Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lynnwood Post Acute Rehabilitation Center during CMS and state inspections, most recent first.
Failure to prevent physical abuse occurred when one resident shared a room with another resident, became involved in a verbal exchange, and then went to the other resident's side of the room and placed both hands around the resident's neck, choking them. The injured resident had muscle weakness and needed help with all mobility and transfers, while the other resident had anxiety and could ambulate independently. Staff and the DON identified the act as physical abuse.
The facility did not include required recertification and complaint survey results, along with associated plans of correction, in the survey binder for two of the past three years. This omission, confirmed by the administrator, prevented residents, their representatives, and visitors from reviewing past survey results as required.
Surveyors identified that the facility did not develop or implement required care plans for four residents, including missing assessments for antipsychotic medication use, lack of care plans for diuretic, anticoagulant, and insulin administration, and failure to follow a care plan for splint application in a resident with contractures. Staff interviews and record reviews confirmed these omissions.
Surveyors observed multiple failures in medication administration and controlled substance disposal, including staff giving the wrong form and dose of medications to residents, not following physician orders, failing to prime an insulin pen before injection, and not obtaining two witness signatures during the destruction of a controlled substance. Staff interviews confirmed these actions did not follow facility policy or standard medication administration procedures.
The facility did not ensure that residents receiving insulin or diuretic medications were monitored for adverse effects such as hypoglycemia, hyperglycemia, dehydration, or changes in edema. Documentation and care plans lacked evidence of required monitoring, and staff confirmed that expected monitoring was not performed or recorded.
Surveyors found that medications and biologicals were not properly labeled, stored, or disposed of, including an ophthalmic medication not discarded after 28 days, expired oxycodone tablets present in a medication cart, and a multi-dose vial of Tubersol without an open date. Additionally, a resident with asthma had prescribed medications left unsecured at bedside rather than in a locked drawer, contrary to facility policy and staff expectations.
A nurse discussed a resident's bowel movement in a hallway and in front of another resident while communicating with a CNA, violating the facility's dignity policy. Interviews with the nurse, Resident Care Manager, and DON confirmed that this conduct was inappropriate and not in line with expectations for resident dignity.
A resident was found with an Albuterol inhaler and Biotene oral spray at bedside and reported self-administering these medications without the required assessment or physician's order. Facility staff, including an LPN, Resident Care Manager, and DON, confirmed that the necessary evaluation for self-administration was not completed prior to the resident having access to these medications.
A resident's record indicated the presence of an advance directive DPOA, but only a financial DPOA was on file, with no documentation of a health care advance directive. Staff confirmed that the available paperwork did not address health care decisions, resulting in the resident's preferences not being properly documented.
A resident was transferred to the hospital without receiving a written notice of transfer or discharge, and the resident's representative was only notified verbally. Staff confirmed that while the notice was included in the discharge packet sent to the hospital, there was no documentation that the required written notice was provided to the resident or their representative.
Two residents had inaccurate MDS assessments: one was incorrectly marked as receiving insulin injections despite no orders or administration, and another was not marked for dialysis despite regular treatments documented in the care plan and physician orders. These errors were confirmed by the MDS Coordinator and DON during record reviews and interviews.
A resident with a diagnosis of anxiety disorder was admitted without this condition being marked on the PASARR Level I form, resulting in no Level II referral being made. Staff confirmed the omission and acknowledged that the diagnosis should have been included, and the administrator was unclear about Level II referral criteria.
A resident received six liters per minute of oxygen via nasal cannula, despite having a physician order for three to four liters per minute via mask. Nursing staff and the DON confirmed that the order was not updated to reflect the resident's change in condition, resulting in a mismatch between the physician's order and the care provided.
The facility exceeded the acceptable medication error rate when two residents received medications in the wrong form or incorrect dosage. An RN gave a tablet instead of a capsule and an insufficient dose of a mineral supplement to one resident, while another RN prepared an enteric coated aspirin instead of the prescribed chewable form for another resident. Both nurses failed to follow the five rights of medication administration and did not adhere to physician orders.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
Two single resident rooms were found to be below the required 100 square feet, with facility records and staff confirming the deficiency. Interviews with two residents occupying these rooms revealed that one was not bothered by the room size, while the other wished for a larger space but was not negatively impacted.
A resident with chronic respiratory failure was not informed of a critical CO2 blood test result, which was communicated to a nurse but not relayed to the resident or their representative. The resident's representative learned of the result weeks later from the Resident Care Manager. The facility's policy requires notifying the resident and responsible party of changes in condition, which was not followed in this case.
