Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Madison Post Acute during CMS and state inspections, most recent first.
Resident rights were not periodically reviewed after admission, and no rights postings were observed in the facility. Residents in Resident Council said staff had not discussed resident rights, meeting minutes did not document any review, and the Activities Director and Administrator confirmed that rights had not been discussed in council meetings and that prior postings were removed during construction and not replaced.
Dining room space was inadequate for resident meals and movement. The facility’s only dining room had four tables, but residents in wheelchairs crowded the room, blocked the doorway, and left no clear path between tables. Residents said the room got too crowded, some had to eat in their rooms if they arrived late, and one resident had to wait to leave because wheelchairs blocked the exit. The ADM acknowledged the room was too small for more than about 10 residents and that the prior larger dining room had been converted to the therapy gym.
The facility failed to keep several residents’ care plans complete and resident-specific. A resident with dementia and high elopement risk was listed in the elopement binder, but the care plan did not include that risk. A resident receiving antipsychotic and antidepressant meds had no psychotropic documentation or side-effect monitoring in the care plan, and multiple residents with frequent pain lacked non-pharmacological pain interventions and complete pain details. Two residents with restorative programs had no corresponding care plan entries, and residents with pressure ulcers or heel offloading needs also lacked wound-related care plan interventions.
Missing Psychotropic Medication Consents: The facility failed to obtain psychotropic medication consents for several residents receiving medications such as an antidepressant, antipsychotic, and mood stabilizers. Records showed the residents received the ordered meds, but the EMR lacked completed consents, and staff stated the RCMs were responsible for obtaining them before administration.
MDS assessments were not transmitted within required timeframes for three residents. Two residents had discharge MDSs that remained in completed status without transmission, and one resident had a quarterly MDS that appeared accepted in the system but was not included on the transmission validation report. The MDS nurse confirmed the assessments were not transmitted as required, and the DON stated the facility could not view the third-party transmission information.
Inaccurate MDS coding affected three residents. One resident’s MDS conflicted with charted vision, pain, and psychotropic medication information, with missing CAA documentation and no related care plan entries. Another resident had obvious dental problems and pain, but the MDS marked oral findings as absent, so no dental CAA was triggered. A third resident with COPD was coded for SOB when lying flat without supporting clinical documentation, resulting in a higher nursing category and reimbursement rate.
PASRR Level II referrals were not completed or tracked for multiple residents with MH diagnoses. A resident with substance abuse, mood, and anxiety disorders had a Level I PASRR requiring Level II, but no eval was completed and the SS director had no evidence of follow-up. Other residents had expired or exempted Level I PASRRs, Level II requirements, or faxed referrals without documented follow-up, and staff stated there was no system to track PASRR Level II needs or 30-day timeframes.
Insufficient RN coverage was identified when staffing records showed six of 31 days without eight consecutive hours of RN coverage. The DON stated the facility was aware it did not meet the RN coverage requirement because it did not have enough RNs on staff.
Dietary staff failed to follow USDA Food Code hair restraint requirements in the kitchen. A cook, the Dietary Manager, and a Dietary Aid were observed with facial hair and no beard coverings while plating and working in food service areas. The Dietary Aid stated they believed beard restraints were not required if facial hair was under an inch long, and the Administrator stated kitchen staff with facial hair needed beard covers.
Failure to Follow Enhanced Barrier Precautions During Resident Care: Staff did not follow EBP for residents with a feeding tube and a central line. An LPN administered meds via feeding tube without a gown, an RN handled IV meds for a resident with a central line without a gown, and two NACs transferred a resident using a Hoyer lift without gowns, despite EBP signage posted at the doors.
A resident experienced a significant decline with weight loss, dysphagia, poor intake, increased weakness, reduced bed mobility, refusal of position changes, and new pressure ulcers, but the facility did not complete a comprehensive SCSA MDS after the change in status. The record later reflected stage 3 pressure ulcers and feeding-related concerns, and the DON acknowledged the resident’s condition was not expected to return to baseline within two weeks and that an SCSA should have been completed.
A resident with pyogenic arthritis and a central line for IV antibiotics received a saline flush and IV infusion even though no physician order for the flush was found in the chart. The RN stated an order was required and that the line should be flushed before and after IV antibiotics, and also reported that an IV nurse had been paged the prior night to clear the line for blockage. The DON stated an order for IV flushes was expected but was not present.
Failure to provide and maintain hearing aids: A resident with bilateral hearing aids ordered and documented in the care plan was repeatedly observed without the devices and stated they could not hear and needed them. Staff reported the aids were not being worn, were not working, could not be charged, and one aid was missing; the hearing aid case was kept in the med cart without a charger, and MAR code 9 entries were not supported by progress notes.
Missing Post-Dialysis Assessments for a Resident Receiving Hemodialysis: A resident with ESRD and CKD received dialysis three times per week, but the facility did not complete the required post-dialysis assessment documentation after multiple dialysis visits. An LPN stated there was no form to complete after return from dialysis, the RCM confirmed the documentation was not completed, and the DON acknowledged ongoing dialysis documentation issues and that post-dialysis documentation was expected.
Failure to provide follow-up dental services for a resident with missing and broken teeth. The resident reported severe dental problems, food avoidance, and sharp pain when biting, while a dental hygienist recommended referral for lower root tip extractions and a full upper denture. Staff acknowledged no dental appts were scheduled, the resident had anxiety about extractions, and there was no evidence of follow-up or contact with the prior dental office.
Resident rooms 107, 108, 110, 302, 305, 306, and 307 did not meet the required square footage standards for multiple-occupancy rooms. Census review showed each room had 2 beds, and repeated observations confirmed the rooms remained set up with 2 beds each. The Administrator stated an exemption had been requested from the state but had not yet been granted.
The facility did not complete required PASRR Level 2 evaluations for a resident with anxiety and depression prior to admission, and failed to update or conduct Level 2 evaluations for two residents with serious mental illness who remained beyond their 30-day exemption period. Staff interviews confirmed a lack of awareness and follow-through on PASRR requirements.
The facility assigned an unqualified individual as the Director of Food and Nutrition Services, who was not a certified Dietary Manager and was only enrolled in a certification program. The facility used the certification of the previous manager in place of the current director's required credentials, as confirmed by staff interviews and record review.
Surveyors identified unsanitary conditions in the kitchen and food storage areas, including a leaking handwashing sink, food debris, improper dishwashing temperatures, ice buildup in the freezer, poor hand hygiene, and unlabeled or undated food items. Staff were aware of these issues, but proper cleaning and maintenance had not been completed.
The facility did not have an effective system to document, track, or resolve grievances raised by residents during Resident Council meetings, including repeated complaints about loud TV noise, staff disturbances at night, and cold food. Staff responsible for grievance resolution were not informed of these concerns, and no formal grievance forms or follow-up actions were documented, resulting in unresolved issues affecting residents' quality of life.
The facility did not provide updated or complete Notification of Medicare Non-Coverage (NOMNC) forms to four residents, using outdated forms that lacked the required appeal organization contact information and failing to document that residents or their representatives received an explanation of the form or appeal process. The Social Service Director was unaware of the need to update the forms or include the necessary information.
The facility did not consistently provide or document required written notices of bed hold, transfer, and discharge to residents, their representatives, and the State Ombudsman during hospitalizations and discharges. Staff interviews revealed confusion about notification responsibilities, and EMR reviews showed missing documentation for several residents who were hospitalized or discharged.
The facility did not ensure that required PASRR Level II evaluations were completed or that recommendations from completed evaluations were incorporated into care plans for several residents with mental health diagnoses. Staff failed to refer residents for further review, did not document communication with the state PASRR evaluator, and were unaware of specific care recommendations, resulting in incomplete care planning.
Two residents requiring hemodialysis did not have consistent pre- and post-dialysis assessments completed, and there was a lack of ongoing communication and documentation from the dialysis center. Staff interviews confirmed missing documentation, incomplete communication packets, and absent after-visit summaries, with no contracts in place between the facility and the dialysis providers.
