Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Martha And Mary Health Service during CMS and state inspections, most recent first.
Delayed assessment and documentation of a controlled fall. A resident with heart disease, arthritis, moderate cognitive impairment, high fall risk, and limited mobility had a transfer event when a CNA had to catch and help the resident into a wheelchair after the resident lost energy and started to sit toward the floor. Staff did not complete timely assessment, incident reporting, alert charting, or provider notification, and the resident was later found to have swelling and bruising of the wrist and ankle with no documented monitoring on subsequent shifts.
The facility failed to follow its abuse protocol requiring immediate, but no later than two-hour, reporting of abuse allegations to the state agency. A resident with dementia and severe cognitive impairment, dependent on staff for toileting hygiene, told a CNA that someone had inserted fingers into their genital/anal area. The CNA reported the allegation to a nurse but did not notify the state agency or management. The allegation was only discovered later during a chart review by the DON, and the report to the state agency was made 16 days after the initial allegation, well outside the required reporting timeframe.
Failure to initiate and document bowel protocol interventions for multiple residents. Four residents had extended periods without BM, but bowel meds and protocol steps were not consistently started or documented as ordered. One resident was cognitively intact and reported constipation, another had memory impairment and needed extensive ADL help, and staff including the DON acknowledged missed bowel med administration and missing or inconsistent bowel documentation.
Fluid restriction intake was not accurately monitored or totaled for two residents. One resident’s fluids were split between POC meal documentation and MAR entries, but the 24-hour total was not calculated and the resident exceeded the 1500 mL restriction on multiple days; several meal entries were left blank. For the other resident, nursing only initialed the fluid restriction on the MAR and did not record the amount provided, preventing calculation of the 24-hour intake total. The DON stated the orders should have identified dietary and nursing allotments and who would reconcile intake.
Infection surveillance documentation was not kept current, as the IP/RN did not have timely line listings, monthly summaries, or a surveillance map for some months reviewed. The IP/RN stated she had fallen behind, was working on the missing records later, and noted the monthly summaries and maps were used to track infection patterns and possible resident-to-resident transmission. The DON stated the infection control program should include monthly line listings, surveillance maps, and summaries, and that the documentation was important for reporting, tracking, and isolation decisions.
The facility failed to promote resident choice for bathing and access to fluids for three residents. Two cognitively intact residents said they were assigned shower days and received fewer baths/showers than they preferred, while their care plans defaulted to weekly bathing and the records showed repeated bed baths with limited documentation of refusals or reoffering care. A third cognitively intact resident repeatedly had no water at bedside and said they went without unless they asked, while staff gave conflicting accounts of who was responsible for offering water and acknowledged the resident was not on a fluid restriction.
Damaged Shower Room Environment: A resident reported cracks in the floor, damaged walls, and missing or cracked tiles in a shower room on the unit. Surveyors observed heavily discolored and worn epoxy flooring with a long caulk-filled crack and damaged FRP wall panels, and the DON confirmed the condition and said the facility had plans to redo the room but had not done so yet.
Care plans were not accurately reviewed and revised for three residents. One resident’s fluid restriction plan lacked the goal, monitoring details, bedside pitcher guidance, and actions for non-adherence; another resident’s COVID-19 plan did not include respiratory monitoring, and the same resident’s fluid restriction plan was incomplete. A third resident’s comprehensive plan did not address documented mental health diagnoses or delusions, and it still listed a discontinued fluid restriction.
Failure to Provide and Reoffer Scheduled Bathing: A resident with dementia and ADL deficits was found with oily, unkempt hair and brown substance under the fingernails after not receiving a shower for an extended period. Staff reported the resident sometimes refused showers, but there was no documentation of refusals or reapproaches, and the resident could not recall when bathing was last offered or completed.
A resident with moderately impaired daily decision-making had a PRN Hydrocodone-Acetaminophen order for moderate to severe pain with a pain score of 6-10, but the MAR showed the medication was given 42 times outside the ordered parameters when documented pain scores were below 6. The Unit Manager/LPN acknowledged the doses should not have been given outside parameters, and the DON stated the practice did not meet expectations.
Medication error rate exceeded the allowed threshold, with 2 observed errors out of 25 opportunities. One resident received ferrous sulfate and pantoprazole after breakfast even though pantoprazole was ordered on an empty stomach before meals, and another resident was left with polyethylene glycol in a cup at bedside after an LPN told the resident to sip it and left the room. The DON stated the bedside medication issue did not meet expectations, and the self-administration assessment was documented after the observation.