A resident with Atrial Fibrillation did not receive their prescribed Apixaban for ten days after admission due to a transcription error. Facility staff acknowledged the oversight, which led to the medication not being administered as ordered.
The facility failed to accurately complete the daily nurse staffing form, omitting actual hours worked and census information for 30 days. Observations and record reviews showed discrepancies, with staff admitting to documenting actual hours on a separate sheet and updating postings late. This inconsistency placed residents, family members, and visitors at risk of not being fully informed of staffing levels.
The facility failed to provide written transfer or discharge notices to three residents who were hospitalized, as required by their policy. Instead, notifications were made verbally or by phone, with no documentation in the EHRs. Staff interviews confirmed this practice, despite expectations for written notification according to guidelines.
The facility failed to provide bed hold notices to residents during hospital transfers, as required by policy. Three residents were transferred without receiving the necessary notices, and staff interviews confirmed the lack of documentation and adherence to procedures. This placed residents at risk for unwanted room changes upon readmission.
A resident's call light was repeatedly observed on the floor, out of reach, despite facility policy requiring it to be accessible. Staff interviews confirmed the expectation for call lights to be within reach, yet the issue persisted throughout the day.
The facility failed to document advance directives for two residents, mistaking financial DPOAs for healthcare directives. Additionally, a resident was administered an antidepressant despite their refusal, as acknowledged by the DON.
A resident's grievance regarding a missing footrest for their custom wheelchair was not addressed by the facility, despite the resident's dependency on the wheelchair for mobility. The facility's policy required a grievance form to be filed for missing personal items, but no such form was completed. Staff interviews confirmed the oversight, and the grievance log showed no entry for the incident.
The facility did not provide written summaries of baseline care plans to two residents within 48 hours of admission, as required. Although verbal summaries were given, there was no documentation in the EHR that written summaries were offered or provided. The DON expected these to be provided during the initial care conference, but this was not documented.
The facility failed to meet professional standards in medication administration. A nurse used unlabeled and undated eye drops found on a resident's nightstand, contrary to policy. Another nurse applied a pain patch without a specified location in the order, relying on the resident's input. The DON acknowledged the need for order clarification but did not see an issue with the current practice.
The facility did not complete the required annual performance evaluation for a CNA, as revealed during a review of personnel files. The Director of Nursing, new to the facility, admitted that conducting evaluations was not prioritized, and efforts to locate the missing evaluation were unsuccessful.
The facility failed to dispose of expired medications and properly label and store drugs, risking compromised care. An expired Vitamin E container was found in a medication cart, and unlabeled eye drops were used on a resident. Staff confirmed that expired and unlabeled medications should not be used.
The facility failed to ensure proper hand hygiene and infection control practices during meal tray pass and equipment disinfection. Staff O and Staff G did not perform hand hygiene between handling meal trays and entering/exiting residents' rooms. Staff H failed to disinfect vital signs equipment between resident uses, using personal cleansing cloths instead of the required disinfectant wipes. These practices increased the risk of infection for residents, visitors, and staff.
A resident at the facility did not receive the pneumococcal and influenza vaccines despite consenting and being eligible, as per the facility's policy. The EHR showed no documentation of vaccine administration, confirmed by the Infection Preventionist and DON, highlighting a lapse in the facility's immunization procedures.
Two single resident rooms in the facility were found to be below the required 100 square feet, measuring 93.02 and 92.03 square feet. Despite this, the residents occupying these rooms were not negatively impacted by the size. The Maintenance Supervisor and Administrator confirmed no changes in room size since the last survey, acknowledging non-compliance with regulations.
Failure to Prevent Resident-on-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent physical abuse for 1 of 3 residents reviewed for abuse investigations. Resident 1 had a diagnosis list that included muscle weakness, did not have impaired thinking or memory, and required assistance for all mobility and transfers. Resident 2 had a diagnosis list that included anxiety, did not have impaired thinking or memory, and could transfer and walk independently. An incident investigation report showed that Resident 2 and Resident 1 shared a room and were heard in a verbal exchange with raised voices. A nurse entered the room and saw Resident 2 leaving Resident 1's side of the room and returning to their own side. Resident 1 reported that Resident 2 placed their hands around Resident 1's neck, and Resident 2 stated they did put their hands around Resident 1's neck because of the way Resident 1 treated and spoke to staff. Resident 1 later stated Resident 2 ran over to their side of the room, put both hands around their neck, and choked them long enough to cause trouble breathing. Staff interviews confirmed that placing hands around another resident's neck and choking them would be considered physical abuse, and the DON stated that Resident 2's actions were physical abuse.