Several residents reported and were observed receiving meals that were lukewarm, overcooked, or unappetizing, with some meals lacking proper temperature control and palatability. Test trays confirmed issues such as dry and bland food, and a grievance documented a foreign object in a meal. The administrator was unaware of these ongoing food quality concerns.
A resident's trust account balance was not reimbursed to the state Office of Financial Recovery within the required 30 days after the resident's death. The Business Office Manager confirmed the delay, resulting in the account not being reconciled as mandated.
Two residents did not have individualized, comprehensive care plans implemented as required. One resident with severe dementia and Dutch as a primary language lacked the Dutch-to-English signage intervention specified in their care plan, and staff were unaware of this intervention. Another resident with a urinary catheter had a care plan that did not document the clinical reason for the catheter or necessary follow-up, and staff could not explain the rationale for its continued use.
Two residents did not receive care in accordance with professional standards: one did not have required blood pressure monitoring or bowel protocol interventions documented when receiving antihypertensive medication and experiencing constipation, and another did not have provider notification documented when blood glucose readings exceeded ordered parameters. Staff interviews confirmed that these protocols were not followed or documented as required.
Two residents did not receive respiratory care in accordance with physician orders and professional standards. One resident's oxygen was consistently set below the prescribed rate, and staff were unaware of the discrepancy. Another resident's CPAP machine lacked active orders for use and maintenance, and the mask was observed to be unclean, with staff unable to confirm cleaning or proper care.
Staff did not follow infection prevention protocols, including failing to use PPE for a resident on Enhanced Barrier Precautions during toileting, neglecting hand hygiene during perineal care for another resident, and not using barriers or proper disinfection when handling medical equipment and medications. These lapses were confirmed by staff and the facility's infection preventionist.
Seven rooms were found to house two residents each despite not meeting the minimum square footage requirement of 80 square feet per resident. Each room measured between 142 and 154 square feet, and staff confirmed that an exemption request was pending but not approved.
A resident's grievances regarding a noisy roommate, missing personal items, and dissatisfaction with a nursing assistant's care were not properly documented or addressed by the facility. Despite the resident's complaints, only one grievance was logged, and the facility failed to ensure the resident's concerns were resolved, as evidenced by continued care from the nursing assistant in question. Staff interviews revealed a lack of awareness and communication regarding the resident's grievances, indicating a failure to adhere to the facility's grievance policy.
A resident with swallowing difficulties was unable to receive daily recreational meals due to staffing limitations, as the facility only provided 1:1 supervision for meals on weekdays. Despite the resident's preference for daily meals, the scheduling practices did not accommodate their needs on weekends, leading to a deficiency in honoring resident choice.
A registered nurse administered medications to a resident with dementia during their meal in the dining room, contrary to facility policy requiring privacy for medication administration. The resident had cognitive impairments and did not request this practice. The Director of Nursing acknowledged the need for further education.
A facility failed to conduct a comprehensive Resident Assessment Instrument (RAI) for a resident with a leg fracture and on hospice care. The Care Area Assessment (CAA) lacked a thorough analysis, missing the resident's goals, preferences, and input. The contracted RN responsible for the MDS and care plans did not complete the necessary comprehensive analysis, risking inadequate service provision.
A facility failed to implement care plan interventions for a resident at high risk for falls, leading to a deficiency. The resident, with a history of falls and poor trunk control, was observed using a positioning wedge improperly without the required strap. Staff interviews revealed a lack of awareness about the wedge's purpose, and the care plan did not address the resident's trunk control issues. This was a repeat citation.
The facility failed to update care plans for two residents, one with discharge planning issues and another with dental care needs. A resident's care plan was not revised despite changes in their discharge situation, while another's dental care plan did not reflect the absence of their upper partial dentures, affecting their ability to chew properly.
The facility failed to implement professional standards of practice for two residents, leading to potential risks. A resident with swallowing difficulties did not receive proper cues during meals, as recommended by the SLP. Another resident's blood pressure was not monitored as required before administering medication, and a lab test was delayed due to errors in the electronic health record system. These deficiencies highlight the facility's failure to adhere to professional standards.
Two residents in an LTC facility did not receive adequate assistance with activities of daily living, including meal assistance and oral hygiene. One resident, with a leg fracture and dementia, was left unattended with meal trays untouched and no oral care provided. Another resident, with a history of stroke and a gastrostomy tube, had dry, coated lips and tongue due to infrequent oral care. Staff interviews revealed inconsistencies in understanding and executing care plans.
The facility failed to provide care according to professional standards for two residents. One resident's alternating air mattress was not set to the prescribed settings, risking skin breakdown. Another resident, admitted to hospice with a leg fracture, was not repositioned as required, lacking a specific schedule in their care plan. Staff interviews revealed a lack of adherence to care interventions, increasing the risk of unmet care needs.
The facility did not complete annual performance reviews for NAC staff, specifically for one NAC whose file was reviewed. Staff K, hired in July 2023, lacked a current evaluation. A change in ownership on May 1 led to confusion about hire dates, contributing to the oversight.
The facility failed to maintain sanitary conditions in food storage, preparation, and service, with undated and expired items found in the kitchen and unit refrigerators. The dishwasher did not reach the required temperature, and meal trays were delivered with uncovered desserts. Staff interviews revealed a lack of adherence to food labeling and temperature monitoring protocols, placing residents at risk of consuming contaminated or spoiled food.
The facility failed to adhere to infection control practices, including improper PPE use for a resident on COVID-19 precautions and inadequate storage of O2 tubing for another resident. Staff entered a resident's room without proper PPE and disposed of it incorrectly. Additionally, clean linens were transported uncovered, increasing infection risk.
The facility failed to ensure that a NAC received the required 12 hours of training per year, with only 6.3 hours documented. The Staff Development Coordinator acknowledged the shortfall and was unable to provide evidence of the required training for the NAC, highlighting a lapse in maintaining comprehensive training records.
The facility failed to meet regulatory requirements for room size in six resident rooms, with multiple rooms not providing the required 80 square feet per resident. Despite this, surveyors found no compromise to resident health or safety. This was a repeat citation.
Resident Rights Not Reviewed or Posted
Penalty
Summary
The facility failed to periodically inform residents of their rights after admission. According to the facility policy titled Resident Rights, residents have the right to be informed of their rights and of the rules and regulations governing resident conduct and responsibilities during their stay. During the Resident Council interview, residents in attendance stated that staff had not talked with them about resident rights, and one resident said they only remembered reading the rights in the admission packet four years earlier. The remaining residents stated no when asked if staff had reviewed resident rights with them. Review of Resident Council minutes from April to May 2026 did not show documented evidence that resident rights were reviewed. An observation found no postings about resident rights in the facility. The Activities Director stated they had never discussed resident rights in Resident Council meetings during the past year, and explained that rights had previously been posted in the dining room but were removed during construction and not put back. The Administrator stated that resident rights were provided on admission and were supposed to be reviewed during Resident Council meetings, and also confirmed that the postings had been taken down during construction and not replaced.
Dining Room Too Small for Resident Use
Penalty
Summary
The facility failed to ensure the resident dining room had enough space for residents to dine and to enter and exit without moving other residents. During an observation, the facility’s only designated dining room contained one refrigerator, one section of upper and lower cabinets, and four tables. Seven residents in wheelchairs were eating breakfast in the room, including one resident seated at a table in the back left corner facing a wall. One resident wheelchair blocked the doorway, and there was no space to walk between the two center tables without moving residents, although there was visible table space for 10 residents. The facility census posted that day was 53 residents. During later observation and interview, residents stated the dining room became crowded, especially with wheelchairs, and that when there were about 10 residents in the room, they would run out of room and some residents had to eat in their rooms if they arrived later. One resident who self-propelled into the room stated they were not crazy about facing the wall and said they had to wait to leave because other residents’ wheelchairs blocked the way, and they wanted a pathway that stayed open. The Maintenance Director measured the dining room at 24 feet by 14 feet and stated that if all 50 or so residents wanted to eat there, that would be an issue. The Administrator stated the prior larger dining room had been converted to the therapy gym and acknowledged the current dining room was too small for more than about 10 residents.
