager, admitted that they did not follow up with the resident's family to obtain the necessary paperwork, nor did they document attempts to do so. The Administrator confirmed that ADs should be reviewed upon admission, quarterly, and as needed, and that Social Services were responsible for obtaining the AD. This failure placed Resident 77 at risk of not having an established decision maker and a diminished quality of life.
Deficient Wheelchair Maintenance for Resident
Penalty
Summary
The facility failed to provide a safe, sanitary, and homelike environment for Resident 62, who was reviewed for environmental conditions. Resident 62, who had diagnoses including cancer and depression, was observed using a personal wheelchair with both armrests in disrepair. The armrests had multiple cracked areas in the vinyl, exposing beige material underneath, creating an uncleanable surface. During interviews, Resident 62 expressed that the armrests were rough to the touch and that staff should have noticed the need for repair or replacement. Staff E, an LPN, confirmed the poor condition of the armrests and acknowledged the need for maintenance and physical therapy intervention. Staff B, the Director of Nursing Services, also stated that the condition of the wheelchair armrests did not meet expectations.
Neglect Due to Missing Transfer Equipment
Penalty
Summary
The facility failed to ensure a resident was free from neglect, as evidenced by the incident involving Resident 78. The resident, who was admitted with diagnoses including palliative care, osteomyelitis, and diabetes, was dependent on staff for transfers in and out of bed using a mechanical lift. However, due to the facility's inability to locate a necessary piece of equipment, Resident 78 was left in their power wheelchair for three consecutive nights, preventing proper transfer and wound care. This situation caused distress to the resident, who subsequently took measures to prevent a recurrence by keeping the equipment with them in bed. Interviews with staff revealed a breakdown in communication and response to the resident's needs. Staff P, a CNA, reported the missing equipment to Staff N, an LPN, who was on vacation at the time. Upon return, Staff N checked the resident's wounds and located the missing equipment. Despite being informed of the situation, Staff B, the DNS, was unaware that the resident had slept in their wheelchair for three nights. Additionally, the resident filed a grievance form alleging neglect, which was reported to the DNS by Staff F from Social Services. The facility's policy requires all allegations of neglect to be reported and investigated, but this was not adequately followed in this case.
Failure to Provide Written Transfer Notifications
Penalty
Summary
The facility failed to provide written notification of the reason for hospital transfer to two residents, Resident 81 and Resident 13, or their representatives, as well as the Washington State Long-Term Care Ombudsman program. Resident 81, who was admitted with encephalopathy and diabetes, was hospitalized and readmitted without receiving a written notice of transfer. Staff C, the Assistant Director of Nursing, acknowledged that the resident or their representative did not receive the required written notice, which should have been provided upon transfer or sent via certified mail. Similarly, Resident 13, who had diagnoses including heart failure and chronic obstructive pulmonary disease, was transferred to the hospital and readmitted without receiving a written notification of the transfer. Staff E, an LPN, admitted to providing only verbal notification, while Staff B, the Director of Nursing Services, could not confirm if a written notification was sent. Additionally, Staff F from Social Services confirmed that the Ombudsman program was not notified in writing about Resident 13's transfer, which was a requirement.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Puyallup
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rainier Rehabilitation | 1.6 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Puyallup | 2 mi | ★★★★★ | 23 | 0 |
| Puyallup Post Acute | 2.5 mi | ★★★★★ | 38 | 0 |
| Life Care Center Of South Hill | 2.5 mi | ★★★★★ | 18 | 1 |
| Canterbury House | 6.4 mi | ★★★★★ | 22 | 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 August 2026) and official state health department websites.