Survey Results and Plan of Correction Not Available for Resident Review
Penalty
Summary
The facility failed to ensure that its survey binder included the recertification and complaint survey results, along with the associated plans of correction, for two of the three preceding years reviewed. During reviews of the survey binder on two separate occasions, it was found that the binder did not contain the required recertification survey results and plans of correction dated 07/22/2024, nor the complaint survey results and plans of correction dated 08/16/2024 and 03/19/2025. The administrator, who was responsible for maintaining the survey binder, confirmed during an interview and joint record review that these documents were missing and acknowledged they should have been included. This omission prevented residents, their representatives, and visitors from exercising their right to review past survey results and the facility's plans of correction, as required by regulation.
Failure to Develop and Implement Comprehensive Care Plans for Multiple Residents
Penalty
Summary
The facility failed to develop and/or implement comprehensive care plans for four residents, as identified through observation, interview, and record review. For one resident prescribed quetiapine for Lewy Body Dementia, the care plan required an Abnormal Involuntary Movement Scale (AIMS) assessment to monitor for tardive dyskinesia, but no such assessment was completed upon admission or after starting the medication. Both the Resident Care Manager and the Director of Nursing confirmed that the assessment was missing despite being required by the care plan. Another resident was prescribed a diuretic and an anticoagulant, with both medications documented in the Medication Administration Record and Minimum Data Set. However, the comprehensive care plan did not include interventions or monitoring for these medications. Staff interviews confirmed that care plans for these medications should have been in place but were not developed. A third resident with diabetes and a physician's order for routine insulin injections did not have a care plan addressing diabetes management or insulin administration until after the deficiency was identified. Additionally, a resident with contractures and an order for a right elbow extension and hand orthotic was not observed wearing the splint as required by the care plan on multiple occasions. Staff interviews and record reviews confirmed that the care plan was not being followed, and staff responsible for applying the splint had not ensured its use as directed.
Medication Administration and Controlled Substance Disposal Deficiencies
Penalty
Summary
The facility failed to ensure appropriate pharmacy services for medication administration and disposal for four residents, as evidenced by direct observations, interviews, and record reviews. For one resident, a registered nurse prepared and was about to administer the incorrect form and dose of prescribed medications, specifically giving tablets instead of capsules for Docusate Sodium and only one tablet instead of two for Magnesium Oxide. The nurse admitted to not having the correct form in supply and did not notify the facility or provider, as required. Another resident was prepared to receive an enteric coated aspirin tablet instead of the prescribed chewable form, with the nurse acknowledging the error and the expectation to follow physician orders and medication rights. A third resident was observed to have insulin prepared and administered without priming the insulin pen, contrary to manufacturer recommendations and facility policy. The staff member confirmed not priming the pen and acknowledged the importance of this step to ensure proper dosing and to avoid air injection. The pharmacist and director of nursing both confirmed that priming is necessary and that staff are expected to follow all medication administration policies and manufacturer instructions. Additionally, the facility failed to follow its own policy for the disposal of controlled substances. For one resident, the destruction of discontinued oxycodone tablets was documented with only one witness signature in the controlled substance accountability record, instead of the required two. Staff interviews confirmed that the process requires two licensed nurses to witness and sign for the destruction, but this was not done in this instance, and the director of nursing acknowledged the omission.
Failure to Monitor for Adverse Effects of Insulin and Diuretic Medications
Penalty
Summary
The facility failed to ensure adequate monitoring for residents receiving insulin and diuretic medications, as required by their own policies and regulatory standards. For one resident with diabetes who was prescribed routine insulin injections, there was no documentation in the physician’s orders, Medication Administration Record (MAR), or care plan indicating monitoring for hypoglycemia or hyperglycemia. Interviews with nursing staff and the Director of Nursing confirmed that such monitoring was expected but not performed or documented. Two other residents were prescribed diuretic medications for conditions such as edema and congestive heart failure. For both, the MAR, Treatment Administration Record (TAR), and care plans lacked evidence of monitoring for adverse side effects related to diuretic use, such as dehydration or changes in edema status. Staff interviews revealed that monitoring for these side effects was expected, but records did not show that it was carried out or documented. The facility’s policy required monitoring for side effects or adverse drug reactions immediately after administration and throughout each shift. Despite this, the records and care plans for the affected residents did not reflect the required monitoring for either insulin or diuretic therapy. Staff acknowledged during interviews that the expected monitoring was not documented or included in the care plans for these residents.