Incomplete care plans for elopement risk, psychotropic meds, pain, restorative care, and wounds
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for multiple residents, including residents with elopement risk, psychotropic medication use, pain needs, restorative programs, and skin conditions. The report states that the facility’s policy required comprehensive care plans to describe the services needed to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being, but the care plans reviewed did not consistently include the resident-specific needs identified in assessments, orders, MARs, TARs, and other records. Resident 11 was admitted with dementia and was identified in the elopement binder as high risk for elopement based on an elopement risk assessment score of 17. Although staff stated the resident was placed in the elopement binder because of high risk and that the care plan should include elopement risk, the care plan did not document that risk. Staff also stated they used the care plan and Kardex to know how to care for residents, and the DON stated elopement risk should have been included in the comprehensive care plan. Resident 72 was admitted with depression, metabolic encephalopathy, and rheumatoid arthritis, had moderate cognitive impairment, and received antipsychotic and antidepressant medications daily. The care plan did not include the psychotropic medications, resident-specific behaviors, or monitoring for adverse side effects. The same resident also had frequent pain and received a narcotic pain medication multiple times daily, but the MAR, TAR, pain assessment, and care plan did not document non-pharmacological pain interventions. Resident 2 had diagnoses including polyneuropathy, low back pain, and partial amputation of the right foot, but the pain care plan addressed only the toe amputation and did not include chronic back pain, neuropathy, specific goals, or non-pharmacological interventions. Resident 77 had osteoarthritis and frequent pain, but the pain care plan did not identify the pain characteristics or location and did not include non-pharmacological interventions; pain assessments also lacked complete documentation of intervention effectiveness or non-pharmacological measures. Resident 30 and Resident 53 had restorative programs listed in the restorative binder for bilateral upper and lower extremities, but the medical record and care plans did not contain corresponding restorative documentation, focus areas, goals, or interventions. Resident 53 also had an unhealed pressure ulcer and was receiving wound treatment, yet the care plan did not include pressure ulcer care. Resident 34 had a left heel pressure ulcer with treatment and a wound consultation recommending offloading with a sage or moon boot, but the care plan did not include heel offloading or specialized boot interventions. Staff interviews confirmed that these items should have been reflected in the care plans, but they were not.
Missing Psychotropic Medication Consents
Penalty
Summary
The facility failed to obtain psychotropic medication consent for 4 of 6 residents reviewed for psychotropic medications: Residents 3, 16, 72, and 77. The facility policy titled, Use of Psychotropic Medication(s), stated the resident or resident representative was to be informed in advance of the risks and benefits of the proposed care and had the right to accept or decline treatment. Review of the records showed Resident 72, who had a diagnosis of depression, was ordered Mirtazapine on 06/14/2026 and received it daily, but there was no progress note documenting discussion about starting the medication and no consent in the electronic chart. Staff I, the RCM, stated consent was required before psychotropic medications were administered but could not provide one for Resident 72 and said a new behavioral health provider had placed the order without notifying nursing staff. Resident 3, who had diagnoses including bipolar disorder and depression, was ordered lamotrigine twice daily on 05/12/2026 and received it in May and June 2026, but no consent was completed in the EMR. Resident 16, with major depressive disorder, anxiety disorder, and bipolar disorder, was ordered olanzapine twice daily on 04/02/2026 and received it in April, May, and June 2026, but no consent was completed in the EMR. Resident 77, who had bipolar disorder and panic disorder, was ordered lamotrigine twice daily on 05/18/2026 and received it in May and June 2026, but no consent was completed in the EMR. Staff G stated LPNs did not obtain psychotropic medication consents and that the RCMs obtained them, while Staff H and Staff I confirmed Residents 3, 16, and 72 did not have psychotropic medication consents completed. The DON stated the expectation was that psychotropic medication consent would be completed before administration.
MDS assessments were not transmitted within required timeframes
Penalty
Summary
The facility failed to ensure that MDS assessments were transmitted to the State within the required timeframes for 3 of 5 residents reviewed. Resident 4 and Resident 50 each had a Discharge MDS that was created and had assessment data collected, but both assessments remained in completed status and had not been transmitted within 14 days of the triggering event. Resident 14 had a Quarterly MDS assessment that showed an accepted status in the facility system dated 05/13/2026, but the MDS reference date was not until 05/15/2026, and the assessment was not included in the validation report of transmitted assessments for the time period. During interview, the MDS Nurse stated that the MDS assessments were completed but not being transmitted, and confirmed that the discharge assessments for Residents 4 and 50 and the quarterly assessment for Resident 14 had not been transmitted within 14 days as required. The DON stated the facility used a third-party software system for transmission and had not been able to view the information and transmissions, and also stated the system should not have marked an assessment as accepted if it was not in a transmission batch and that validation reports should have been reviewed to ensure all assessments had been transmitted and accepted.
Inaccurate MDS Assessments for Vision, Pain, Psychotropic Use, Dental Status, and COPD Coding
Penalty
Summary
The facility failed to ensure Minimum Data Set (MDS) assessments were accurate for three residents reviewed for resident assessment. For one resident with rheumatoid arthritis, depression, and metabolic encephalopathy, the admission MDS documented vision as adequate with no glasses, even though the resident stated they could not see things up close and used eyeglasses to read. The resident’s care plan, however, documented impaired visual function and that the resident wore glasses and requested assistance with them, creating a mismatch between the assessment and the care plan. For the same resident, the MDS documented that non-medication pain interventions were provided, but the June 2026 MAR and progress notes did not show documentation that such interventions were provided before pain medication was given. The resident’s care plan also did not document non-medication pain interventions. In addition, the MDS indicated the resident received antipsychotic medication but was coded as not receiving any antipsychotic medications. The related CAA for pain was left blank for pain characteristics, frequency, intensity, non-verbal indicators, and resident or representative input, and the psychotropic drug use CAA also lacked documentation of behaviors, adverse side effects, and resident or representative input. The care plan did not include psychotropic drug use. For another resident, the admission assessment documented missing and broken teeth, and the resident was observed with visible tooth fragments and missing teeth, reporting long-standing dental problems and pain when biting down. Despite this, the admission MDS marked no for abnormal mouth tissue, broken natural teeth, and inflamed or bleeding gums, so no dental CAA was triggered and the comprehensive care plan was not revised. For a third resident with COPD, the admission MDS coded shortness of breath or trouble breathing when lying flat, which placed the resident into a special high nursing category and resulted in a higher reimbursement rate, but the electronic record contained no clinical documentation supporting that coding during the assessment window.
PASRR Level II referrals were not completed or tracked for residents with mental health diagnoses
Penalty
Summary
The facility failed to ensure PASRR Level I screenings that identified mental illness or intellectual disability indicators were referred for PASRR Level II evaluation and followed up on for 6 of 7 residents reviewed. Resident 56 was admitted with substance abuse, mood disorder, and anxiety disorder diagnoses; the Level I PASRR identified mood disorder, anxiety disorder, and substance abuse disorder and required a Level II evaluation, and a Notice of Determination in the record stated the resident had been in the SNF for more than 30 days and required Level II evaluation. However, no Level II evaluation had been completed since admission, and the Social Services Director stated the facility had received the Notice of Determination but had no evidence of communication or follow-up with the PASRR coordinator. Resident 72 was admitted with depression and metabolic encephalopathy, and the PASRR on file showed a 30-day exemption, but the PASRR date had expired before admission and no other PASRR was in the chart. Resident 30 was readmitted with bipolar disorder; the updated Level I PASRR identified serious mental illness and required Level II evaluation, but none was completed before admission. Resident 2 had major depressive disorder and generalized anxiety disorder; the Level I PASRR indicated Level II was not required due to a 30-day hospital exemption unless discharge did not occur as scheduled, and staff documented faxing the Level I to the Level II evaluator. Resident 3 had bipolar disorder and depression; the Level I PASRR required Level II evaluation and was faxed to the evaluator, but there was no documentation of follow-up. Resident 77 had bipolar disorder and panic disorder; the Level I PASRR indicated a hospital exemption and required Level II if discharge did not occur within 30 days, and staff documented faxing the Level I to the evaluator. Staff stated they did not have a system to track residents needing PASRR Level II follow-up or to monitor residents approaching 30 days when previously exempted, and they had not followed up with the evaluator for Residents 2, 3, and 77 within the required timeframes.