A resident who underwent spinal surgery was discharged without removal of surgical staples as ordered by the physician, and staff did not document staple removal or communicate the need for removal to the receiving facility. Staff interviews confirmed the oversight and lack of communication regarding the surgical wound care.
A resident who was dependent on staff for toileting and bed mobility was left on a bedpan overnight due to a lack of communication between shifts. The resident, who had pressure ulcers and required frequent repositioning, was not turned or assisted for an extended period, resulting in a possible deep tissue injury. Staff interviews confirmed the resident needed help to turn due to pain and weakness, and that regular repositioning was expected.
The facility failed to update and accurately reflect care plans for several residents, leading to discrepancies in medication use, diagnoses, and care needs. For instance, a resident's care plan inaccurately identified medication diagnoses, while another's care plan was outdated regarding a removed PEG tube. Additionally, care plans for residents no longer requiring specific precautions or medications were not revised, as confirmed by staff.
The facility failed to assess and document the use of bed rails for four residents, leading to potential safety risks. Despite policy requirements for assessments and informed consent, the facility did not conduct necessary evaluations for bed rail use, leaving residents unable to independently manage the rails. Staff interviews confirmed the lack of documentation and assessments, highlighting a significant oversight in resident safety and regulatory compliance.
The facility failed to use non-pharmacological interventions (NPIs) before administering PRN pain medications for four residents, leading to potential unnecessary medication use. A resident with dementia and chronic pain received oxycodone and acetaminophen without documented NPIs. Another resident with osteoporosis received Tramadol without side effect or NPI documentation. A third resident received morphine and acetaminophen without NPIs or pain scores, and a fourth resident with chronic pain had PRN oxycodone without NPIs. Staff interviews confirmed the lack of documentation and the expectation for NPI use.
The facility failed to ensure residents were free from unnecessary psychotropic medications by not completing AIMS assessments, monitoring target behaviors, or documenting non-pharmacological interventions. For example, a resident's AIMS assessments were incomplete, and there was no follow-up documentation for observed behaviors. Staff interviews revealed expectations for monitoring and documentation were not met, leading to deficiencies in managing psychotropic medication use.
The facility failed to implement proper Enhanced Barrier Precautions (EBP) for residents with wounds and urinary catheters, as required signage was missing. Infection control practices were inconsistent, with staff not wearing gowns during high-contact activities and missing hand hygiene opportunities. Equipment like the Hoyer lift was not cleaned between uses. The facility's infection surveillance and Legionella Water Management Program were incomplete, and CPAP machines were not stored or cleaned properly, indicating significant gaps in infection prevention measures.
The facility failed to provide accurate drug information to two residents, impacting their informed consent. One resident received Abilify, an antipsychotic, but the consent form incorrectly listed it as an antidepressant. Another resident was prescribed Nuedexta, inaccurately identified as an antipsychotic and mood stabilizer, with incorrect indications for use. Staff acknowledged these errors in drug classification and information.
A facility failed to document and assess the use of body pillows as potential restraints for a resident who was dependent on mobility and had impaired decision-making abilities. Observations showed pillows placed under the fitted sheet without proper assessment, consent, or care plan. Staff acknowledged the oversight, and the DON confirmed the lack of necessary documentation.
The facility failed to ensure accurate MDS assessments for two residents, one with a suprapubic catheter and another with mental health needs. A resident with a catheter was incorrectly documented as incontinent, while another's MDS omitted a Level 2 PASRR, crucial for identifying mental health conditions. These inaccuracies were acknowledged by the DNS and MDS staff.
A facility failed to ensure accurate PASRR assessments and timely Level II evaluations for a resident with severe cognitive impairment and multiple mental health diagnoses. The resident's Level I PASRR assessment omitted key diagnoses, and no documentation was found for a required Level II evaluation, risking inappropriate placement and delayed mental health services.
The facility failed to implement comprehensive care plans for several residents, leading to deficiencies in individualized care. A resident with sleep apnea lacked a care plan for CPAP concerns and AGP procedures. Another resident with chronic pain did not have non-pharmacological interventions in their care plan. A resident with dysphagia had an incorrect diet documented, and a resident with depression and PTSD had incomplete pain management and psychotropic medication care plans.
The facility failed to meet professional standards for three residents, including incomplete documentation of oxygen administration, delayed lab tests, and unsecured medications. A resident's oxygen flow rate was not documented for six weeks, another had incomplete CPAP orders and delayed lab tests, and a medication cart was left unlocked. Additionally, a resident had medication at their bedside without a self-administration assessment.