Medication Storage, Labeling, and Disposal Deficiencies
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage, labeling, and disposal of medications and biologicals. On two medication carts, an opened bottle of atropine sulphate ophthalmic medication was found with an open date but had not been discarded after the required 28 days, as confirmed by both the LPN and the Director of Nursing. Additionally, a blister pack containing expired oxycodone tablets was found in another medication cart, and staff acknowledged that expired medications should not be present and should have been destroyed. In the medication storage room, an opened multi-dose vial of Tubersol was found in the refrigerator without an open date. The Resident Care Manager confirmed that any opened medication should be dated, and the Director of Nursing stated that staff are expected to label multi-dose vials with the date they are opened. For one resident with a diagnosis of asthma, surveyors observed that prescribed medications, including an Albuterol Sulfate inhaler and Biotene oral spray, were kept on top of the bedside table and not secured in a locked drawer as required for self-administered medications. Staff interviews confirmed that these medications should have been kept in a locked drawer or box when not in use.
Failure to Maintain Resident Dignity During Staff Communication
Penalty
Summary
Staff failed to provide care and services in a dignified manner for one resident. During observation, a Registered Nurse exited a resident's room and stated in the hallway, within earshot of others, that the resident was having a bowel movement. The same nurse then entered another room and informed a CNA, in front of another resident, about the first resident's bowel movement. These actions were witnessed and documented by surveyors. Interviews with the involved nurse, the Resident Care Manager, and the Director of Nursing confirmed that such statements were not appropriate and did not align with facility policy, which requires staff-to-staff communication about residents to occur outside the hearing range of residents and the public. The facility's policy emphasizes treating residents with dignity and respect at all times, and the staff acknowledged that the observed behavior did not meet these expectations.
Failure to Assess Resident for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that an evaluation and assessment for safe self-administration of medications was conducted for a resident who was observed to have medications at their bedside. According to the facility's policy, residents desiring to self-administer medications must be assessed by the interdisciplinary team for their cognitive, communication, visual, and physical abilities, and a physician's order must be obtained if the resident is deemed capable. However, review of the resident's records showed no documentation of such an assessment prior to the resident having access to their prescribed Albuterol Sulfate inhaler and Biotene oral spray at their bedside. Observations confirmed that the resident had both medications within reach and reported using them as needed for asthma and dry mouth. Interviews with facility staff, including an LPN, Resident Care Manager, and DON, confirmed that the required assessment and physician's order were not completed before the resident was allowed to self-administer these medications. Staff acknowledged that the resident should not have had medications at bedside without the proper assessment and authorization.
Failure to Obtain and Document Advance Directive for Resident
Penalty
Summary
The facility failed to ensure that an advance directive, specifically a written instruction such as a living will or Durable Power of Attorney (DPOA) for health care, was obtained and properly documented for one resident. Upon review of the resident's care plan, it was indicated that the resident had an advance directive DPOA. However, examination of the electronic health record revealed only a financial DPOA on file, with no documentation of a health care DPOA or other advance directive. Staff interviews confirmed that the DPOA paperwork available pertained solely to financial matters and did not address health care decisions, despite the care plan indicating otherwise. Further investigation showed that the facility's process involved asking residents at admission if they had an advance directive and requesting a copy for the medical record. In this case, the staff acknowledged that the documentation on file did not meet the requirements for a health care advance directive. The absence of the appropriate advance directive in the resident's record meant that the resident's preferences regarding health care decisions were not properly documented or available to guide care.
Failure to Provide Written Transfer/Discharge Notice
Penalty
Summary
The facility failed to provide a written notice of transfer or discharge to a resident and their representative prior to the resident's transfer to the hospital. Review of the clinical record showed that the Nursing Home Transfer or Discharge Notice was dated and indicated the reason for transfer was that the resident's needs could not be met at the facility. However, the notice was only provided verbally to the resident's representative, who was out of town at the time, and there was no documentation that a written notice was given to either the resident or their representative. Interviews with facility staff confirmed that their process was to fill out the notice and send it with the resident, but in this case, there was no evidence that the written notice was provided or documented. The staff acknowledged that the notice was included in the discharge packet sent to the hospital, but could not provide documentation that the resident or their representative received the written notice as required.
Inaccurate MDS Assessments for Medication and Dialysis
Penalty
Summary
The facility failed to ensure accurate completion of resident assessments for two out of ten residents reviewed for the Minimum Data Set (MDS). For one resident, the quarterly MDS inaccurately indicated the use of insulin injections and orders for insulin in Section N, despite physician orders and the Medication Administration Record (MAR) showing that the resident was neither prescribed nor administered insulin during the look-back period. The MDS Coordinator confirmed during a joint record review that the resident should not have been marked for insulin use, and the Director of Nursing stated that the MDS was expected to be completed accurately. For another resident, the quarterly MDS failed to indicate that the resident was receiving dialysis in Section O, even though physician orders and the care plan documented regular dialysis treatments for renal failure. The MDS Coordinator acknowledged that the MDS should have reflected the resident's dialysis treatments. These inaccuracies were identified through interviews and record reviews, demonstrating that the facility did not ensure the MDS assessments were completed in accordance with the requirements outlined in the RAI Manual.