Insufficient RN Coverage
Penalty
Summary
The facility failed to ensure there were eight consecutive hours of RN coverage each day. Review of the 30-day staffing pattern form dated 05/23/2026 through 06/22/2206 showed that six of the 31 days did not have eight consecutive hours of RN coverage. During an interview on 06/25/2026 at 10:06 AM, the DON stated they were aware the facility did not meet the RN coverage requirement because they did not have enough RNs on staff.
Dietary Staff Failed to Wear Beard Restraints in Kitchen
Penalty
Summary
The facility failed to ensure dietary staff followed USDA Food Code requirements for hair restraints in the kitchen. During an observation through the kitchen door, one cook and two other kitchen staff were plating breakfast items, and the cook and one dietary staff member were observed with beards and without beard coverings. In a later observation, the Dietary Manager and a Dietary Aid were also observed with facial hair and without beard coverings in the food service areas. The Dietary Aid stated they believed beard restraints were not required because their facial hair was not over an inch long and said they did not have beard restraints available because of that belief. The Administrator stated any kitchen staff with facial hair needed to wear a beard cover and said reminders had recently been given, but was not aware beard restraints had not been ordered or available in the kitchen due to misinformation about the requirement. This was identified as a repeat deficiency from a prior statement of deficiencies.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to ensure Enhanced Barrier Precautions were followed for residents with a feeding tube, a central line, and during high-contact care activities. Facility policy titled "Enhanced Barrier Precautions," dated 2025, stated EBP would be used during care of feeding tubes and central lines, and during high-contact care activities such as transferring. During observation, an LPN administered medication via a feeding tube to a resident with EBP signage posted at the door but did not wear a gown, and stated the sign was for the resident because of the feeding tube and that a gown should have been worn. During another observation, an RN flushed and connected IV medication for a resident with a central line without wearing a gown, and stated the EBP sign was for the resident and that a gown should have been worn prior to administering the IV medication. During a separate observation, two NACs transferred a resident with a feeding tube from bed to wheelchair using a Hoyer lift while EBP signage was posted at the door, but neither staff member wore gowns. One NAC initially stated the sign meant gowns were to be worn when changing briefs or cleaning the resident, then added that a gown should have been worn when transferring the resident to the wheelchair. The Infection Control Nurse stated staff do rounds, spot checks, and audits and provide education when precautions signs are not followed, but could not explain why staff did not follow the precaution signs. The DON stated staff could verbalize that gowns and gloves were to be worn during high-contact care for residents on EBP, but could not explain why staff did not follow the precaution signs.
Failure to Complete SCSA After Multi-System Decline
Penalty
Summary
The facility failed to timely complete a Significant Change in Status Assessment (SCSA) MDS for Resident 53 after the resident experienced a multi-system decline. The resident’s record showed a quarterly MDS that documented no pressure ulcer, no skin treatment, rejecting care one to three days, and dependent assistance for toilet transfers, followed by dietary notes documenting 8.1% weight loss over 180 days and then 11.2% weight loss over 180 days. A progress note documented dysphagia and intake of less than 50% of meals, and a skin observation later showed the development of two pressure ulcers. An initial wound consultant progress note documented discussion with nursing staff and the DON that the resident had significant decline in function, weight loss, increased weakness, a decline in getting out of bed, and refusal of position changes over the past several months. A later quarterly MDS coded the resident with stage three pressure ulcers, pressure ulcer care, holding food in the mouth/cheeks or residual food after meals, and toilet transfers as not applicable. The EHR showed no completed comprehensive SCSA after the resident sustained this decline in status that impacted multiple areas of health status, and the DON stated the resident’s condition was not expected to return to baseline within two weeks and that an SCSA should have been completed following the decline.
Missing IV Flush Order for Central Line Care
Penalty
Summary
The facility failed to ensure professional standards were met for one resident receiving IV medication administration because there was no physician order for the IV flush. Resident 76 was admitted with pyogenic arthritis and had a central line used to give IV antibiotics. During observation, a registered nurse flushed the resident’s central line with 5 ml of normal saline and then started the IV antibiotic infusion. Review of the resident’s physician orders did not show an IV flush order. In interview, the nurse stated an order was required for IV flushes and that the line should be flushed before and after the IV antibiotics, but could not find the order. The nurse also stated that the night before, an IV nurse had to be paged to the facility to clear the resident’s central line for blockage. The DON stated it was expected to have an order for IV flushes and they were unsure why the resident did not have one.
Failure to Provide and Maintain Hearing Aids
Penalty
Summary
The facility failed to ensure Resident 30 received proper assistive devices to maintain hearing abilities. The resident was readmitted to the facility and had a care plan, initiated 11/25/2023, documenting bilateral hearing aids. The June 2026 MAR also documented an order to provide bilateral hearing aids in the morning and remove them at night, effective since 08/25/2025. During multiple observations and interviews on 06/22/2026 and 06/23/2026, Resident 30 stated they could not hear and needed their hearing aids, and the resident was observed not wearing hearing aids on several occasions. Staff interviews showed the hearing aids were not being consistently provided or functioning as ordered. A NAC stated Resident 30 had hearing impairment and did not have hearing aids, and that staff increased their speaking volume and spoke closely into the resident’s left ear because the left side had better hearing. Another NAC stated they had not seen the resident wear hearing aids, and an LPN later placed the hearing aids on the resident, but the resident stated they still could not hear and the hearing aids did not work. On 06/24/2026, an LPN stated the hearing aids could not be charged and one aid was missing; the hearing aid case was kept in the medication cart without a charger, and only one hearing aid was present. The MAR contained code 9 entries for 06/06/2026 and 06/22/2026, but the corresponding progress notes did not document the reason for those entries.
Missing Post-Dialysis Assessments for a Resident Receiving Hemodialysis
Penalty
Summary
The facility failed to ensure dialysis communication documents were completed after a resident returned from dialysis appointments. Resident 77 was admitted with diagnoses including end stage renal disease and severe chronic kidney disease, and the care plan documented dialysis three days per week on Mondays, Wednesdays, and Fridays at a dialysis clinic. Review of the resident’s pre and post dialysis assessments for multiple dates showed that the post dialysis assessment documentation was not completed. The facility policy titled "Hemodialysis" stated the facility would assure residents received care and services for hemodialysis consistent with professional standards of practice, including ongoing assessment and monitoring for complications before and after dialysis treatments and documentation of the resident’s access site upon return from dialysis. During interviews, an LPN stated there was no assessment or form to complete after the resident returned from dialysis, the RCM confirmed the post dialysis assessment form should have been completed and was not, and the DON stated there were issues with dialysis documentation and that the expectation was for the post dialysis assessment and documentation to be completed.