Failure to Accurately Complete PASARR Screening and Referral
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASARR) Level I form was completed accurately and that a Level II PASARR referral was made for a resident with a diagnosis of anxiety disorder. Specifically, the resident was admitted with a diagnosis that included anxiety disorder, but this diagnosis was not marked in Section IA (Serious Mental Illness) of the Level I PASARR form. As a result, Section IV of the form indicated that no Level II evaluation was needed, contrary to the resident's documented medical condition. During a joint record review and interview, it was confirmed that the resident's diagnosis of anxiety disorder was present in their medical records but was omitted from the PASARR Level I form. Staff involved acknowledged that the diagnosis should have been included and that a Level II referral should have been made. The facility's administrator also stated that the PASARR form should accurately reflect all SMI diagnoses, but was unsure about the specific criteria for Level II referrals.
Failure to Obtain and Follow Accurate Oxygen Orders for Resident
Penalty
Summary
The facility failed to provide respiratory care in accordance with accepted professional standards for one resident who required oxygen therapy. The facility's policy required that oxygen be administered only with a physician's order, and that the order should specify the method and flow rate. Review of the resident's physician orders showed an order for oxygen via mask at 3-4 liters per minute (LPM) continuously. However, multiple observations revealed that the resident was receiving six LPM of oxygen via nasal cannula, which did not match the physician's order on record at the time. Interviews with nursing staff and record reviews confirmed that the resident's oxygen delivery method and flow rate had changed due to a change in condition, but the physician's order was not updated to reflect this change until several days later. Staff acknowledged that the order should have been clarified and updated to match the resident's current needs, and that the resident was receiving a higher flow rate and a different delivery method than what was ordered. This discrepancy between the physician's order and the care provided constituted a failure to follow professional standards and facility policy for respiratory care.
Medication Error Rate Exceeds Acceptable Threshold Due to Incorrect Form and Dosage Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required by policy, resulting in a documented error rate of 12% during observed medication administration. Specifically, three out of twenty-five medications administered to two out of five residents were not given as ordered. For one resident, a registered nurse administered Docusate Sodium in tablet form instead of the prescribed capsule form and provided only one Magnesium Oxide 400 mg tablet instead of the ordered two tablets. The nurse acknowledged that the correct form of Docusate Sodium was not available and did not notify the facility or provider, as required by protocol, and also failed to administer the correct dose of Magnesium Oxide. For another resident, a registered nurse prepared and was ready to administer an enteric coated Aspirin 81 mg tablet instead of the prescribed chewable form. Both nurses involved stated they were aware of the need to check the five rights of medication administration and to follow physician orders, but did not do so in these instances. Facility leadership confirmed that staff are expected to verify all medication rights and follow orders precisely, and acknowledged the errors in medication form and dosage for the residents involved.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence or inadequacy of a comprehensive infection prevention and control program, but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Single Resident Rooms Below Minimum Size Requirement
Penalty
Summary
Two single resident rooms, specifically Rooms 17 and 18, did not meet the minimum required size of 100 square feet for single occupancy as mandated by regulations. Facility-provided documentation confirmed that these rooms measured 93.2 and 92 square feet, respectively. The facility census indicated that these rooms were occupied at the time of the survey. During interviews and observations, one resident expressed no concern about the room size, while another stated a preference for a larger room but did not report any negative impact from the current size. Staff interviews, including with the Plan Operations Director and the Administrator, confirmed that there had been no changes to the square footage of these rooms since the last recertification survey. Both staff members acknowledged that the rooms in question did not meet the regulatory requirements for single resident room size. The deficiency was identified through observation, interview, and record review, with no evidence of negative impact on the residents at the time of the survey.
Failure to Inform Resident and Representative of Critical CO2 Test Result
Penalty
Summary
The facility failed to inform a resident and their representative about a high carbon dioxide (CO2) blood test level, which was a significant change in the resident's condition. The resident, who had intact cognition and a diagnosis of chronic respiratory failure with hypoxia, had a CO2 level greater than 45 mmol/L, exceeding the normal range of 21 to 31 mmol/L. The laboratory staff communicated the result to a registered nurse, Staff B, on January 28, 2025, who confirmed the result and requested a paper copy. However, Staff B did not notify the resident or their representative about the high CO2 level. The resident's representative, RR1, was not informed of the test result until February 10, 2025, when they spoke with Staff C, the Resident Care Manager. RR1 had only received a voicemail on January 30, 2025, about a blood draw, with no mention of the test result. Staff C stated that critical laboratory results should be sent to the provider if they are not in the facility and that the charge nurse is expected to notify the resident or their representative. The Director of Nursing, Staff A, confirmed that staff are expected to inform residents of their test results, and the power of attorney is informed if the resident is incapacitated.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of Apixaban, a medication used to prevent blood clots. The resident, who was admitted to the facility from a local hospital with a diagnosis of Atrial Fibrillation, did not receive their prescribed heart medication for a period of ten days following their admission. This lapse occurred despite the hospital discharge medication list indicating that Apixaban should be administered twice daily. Interviews with facility staff revealed that the medication was not transcribed from the hospital discharge list to the Medication Administration Record (MAR) upon the resident's admission. Both registered nurses and the Director of Nursing Services acknowledged that the medication should have been transcribed and administered as ordered. The Director of Nursing Services admitted that the transcription error was an oversight, resulting in the resident not receiving the medication until ten days after admission.
Inaccurate Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure the daily nurse staffing form was accurately completed for the number of staff worked, actual hours worked, and included the census for 30 of 30 days reviewed. Observations on multiple dates showed that the Daily Nursing Staffing Information postings did not include the census and the actual hours worked. Instead, the column under Actual Hours worked contained the same numbers as the column for the number of staff. Record reviews from 06/19/2024 to 07/19/2024 revealed that the actual hours worked were not accurately completed, and the census was missing on several dates. Additionally, the number of staff for Certified Nursing Assistants (CNAs) was not updated when there were call outs on specific dates. Interviews with staff members revealed a lack of clarity and consistency in updating the nurse staffing information. Staff K, the Staffing Coordinator, admitted that the actual hours worked were documented on a separate sheet and not accurately reflected in the daily postings. Staff L, the Administrative Assistant, stated that they were responsible for updating the postings but often completed them the next day or later. The Administrator, Staff A, expressed an expectation for staff to follow regulations, indicating a disconnect between expectations and actual practices. This failure to post complete and accurate staffing information daily placed residents, family members, and visitors at risk of not being fully informed of the current staffing levels.
Failure to Provide Written Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide written transfer or discharge notices to residents and/or their representatives for three residents who were hospitalized. The facility's policy, revised in February 2016, mandates that transfer or discharge notices be provided in writing, in a language the resident understands, to the resident, their surrogate decision maker, and family. However, for Resident 45, who was sent to the emergency room due to bleeding, there was no documentation in the Electronic Health Record (EHR) of a written notice being provided. Staff interviews revealed that notifications were made verbally or by phone, contrary to the policy. Similarly, Resident 47 was transferred to the hospital for further evaluation, and Resident 46 was sent to the emergency room for evaluation, with no written notices documented in their EHRs. Staff interviews consistently indicated that the practice was to notify residents and/or their representatives verbally, either in person or by phone, and not in writing. The Director of Nursing and the Administrator acknowledged the expectation for written notification according to guidelines, but the practice did not align with this requirement.
Failure to Provide Bed Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to provide bed hold notices to residents and/or their representatives during hospital transfers, as required by their policy. This deficiency was identified for three residents who were transferred to the hospital. Resident 45 was sent to the emergency room due to bleeding, but the Admission Coordinator admitted that a bed hold notice was not offered within the required 24-hour period. Similarly, Resident 47 was transferred to the hospital for further evaluation, but there was no documentation in the electronic health record (EHR) indicating that a bed hold notice was provided. Staff interviews confirmed that the expected procedure was not followed. Resident 46 was also transferred to the hospital, and both the resident and their representative reported not being informed of a bed hold. The EHR lacked documentation of any bed hold notice, despite the Admission Coordinator stating that a conversation occurred with the resident's representative. The Director of Nursing and the Administrator both expressed expectations that staff should follow the policy and document the provision of bed hold notices. The failure to provide these notices placed residents at risk for unwanted room changes upon readmission.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that the call light was within reach for a resident, identified as Resident 102, which is a requirement for accommodating the needs and preferences of residents. The facility's policy, revised in May 2007, mandates that the call device should be placed within the resident's reach before staff leave the room. However, observations on multiple occasions on the same day showed that Resident 102's call light was on the floor next to their bed, indicating non-compliance with the policy. During an interview and joint observation, a CNA acknowledged that the call light was not supposed to be on the floor and placed it back on the bed. Both the Resident Care Manager and the Director of Nursing confirmed that they expected call lights to be within reach and that staff should check the placement of call lights when entering residents' rooms. Despite these expectations, the call light for Resident 102 remained on the floor for an extended period, from morning until afternoon, without being addressed by staff.