Failure to Provide Follow-Up Dental Services
Penalty
Summary
The facility failed to ensure routine and emergency dental services were provided for one resident with missing and broken teeth. The resident was admitted with documented oral/dental problems, and a baseline care plan was started related to those issues. During an observation and interview, the resident stated their teeth were in terrible condition, showed visible tooth fragments and missing teeth, reported avoiding certain foods, and described sharp shooting pain when biting down wrong. The resident also said they had previously been seen by someone at the facility who told them all of the teeth needed to be pulled, and they voiced anxiety because they had not been told about any further follow-up. A dental hygienist visit note documented instructions to refer the resident to a dentist for lower root tip extractions and a full upper denture. However, the record contained no evidence of follow-up related to those recommendations. In interviews, staff acknowledged the resident had broken teeth and that extraction had been recommended, but stated no dental appointments were scheduled. Staff also said the resident may refuse because of anxiety, had not recently been asked about the teeth, had not been aware of complaints about diet or tooth pain, and had not contacted the prior dental office for information.
Resident Rooms Did Not Meet Required Square Footage
Penalty
Summary
The facility failed to ensure that 7 resident rooms, including Rooms 107, 108, 110, 302, 305, 306, and 307, met the required square footage standards of at least 80 square feet per resident in multiple resident rooms and at least 100 square feet in single resident rooms. Review of the facility census showed that each of these rooms had two beds, and the reported room sizes were 142 sq ft, 143 sq ft, 143 sq ft, 154 sq ft, 154 sq ft, 154 sq ft, and 153 sq ft. Observations on 06/22/2026, 06/23/2026, 06/24/2026, 06/25/2026, and 06/26/2026 confirmed that these rooms each contained two beds. During an interview on 06/26/2026 at 11:30 AM, the Administrator stated that an exemption had been requested from the state for these rooms but had not been granted as of that time.
Failure to Complete Required PASRR Evaluations for Residents with Mental Health Needs
Penalty
Summary
The facility failed to ensure that required Pre-Admission Screening and Resident Review (PASRR) processes were completed for three out of five residents reviewed. For one resident with diagnoses of anxiety and depression, the PASRR Level 1 screen indicated the need for a Level 2 evaluation prior to admission, but there was no evidence in the electronic health record that this evaluation was completed. Staff interviews revealed a lack of awareness regarding the requirement for a Level 2 evaluation before admission when indicated by a positive Level 1 screen. For two other residents, the PASRR Level 1 screens documented indicators of serious mental illness and granted a 30-day exemption from Level 2 evaluation, contingent on discharge within that period. However, when these residents remained beyond 30 days, there was no evidence that updated PASRR Level 1 screens or required Level 2 evaluations were completed. Staff confirmed that no requests for Level 2 evaluations were submitted for these residents, despite the extended stays.
Unqualified Dietary Manager Serving as Director of Food and Nutrition Services
Penalty
Summary
The facility failed to ensure that the individual designated as the Director of Food and Nutrition Services possessed the required qualifications. The person serving in this role, identified as the Dietary Manager, confirmed during interview that they were not a certified Dietary Manager and were only enrolled in an educational program to obtain certification. The facility was using the certification of the Assistant Dietary Manager, who previously held the position, in place of the current director's required certification. Review of the staff roster and facility assessment documented the current director as the certified dietary manager, despite the lack of certification. The facility administrator acknowledged that the previous manager's certification was being used until the current director became certified.
Deficient Sanitary Practices in Food Storage, Preparation, and Service
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen and food storage areas regarding sanitary food storage, preparation, and service. The dishwashing area had a large hole in the wall, a rusty can supporting a pipe, and a pool of discolored liquid beneath a leaking handwashing sink. Food debris and cracker wrappers were present on the floor. Staff interviews confirmed awareness of these issues, including reports of cockroaches and ongoing pest control measures. The dishwashing temperature log had missing entries, and recorded temperatures were below the required level for proper sanitation. Staff operating the dishwasher indicated that the machine was a low-temperature chemical model and described running it empty to reach the correct temperature, but logs showed temperatures as low as 116-127 degrees Fahrenheit. The freezer had significant ice buildup due to missing door seals, which staff acknowledged were pending replacement. Hand hygiene practices were not followed, as staff were observed changing gloves without performing hand hygiene between tasks. The nourishment refrigerator contained opened and undated beverage items, and the dry storage area had multiple opened and unlabeled food items, including cereals and pasta. Staff interviews confirmed awareness of the need for deep cleaning and equipment replacement, but these actions had not yet been completed at the time of the survey. No specific residents were identified as being directly affected in the report.
Failure to Address and Resolve Resident Grievances from Resident Council Meetings
Penalty
Summary
The facility failed to implement a system to ensure that grievances voiced by residents, particularly through Resident Council meetings, were properly documented, tracked, investigated, and resolved. Residents repeatedly reported issues such as loud TV noise, staff being boisterous at night, and cold food during meals. These concerns were consistently brought up in Resident Council meetings over several months, but there was no documentation of resolutions or evidence that grievance forms were completed or logged. The facility's grievance log did not reflect these ongoing concerns, and there was no follow-up or investigation into the issues raised. Interviews with staff revealed a lack of clarity and communication regarding the grievance process. The Activity Director, who assisted with Resident Council meetings, did not consider concerns raised in these meetings as formal grievances and therefore did not complete grievance forms or track the issues. The Social Service Director, designated as the Grievance Officer, was not notified of any concerns from the Resident Council meetings and had not received any related grievance forms. The Administrator expected that grievances from Resident Council meetings would be documented and processed, but acknowledged that this was not occurring and that there was no established process for handling these concerns. Specific residents reported ongoing disturbances at night due to loud TVs and staff noise, which affected their ability to sleep. Observations confirmed that noise levels were high, including loud communication from staff devices. Despite these repeated complaints and direct observations, there was no evidence that the facility took appropriate steps to address or resolve the grievances, and staff members responsible for resolving such issues were unaware of the ongoing concerns.
Failure to Provide Updated and Complete NOMNC Forms
Penalty
Summary
The facility failed to provide complete and updated Notification of Medicare Non-Coverage (NOMNC) forms to four sampled residents. For each resident, the NOMNC form used was outdated, having last been approved by CMS in 2011 rather than the most recent version. Additionally, the forms lacked required information, specifically the name and telephone contact of the appeal organization. There was also no documentation in the residents' electronic health records indicating that the residents or their representatives were given an explanation of the NOMNC form or the appeal process. Interviews with the Social Service Director revealed a lack of awareness regarding the need to update the NOMNC form and include the appeal organization's contact information. The Social Service Director stated they were responsible for issuing and explaining the NOMNC form but was unaware that the forms in use were outdated and missing required information. This deficiency was identified through both record review and staff interviews.
Failure to Provide Required Bed Hold and Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide required written notices of bed hold, transfer, and discharge to residents, their representatives, and the State Ombudsman in cases of hospitalization and discharge. For three residents reviewed, documentation was missing regarding the issuance of bed hold policies and transfer/discharge notifications during hospital transfers or discharges. Specifically, one resident was hospitalized and re-admitted without any progress notes or EMR documentation indicating that a bed hold or transfer/discharge notice was offered or provided. Staff interviews revealed confusion and inconsistent practices regarding who was responsible for completing and sending these notifications, with some staff unaware of the requirement to notify the State Ombudsman for hospital transfers or unplanned discharges. Additionally, for another resident who was sent to the emergency room, there was no evidence in the EMR that the State Ombudsman was notified. In the case of a resident discharged to an adult family home, the EMR lacked documentation of notification to the State Ombudsman. Staff reported that notifications for planned discharges were sent monthly, but could not provide documentation that notifications were sent for each individual discharge as required. The facility's own policy required timely notification and documentation, but these procedures were not consistently followed.