Failure to Document Advance Directives and Respect Medication Refusal
Penalty
Summary
The facility failed to ensure that advance directives were obtained and documented for two residents, and did not honor a resident's right to refuse medication. For Resident 37, the facility did not have documentation of an advance directive in the electronic health record (EHR), despite the Social Services Director's belief that a Durable Power of Attorney (DPOA) was on file. It was later revealed that the DPOA was only for financial matters, not healthcare. Similarly, for Resident 102, the facility's records indicated that an advance directive was to be provided, but only a financial DPOA was on file. Staff misunderstood the nature of the DPOA, assuming it covered healthcare decisions, which it did not. Additionally, the facility failed to respect Resident 253's right to refuse medication. Despite a progress note indicating that Resident 253 and their representative declined a new order for an antidepressant, the medication was administered from July 12 to July 17. The Director of Nursing acknowledged the error, stating that the medication should have been discontinued. These failures placed the residents at risk of not having their healthcare preferences honored.
Failure to Address Grievance for Missing Wheelchair Footrest
Penalty
Summary
The facility failed to properly address a grievance related to a missing footrest for a custom wheelchair used by a resident, identified as Resident 17. The resident, who was dependent on a wheelchair for mobility, reported the missing footrest to staff, but no grievance was filed as required by the facility's policy. The resident had been using the wheelchair without the footrest for four to five weeks, which was confirmed through observations and interviews with the resident and staff. Despite the facility's policy mandating the filing of a grievance form for missing personal items, no such form was completed for this incident. Interviews with staff, including the Physical Therapist and Social Services Director, revealed that the grievance process was not followed. The Physical Therapist acknowledged documenting the missing footrest but did not initiate a grievance. The Social Services Director and the Administrator both confirmed that a grievance should have been filed, as the custom wheelchair was considered a personal item. A review of the grievance log showed no entry for the missing footrest, indicating a lapse in the facility's grievance handling process.
Failure to Provide Written Baseline Care Plan Summaries
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan to two residents, which is a requirement within 48 hours of admission. For Resident 49, the admission Minimum Data Set (MDS) was completed, but there was no documentation in the Electronic Health Record (EHR) that a written summary of the baseline care plan was provided. Interviews with staff revealed that while the baseline care plan was verbally discussed, there was no documentation of a written summary being offered or provided. The Director of Nursing expected the summary to be provided during the initial 72-hour care conference, but no documentation confirmed this occurred. Similarly, for Resident 102, the admission MDS was completed, but the EHR lacked documentation of a written summary of the baseline care plan being provided. Staff interviews indicated that while a verbal summary was given, a written summary was never provided to the resident or their representative. The Director of Nursing stated that the baseline care plan was completed within the required timeframe, but there was an expectation that staff would offer a written summary, which was not documented.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards of practice in medication administration, as observed in two separate incidents involving licensed staff. In the first incident, Staff P, a Registered Nurse, administered eye drops to a resident using an unlabeled and undated container found on the resident's nightstand. This action was contrary to the facility's policy, which requires medications to be dated upon opening and not left at the bedside unless there is a specific order for self-administration. Interviews with Staff P, the Resident Care Manager, and the Director of Nursing confirmed that the eye drops should not have been used and should have been disposed of due to the lack of labeling and dating. In the second incident, Staff F, an LPN, applied a pain medication patch to a resident without a specified location in the physician's order. The order only indicated that the patch should be applied to the skin, and Staff F relied on the resident's input to determine the application site. The Resident Care Manager and the Director of Nursing acknowledged that the order should have been clarified to specify the location for the patch application. Despite this, the Director of Nursing did not see an issue with the current practice of asking residents where to apply the patch.
Failure to Conduct Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to complete the required annual performance evaluations for a Certified Nursing Assistant (CNA), identified as Staff J, whose personnel file was reviewed. Staff J was hired in 2018 and transferred to the facility on an unspecified date, but the facility could not provide documentation of an annual performance evaluation as required by regulations. During an interview, the Director of Nursing, Staff B, acknowledged that performance evaluations were supposed to be conducted yearly but admitted that they had not prioritized this task due to being new to the facility. Despite efforts to locate Staff J's evaluation, Staff B confirmed that it was not completed, which is a regulatory requirement.