Failure to Complete and Implement PASRR Evaluations and Recommendations
Penalty
Summary
The facility failed to ensure proper coordination and completion of the Preadmission Screening and Resident Review (PASRR) process for four out of six residents reviewed. Specifically, residents with diagnoses including depression, major depressive disorder, anxiety disorder, dementia, and borderline personality disorder were either not referred for required Level II PASRR evaluations or had recommendations from completed Level II evaluations omitted from their care plans. Documentation showed that Level I PASRR screenings indicated the need for Level II evaluations for several residents, but there was no evidence that these evaluations were completed or that the state PASRR evaluator was contacted as required. For one resident with a diagnosis of depression, the Level I PASRR indicated a need for a Level II evaluation, but no such evaluation was found in the electronic health record, and the state PASRR evaluator confirmed no referral was received. Another resident with major depressive disorder also required a Level II evaluation, but staff could not locate documentation of its completion. A third resident with dementia, anxiety disorder, and depression had an invalidated Level II PASRR and, after a repeat Level I PASRR, again required a Level II evaluation, but there was no documentation of follow-up or communication with the state evaluator. A fourth resident with depression and borderline personality disorder had a completed Level II PASRR evaluation with specific recommendations for care, including environmental modifications and trauma-informed approaches. However, none of these recommendations were incorporated into the resident's care plan, and staff were unaware of the evaluation's findings or the resident's trauma history. Interviews with staff revealed a lack of awareness and follow-through regarding PASRR requirements and care plan updates, and management was unaware of the deficiencies until informed during the survey.
Failure to Ensure Communication and Documentation for Dialysis Services
Penalty
Summary
The facility failed to ensure ongoing communication and collaboration with the hemodialysis center and did not consistently complete pre- and post-dialysis assessments for two residents requiring hemodialysis services. For one resident with end stage kidney disease and diabetes, the care plan required monitoring for complications and regular dialysis attendance, but documentation revealed missing post-dialysis assessments on multiple dates and a lack of after-visit summaries from the dialysis center. Staff interviews confirmed that communication packets were inconsistently managed, and necessary documentation from the dialysis center was often not received or completed. For another resident with similar diagnoses, the care plan also required monitoring and regular dialysis, but there were no completed pre- or post-dialysis assessments for an extended period, and specific assessments were missing on additional dates. Progress notes indicated that the resident was sent to the hospital from dialysis without timely communication. Staff acknowledged gaps in documentation and communication with the dialysis center, including missing run sheets that contained critical clinical information. The facility did not have contracts with the dialysis centers providing care to these residents, and no additional documentation was provided regarding their dialysis care.
Failure to Provide Palatable and Properly Tempered Food
Penalty
Summary
Surveyors identified that the facility failed to provide appetizing and palatable food at safe and appetizing temperatures to several residents. Multiple residents reported that their meals were served lukewarm or only warm, rather than hot, and observations confirmed that plates were cool to the touch and lacked heated plate warmers. Residents described the food as overcooked, dry, or difficult to chew, with specific complaints about sausage patties, salmon, and macaroni salad. Test tray observations further revealed issues such as dry salmon, bland soup, overcooked and lukewarm asparagus, and macaroni salad with an unappealing taste. Additionally, a grievance was documented regarding a foreign object (bread tie) found in a sandwich. Resident council meeting minutes indicated that the kitchen was aware of temperature issues and was working on acquiring temperature-controlled carts, but at the time of the survey, these issues persisted. The facility administrator was unaware of the food concerns raised by residents and the lack of palatable meals. The findings were based on interviews, direct observations, and review of resident council minutes and grievances, demonstrating a pattern of inadequate food quality and temperature control for multiple residents.
Delayed Reimbursement of Resident Trust Funds After Death
Penalty
Summary
The facility failed to reimburse funds from a resident's trust account to the appropriate party within 30 days following the resident's death, as required by regulation. Record review showed that a resident who had passed away had a remaining trust account balance of $378.67, which had not been submitted to the state Office of Financial Recovery (OFR) within the required timeframe. During an interview, the Business Office Manager confirmed that the funds had not yet been submitted as required. This delay resulted in the resident's account not being reconciled within the mandated 30-day period.
Failure to Develop and Implement Individualized Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement individualized, comprehensive care plans for two residents, one with dementia and one with a urinary catheter. For the resident with dementia, the care plan noted severe cognitive impairment, depression, and anxiety, and included interventions such as asking yes/no questions, cueing, and monitoring cognitive changes. A separate care plan addressed the resident's primary language, Dutch, and called for the use of Dutch-to-English signage provided by the family. However, during observation, no such signage was present in the resident's room, and staff were unaware of this intervention, indicating the care plan was not fully implemented. For the resident with a urinary catheter, the care plan documented the presence of the catheter but did not specify the clinical reason for its use, whether it was unavoidable, or the required follow-up care. Interviews with staff revealed a lack of awareness regarding the rationale for the catheter and acknowledged that the care plan was vague and incomplete. The absence of individualized and comprehensive care planning for both residents was confirmed through observation, interviews, and record review.
Failure to Follow Medication and Monitoring Protocols for Two Residents
Penalty
Summary
The facility failed to ensure that professional standards were met for two residents in relation to medication administration and monitoring. For one resident with heart failure, the facility did not document blood pressure readings as required when administering antihypertensive medication, despite provider orders specifying to hold the medication if blood pressure readings were below certain parameters. There were also periods where no blood pressure readings were documented at all, and staff interviews confirmed that the expectation was to follow the provider's orders and document the necessary parameters. Additionally, the same resident experienced constipation, and the facility did not follow its own bowel protocol. The resident went several days without a bowel movement, but the prescribed sequence of interventions—such as administering Milk of Magnesia, a glycerin suppository, and an enema—was not followed or documented. Staff interviews indicated that nurses were expected to monitor bowel movements and administer medications according to the protocol, but this did not occur. For another resident with diabetes, the facility failed to notify the medical provider when the resident's blood sugar levels exceeded the ordered parameters on multiple occasions. The resident's orders required provider notification for blood sugar levels above 400, but there was no documentation of such notifications in the medical record. Staff confirmed that they were educated to follow these parameters and document provider notifications, but this was not done in these instances.
Failure to Provide Respiratory Care per Physician Orders and Standards
Penalty
Summary
The facility failed to provide respiratory care and services in accordance with physician's orders and accepted professional standards for two residents requiring respiratory support. For one resident with an order for oxygen at 2 liters per minute (lpm) via nasal cannula to maintain oxygen saturation above 90%, observations showed the oxygen concentrator was set at 1.5 lpm on multiple occasions. The resident reported that the prescribed setting was 2 lpm and expressed reluctance to request an adjustment. Documentation confirmed the order for 2 lpm, and the care plan reflected this intervention, but staff were unaware of the discrepancy and could not explain how oxygen saturation was being maintained as ordered. For another resident using a CPAP machine, there were no active orders in the medication administration record regarding the CPAP, including settings, maintenance, or cleaning instructions. The resident reported that staff had never cleaned the CPAP mask, and repeated observations revealed visible debris and oily substances on the mask. Staff interviews confirmed a lack of knowledge and responsibility for CPAP care, and the Director of Nursing was unable to locate any active orders or confirm proper maintenance. These findings demonstrate a failure to ensure respiratory care was provided as ordered and according to facility policy.
Failure to Follow Infection Control Protocols During Resident Care and Medication Administration
Penalty
Summary
Staff failed to comply with infection prevention and control guidelines in several instances involving residents on transmission-based precautions, during perineal care, and while administering medications. For one resident with a right lower leg fracture and ankle wound, who was on Enhanced Barrier Precautions (EBP), a nursing assistant entered and exited the resident's room without donning any personal protective equipment (PPE) despite a posted EBP sign and available PPE cart. The nursing assistant later confirmed assisting the resident with toileting without PPE, and another staff member was unclear about the PPE requirements for this resident. During perineal care for another resident, a nursing assistant did not perform hand hygiene after removing gloves and before donning new ones, instead placing contaminated hands into the glove box and continuing care. The staff member acknowledged the lapse, and the facility's infection preventionist confirmed that hand hygiene should be performed each time gloves are removed during perineal care. In medication administration, a nurse used a glucometer in a resident's room and then placed the contaminated device and supplies on the medication cart without a barrier, disinfected the glucometer but not the cart, and repeated similar actions with an insulin pen. The nurse admitted that used equipment should be considered contaminated until disinfected and that barriers should have been used under the equipment both in the resident's room and on the medication cart. The infection preventionist confirmed that these steps were required by facility policy.
Resident Rooms Below Required Square Footage Standards
Penalty
Summary
The facility failed to ensure that seven resident rooms (107, 108, 110, 302, 305, 306, and 307) met the required minimum square footage per resident, as specified by regulatory standards. Observations and record reviews confirmed that each of these rooms contained two beds, but the measured square footage for each room ranged from 142 to 154 square feet, which is below the required 160 square feet for double occupancy rooms (80 square feet per resident). The facility census confirmed that these rooms were occupied by two residents each during the survey period. Staff interviews revealed that an exemption had been requested from the state for these rooms, but it had not been granted at the time of the survey.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to ensure that resident grievances were properly filed and addressed, as evidenced by the case of a resident who experienced multiple unresolved issues. The resident, who was alert and oriented, had previously stayed at the facility and reported several grievances during their stay. These included a noisy roommate, missing personal property, and dissatisfaction with a particular nursing assistant's care. Despite the resident's complaints, these grievances were not documented in the facility's grievance logs, except for one related to handwashing. The resident expressed concerns about a roommate's loud television and encroachment on personal space, which were verbally communicated to staff but not formally recorded as grievances. Additionally, the resident reported missing a pair of plaid lounge pants, which the laundry manager acknowledged but did not document as a grievance. Furthermore, the resident requested not to have a specific nursing assistant, Staff K, provide care due to unsanitary practices. However, Staff K continued to care for the resident on two occasions after the grievance was reported, and the grievance form lacked follow-up documentation to confirm the resident's satisfaction with the resolution. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's grievances. The Director of Nursing Services was unaware of the missing item and noisy roommate issues, and the scheduler admitted to not properly reassigning Staff K despite knowing the resident's preference. The infection preventionist failed to document the resident's dissatisfaction with the resolution of their grievance. These oversights highlight the facility's failure to adhere to its grievance policy, which requires prompt resolution and follow-up with residents to ensure their concerns are addressed satisfactorily.
Failure to Honor Resident's Meal Preferences Due to Staffing
Penalty
Summary
The facility failed to honor the preferences of a resident, identified as Resident 26, regarding their Activities of Daily Living, specifically related to recreational meal intake. Resident 26, who was admitted with a stroke affecting their ability to swallow and maintain adequate nutrition, had physician orders for tube feeding to meet 100% of their nutritional needs. Despite being assessed as able to safely tolerate some oral intake with 1:1 supervision, the facility only provided this support for lunch from Monday through Friday, due to staffing limitations on weekends. This restriction was not aligned with the resident's preference to have a recreational meal every day, as they enjoyed the social aspect of the meals. Interviews with staff revealed that the scheduling practices did not account for the resident's needs on weekends. Staff G, the primary caregiver for Resident 26's meals, confirmed that the resident only received assistance during weekdays because they did not work on weekends, and no other staff were scheduled to provide this support. Staff I, responsible for scheduling, was unaware of any limitations affecting Resident 26's meal assistance. The Director of Nursing Services acknowledged the scheduling practices but did not provide further information on why the resident's meals were limited to weekdays. This oversight placed Resident 26 at risk for decreased quality of life, as their preference for daily social interaction during meals was not met.
Medication Administration During Meals
Penalty
Summary
The facility failed to ensure a homelike dining environment by allowing a registered nurse to administer medications to a resident during their meal in the dining room. This action was observed during a dining observation where Staff C, a registered nurse, gave a spoonful of crushed medications to Resident 5 while they were eating. The facility's policy stated that medications should be administered in the privacy of the resident's room or another private area, unless the resident requested otherwise. However, there was no indication that Resident 5 had requested to receive medications in the dining room. Resident 5, who was admitted with a diagnosis of dementia, had cognitive impairments and was unable to complete interview questions related to cognition. The staff assessment confirmed memory impairment and impaired decision-making. Despite this, Staff C stated that administering medications during meals was their usual practice for cognitively impaired residents, as they were more likely to take them at that time. This practice was acknowledged by Staff B, the Director of Nursing Services, who recognized the need for further education on the matter.
Deficiency in Comprehensive Resident Assessment
Penalty
Summary
The facility failed to ensure that the Resident Assessment Instrument (RAI) for a resident was comprehensive and included thorough summaries of the Care Area Assessments (CAA). Specifically, for one resident who was admitted with a fracture of the right upper leg and later admitted to hospice services, the CAA assessment did not contain a comprehensive analysis of findings. The assessment lacked the resident's goals, preferences, strengths, needs, or input from the resident or their representative. Instead, the CAA contained a brief narrative that suggested continuing to care plan to slow or minimize decline in Activities of Daily Living (ADLs). The contracted Registered Nurse responsible for completing the Minimum Data Set (MDS), including the CAA and care plans, stated that the process involved reviewing gathered information and providing a shorter description to proceed to the care plan. Despite daily telephonic meetings with the facility's Resident Care Manager and Director of Nursing Services to discuss residents, the comprehensive analysis required for the CAA was not completed. This oversight placed the resident at risk of not receiving appropriate services based on their individualized needs.
Failure to Implement Care Plan Interventions for Fall Prevention
Penalty
Summary
The facility failed to implement care plan interventions for a resident who was at high risk for falls, which placed them at risk for injury and decreased quality of life. The resident, who had a history of falls and poor trunk control, was readmitted to the facility with diagnoses including a fall, high blood pressure, and a fracture of the right upper leg. An incident report from January 2024 indicated that the resident fell out of bed due to poor trunk control, and therapy recommended using a positioning wedge with a secure strap to prevent further falls. However, during observations in July and August 2024, the resident was seen using the wedge improperly, without the strap, and stated they did not use it the previous night. The care plan for the resident, updated in January and revised in June 2024, directed staff to ensure the wedge was secured with a strap for safety. However, the treatment administration record for July 2024 did not document the use of the wedge, and staff interviews revealed a lack of awareness and understanding of the wedge's purpose and the need for the strap. The Director of Nursing Services was unaware of the resident's refusal to use the strap, and the care plan did not address the resident's poor trunk control. This deficiency was a repeat citation from October 2023.
Failure to Revise Care Plans for Discharge and Dental Services
Penalty
Summary
The facility failed to revise comprehensive care plans for two residents, leading to potential risks for unmet care needs. Resident 20, who was admitted with conditions including an above-the-knee amputation, diabetes, and high blood pressure, had a care plan that was not updated to reflect changes in their discharge planning. Despite being over-resourced and unable to move to an Assisted Living Facility as initially planned, the care plan was not revised to address these changes, although progress notes were documented in the medical record. Resident 3, admitted with diagnoses such as congestive heart failure and sleep apnea, experienced issues with their dental care plan. The resident's care plan did not reflect the absence of their upper partial dentures, which had been sent for repair before the COVID pandemic and not returned. Despite staff acknowledging the issue and working to resolve it, the care plan remained outdated, failing to address the resident's current needs for dental care and assistance with oral hygiene.
Failure to Implement Professional Standards of Practice
Penalty
Summary
The facility failed to implement professional standards of practice for two residents, leading to potential risks for adverse outcomes. Resident 26, who had a stroke affecting their ability to swallow, was prescribed a tube feeding to meet their nutritional needs and was assessed to tolerate some oral intake with specific swallow strategies. However, the care plan and Kardex did not include these strategies, and staff failed to consistently cue the resident during meals, as observed on multiple occasions. This lack of adherence to the Speech Language Pathologist's recommendations placed Resident 26 at risk for swallowing difficulties. Resident 21, diagnosed with Diabetes Mellitus Type 2, chronic pain, and high blood pressure, was prescribed Amlodipine Besylate with specific parameters to hold the medication if their systolic blood pressure was below 100 mm Hg. The Medication Administration Record (MAR) for July and August 2024 showed no documented blood pressures, indicating a failure to follow the physician's orders. Additionally, an A1C lab test ordered on 07/18/2024 was not completed until 15 days later, due to the order being placed in the wrong section of the electronic health record, which was not processed by the nursing staff. Interviews with the Director of Nursing Services and a facility consultant revealed that the transition to an electronic medical record system contributed to these errors. The blood pressure monitor was inadvertently left off the MAR, and the provider's notes were not fully integrated into the system, causing delays in processing orders. These deficiencies highlight the facility's failure to ensure professional standards of practice, as required by regulations.