Expired Medications and Improper Storage in LTC Facility
Penalty
Summary
The facility failed to ensure the timely disposal of expired medications and proper labeling and storage of drugs and biologicals, which placed residents at risk for receiving compromised and ineffective medications. During an observation of the Cascade Hall Cart, a container of Vitamin E with an expiration date of June 2024 was found, despite the facility's policy requiring expired medications to be removed and destroyed. Staff interviews confirmed that expired medications should not be kept in the cart, but the Director of Nursing noted that the Vitamin E was still covered and had only expired the previous month. Additionally, the facility did not appropriately label and store medications for a resident. Observations revealed an unlabeled and undated container of eye drops on the resident's nightstand, which was used by a registered nurse despite the lack of labeling. Staff interviews indicated that medications should be identified with the resident's name and should not be used if found unlabeled and undated. The Director of Nursing stated that medications should not be at a resident's bedside unless there is an order for self-administration.
Infection Control Deficiencies in Hand Hygiene and Equipment Disinfection
Penalty
Summary
The facility failed to ensure proper hand hygiene and infection control practices during meal tray pass, as observed with Staff O and Staff G. Staff O, a Certified Nursing Assistant (CNA), was seen handling meal trays and utensils without performing hand hygiene before and after entering residents' rooms. Additionally, Staff O picked up a sealed cup of juice that had fallen on the floor and placed it back on the tray without replacing it, contrary to the facility's expectations. Staff G also failed to perform hand hygiene between handling meal trays and entering/exiting residents' rooms, even when using Personal Protective Equipment (PPE) in an Enhanced Barrier Precaution (EBP) room. The facility's infection prevention and control program was further compromised by Staff H's failure to disinfect medical equipment between resident uses. Staff H, another CNA, was observed using vital signs equipment on multiple residents without disinfecting it between uses. Although Staff H claimed to disinfect the equipment with wipes, it was found that they were using personal cleansing cloths instead of the required Micro-Kill One germicidal wipes. This practice was not in line with the facility's policy, which mandates the use of appropriate disinfectant wipes between resident uses. Interviews with various staff members, including the Infection Preventionist and the Director of Nursing, revealed that the facility's expectations for hand hygiene and equipment disinfection were not being met. Staff members acknowledged the need for hand hygiene before and after resident contact and the use of PPE, as well as the requirement to disinfect equipment between uses. However, the observed practices of Staff O, Staff G, and Staff H did not align with these expectations, leading to increased risk of infection for residents, visitors, and staff.
Failure to Administer Vaccines to Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 34, received the pneumococcal and influenza vaccines, which are crucial for preventing pneumonia and influenza infections. Despite the facility's policy, revised in July 2023, which mandates offering and administering these vaccines to eligible residents, Resident 34 did not receive them. The resident had consented to receive both vaccines as per the Centers for Disease Control and Prevention recommendations, as documented on a consent form signed in February 2024. However, a review of the resident's Electronic Health Record (EHR) showed no documentation of the vaccines being administered. Interviews with the facility's Infection Preventionist and the Director of Nursing confirmed that the resident should have been offered and administered the vaccines upon admission, especially during the flu season. Both staff members acknowledged the oversight, as the EHR lacked any record of the vaccines being given to Resident 34, despite the resident's eligibility and consent. This lapse in following the facility's immunization policy placed residents at risk of acquiring and transmitting preventable diseases.
Non-compliance with Room Size Requirements
Penalty
Summary
Two single resident rooms in the facility, Rooms 17 and 18, were found to be non-compliant with the regulatory requirement of at least 100 square feet for single resident rooms. Room 17 measured 93.02 square feet, and Room 18 measured 92.03 square feet. Despite the deficiency, interviews and observations with the residents occupying these rooms revealed that they were not negatively impacted by the room size. Resident 32 and Resident 41 both expressed that the room size did not bother them. The Maintenance Supervisor and the Administrator confirmed that there had been no changes in the rooms' square footage since the last recertification survey, acknowledging that the rooms did not meet the required square footage per federal and state regulations.
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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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Nursing homes near Lynnwood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alderwood Post Acute & Rehabilitation | 1.4 mi | ★★★★★ | 61 | 0 |
| Edmonds Post Acute | 1.9 mi | ★★★★★ | 60 | 0 |
| Pine Ridge Post Acute | 1.9 mi | ★★★★★ | 18 | 0 |
| Bothell Health Care | 4.1 mi | ★★★★★ | 2 | 0 |
| Bridges To Home | 4.5 mi | ★★★★★ | 9 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.