Deficiency in Assistance with Activities of Daily Living
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living for two dependent residents, leading to a deficiency in care. Resident 30, who was admitted with a fracture of the right upper leg, required supervision or touching assistance with eating and partial/moderate assistance for oral hygiene. Despite these needs, observations revealed that Resident 30 was left unattended for extended periods, with meal trays left untouched and no assistance provided for oral hygiene. Interviews with staff indicated a lack of clarity and consistency in the care provided, with some staff believing the resident required only setup assistance, while others noted the resident's increasing dementia and need for more supervision. Resident 26, who had a history of stroke, impaired swallowing, and required a gastrostomy tube for nutrition, also did not receive adequate oral care. The care plan indicated the need for one-person assistance with oral care using glycerin swabs, but observations showed the resident's mouth was dry and coated with white matter, and the resident reported infrequent assistance with mouth swabbing. Staff interviews revealed inconsistencies in the understanding and execution of the resident's oral care needs, with some staff unaware of the specific requirements for glycerin swabs and the frequency of care needed. The facility's failure to provide necessary assistance with activities of daily living for these residents, particularly in terms of meal assistance and oral hygiene, placed them at risk for diminished quality of life. The lack of clear communication and adherence to care plans among staff contributed to the deficiency, as evidenced by the observations and interviews conducted during the survey.
Deficiencies in Resident Care and Repositioning
Penalty
Summary
The facility failed to ensure that residents received care and treatment in accordance with professional standards of practice, specifically for two residents. Resident 21, who was at risk for pressure ulcer development due to immobility and other comorbidities, had an alternating air mattress that was not set to the prescribed settings. Despite the mattress being ordered for wound prevention, the settings were incorrectly set at 450/25 instead of the required 300/15, as indicated on the pump's sticker. This discrepancy was not identified by the staff responsible for monitoring the mattress settings, leading to a potential risk of skin breakdown. Resident 30, who was admitted to hospice services and had a fracture of the right upper leg, was not repositioned according to the facility's policy. Observations showed that Resident 30 spent extended periods in bed without assistance from staff for repositioning or care, despite requiring extensive assistance for repositioning due to impaired balance and pain. The care plan for Resident 30 did not include a specific repositioning schedule or address the positioning of the resident's heels, which could contribute to pressure-related issues. Interviews with staff revealed a lack of awareness and adherence to the required care interventions for both residents. Staff responsible for Resident 21's care were unaware of the incorrect mattress settings, and staff caring for Resident 30 did not consistently follow a repositioning schedule. These failures in care delivery placed both residents at increased risk of unmet care needs and potential skin breakdown.
Failure to Complete Annual NAC Performance Reviews
Penalty
Summary
The facility failed to ensure that annual performance reviews for Nurse Aide Certified (NAC) staff were completed, specifically for one of the four NACs whose files were reviewed. Staff K, who was hired on July 6, 2023, did not have a current employee evaluation in their file, and there was no evidence that an evaluation was completed or discussed with them. During interviews, it was revealed that the facility underwent a change in ownership on May 1, 2024, and all staff completed new hire paperwork on that date. However, there was confusion regarding whether staff should retain their original hire dates or adopt the new May 1st date, which contributed to the oversight in completing performance evaluations.
Sanitation Deficiencies in Food Handling and Storage
Penalty
Summary
The facility failed to maintain sanitary conditions in food storage, preparation, and service, as observed in the kitchen, snack/nourishment refrigerators, and during meal delivery. In the kitchen, undated and expired food items were found, including a sandwich, a thickened dairy beverage, and pitchers of lemonade and iced tea. Temperature logs for the kitchen refrigerator were incomplete, and the dishwasher was not reaching the required temperature of 120 degrees Fahrenheit, initially recorded at only 100 degrees Fahrenheit. Staff interviews revealed a lack of awareness and adherence to proper food labeling and temperature monitoring protocols. In the unit nourishment refrigerator, several items were found without labels or dates, including cheese slices, oats, and muffins, along with expired ketchup and Capri Sun drinks. Staff interviews indicated confusion about responsibility for checking and discarding expired or unlabeled items. During meal delivery, desserts such as Jello were observed uncovered on trays, contrary to sanitary serving practices. These deficiencies in food handling and storage practices placed residents at risk of consuming contaminated or spoiled food.
Infection Control Deficiencies in PPE Use and Linen Handling
Penalty
Summary
The facility failed to adhere to infection prevention and control practices, specifically in the use of personal protective equipment (PPE) and the handling of oxygen (O2) tubing. For Resident 23, who was on aerosol contact precautions due to COVID-19, staff did not properly don and doff PPE. Staff S entered the resident's room wearing only an N95 respirator, unaware of the need for additional PPE such as a gown and gloves. Staff P also failed to wear the appropriate mask and improperly doffed the gown and gloves outside the resident's room, disposing of them down the hallway. Resident 3, who used oxygen therapy at night due to obstructive sleep apnea, had their O2 tubing improperly stored. The tubing was observed lying on the floor and later rolled and placed on top of the concentrator, contrary to good practice. Staff interviews revealed that the tubing should be stored in a plastic bag when not in use, but this was not consistently done, as the bags often disappeared. Additionally, the facility did not cover clean linens during transport, as observed with Staff D and Staff U carrying uncovered clothing protectors and towels through the hallways. Interviews with staff confirmed that clean linens should be covered when transported, but this practice was not followed, contributing to the risk of infection spread within the facility.
Deficiency in Nurse Aide Training Hours
Penalty
Summary
The facility failed to develop, implement, and maintain an in-service training program to ensure that Nursing Assistants Certified (NACs) received the required 12 hours of training per year. This deficiency was identified during a review of the employee file for one of the NACs, referred to as Staff K, who had only completed 6.3 hours of training instead of the mandated 12 hours. The facility's assessment indicated that training topics included communication, resident rights, abuse prevention, infection control, and culture change, but there was no documented evidence of the required training duration or start times for Staff K. During an interview, the Staff Development Coordinator acknowledged the shortfall in training hours for Staff K and mentioned efforts to ensure compliance with the 12-hour training requirement. Although the facility was able to locate the necessary training documentation for other NACs, they could not provide evidence for Staff K, indicating a lapse in maintaining comprehensive training records. This failure placed residents at risk for potential unmet care needs due to insufficiently trained staff.
Deficiency in Resident Room Size Requirements
Penalty
Summary
The facility failed to ensure that six resident rooms met the regulatory requirements for square footage, with multiple resident rooms needing at least 80 square feet per resident and single resident rooms requiring at least 100 square feet. Specifically, rooms 107, 108, 302, 305, 306, and 307 did not meet these standards. Observations and record reviews revealed that rooms 107, 302, 305, and 307 each had two beds but did not provide the required space per resident, with room sizes ranging from 142 to 154 square feet for two beds. Despite these deficiencies, surveyor observations determined that the health and safety of the residents residing in these rooms were not compromised due to the size of the rooms. This issue was noted as a repeat citation from a previous survey conducted on October 16, 2023.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 655 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Everett
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| View Ridge Care Center | 1.7 mi | ★★★★★ | 16 | 0 |
| Everett Transitional Care Services | 2.9 mi | ★★★★★ | 8 | 0 |
| Bethany At Silver Lake | 3.2 mi | ★★★★★ | 10 | 0 |
| Bethany At Pacific | 3.6 mi | ★★★★★ | 19 | 0 |
| Everett Center | 3.9 mi | ★★★★★ | 6 | 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 October 2026) and official state health department websites.