A resident with severe cognitive impairment did not receive adequate bathing assistance, receiving only three showers over a 30-day period. The care plan required offering a bed bath if a shower was not possible, but this was not consistently done due to staff shortages and reassignments, as confirmed by the Unit Manager and DON.
The facility failed to follow professional standards for bowel management and hospice services for three residents. A resident did not receive documented non-pharmacological interventions for constipation, while another did not have bowel movements for several days without appropriate interventions. Additionally, a resident receiving hospice care lacked a current plan of care, leaving staff uncertain about the services to be provided.
A resident with pressure ulcers was found with a pressure relieving mattress set incorrectly at level 5 instead of the prescribed level 3, as per their care plan. The resident's weight had not been updated since late November, and staff interviews confirmed that mattress settings should be based on weight and checked each shift.
The facility failed to provide proper respiratory care for three residents, including inadequate documentation of oxygen administration, incomplete CPAP orders, and lack of nebulizer equipment maintenance. These deficiencies placed residents at risk for ineffective respiratory support.
A facility failed to promptly notify the provider of lab results outside clinical reference ranges for a resident with severe cognitive impairment, diabetes, and heart failure. The resident's A1C test was delayed by 41 days, and the elevated result was not communicated to the provider until 34 days after it was available. Other required lab tests were also not conducted as ordered. Staff confirmed the delays and acknowledged the failure to meet the facility's policy for prompt notification.
Three staff members failed to follow CDC guidelines for PPE use when caring for COVID-19 positive residents. A CNA did not wear eye protection and did not discard their N95 respirator after care. Another CNA did not perform hand hygiene before donning a new N95 respirator. An LPN also failed to discard their N95 respirator after care. The Infection Preventionist confirmed the expectation to remove and discard PPE after each encounter.
Delayed assessment and documentation of a controlled fall
Penalty
Summary
The facility failed to assess, monitor, and document a controlled fall in a timely manner for one resident who was at high risk for falls and had limited physical mobility. The resident had diagnoses of heart disease and arthritis and was noted on the annual MDS to have moderate cognitive impairment. The fall risk care plan identified the resident as high risk for falls. According to the report, a CNA was transferring the resident from the toilet to the wheelchair when the resident suddenly lost energy and had to be caught and helped the rest of the way to the wheelchair. The CNA stated the resident said they could not complete the transfer and started to sit as they were going to the floor, and the CNA then caught and hoisted the resident the rest of the way to the wheelchair. The CNA told the nurse on the unit about the event because it was unusual for the resident. Staff later stated that the event was not further assessed, no incident report was completed at that time, and the resident was not placed on alert charting. The next day, the resident was found during a shower assessment to have significant bruising and swelling of the right ankle and wrist, and the resident stated they had fallen the other night in the bathroom. Staff later reported that an order request was placed in the provider binder for a swollen and painful wrist and bruising, but the provider was not contacted until the following day when the provider reviewed the binder. The record review showed no alert charting or monitoring of the resident's right wrist or bruised leg on day, evening, or night shift after the event.
Failure to Timely Report Resident’s Allegation of Sexual Abuse to State Agency
Penalty
Summary
The facility failed to timely report an allegation of sexual abuse to the state agency as required by its abuse and neglect protocol. The policy, revised July 2024, defined sexual abuse to include sexual coercion or sexual assault and required that any incident or suspected incident of resident abuse be reported immediately, but not later than two hours after the allegation is made if the events involve abuse. Resident 1, who had dementia, severe cognitive impairment, and was dependent on staff for toileting hygiene per a Quarterly MDS dated 12/23/2025, made an allegation on 03/07/2026 that someone had inserted a finger into their vagina at around 2:00 PM. On 03/07/2026, a CNA (Staff B) reported that while providing care, the resident stated they had woken up the previous night with two fingers in their bottom. Staff B stated they immediately reported this allegation to the licensed nurse but did not report it to the state agency, explaining they were agency staff and unfamiliar with the resident and situation. An incident report dated 03/23/2026 showed that during a chart review, a licensed nurse noticed the 03/07/2026 progress note documenting the resident’s allegation of inappropriate touching, and the facility then reported the allegation to the state agency on 03/23/2026, 16 days after it was made. The DON (Staff A) confirmed that any allegation of abuse should be reported to the state agency within two hours, acknowledged that this was an abuse allegation, and stated they were not aware of it until the chart review on 03/23/2026, indicating that staff had not reported the allegation to the state abuse hotline or to management when they first became aware.
Failure to Initiate and Document Bowel Protocol
Penalty
Summary
The facility failed to initiate the bowel protocol and failed to accurately document bowel protocol interventions for four sampled residents who were reviewed for bowel care. The report cites the facility policy titled, Bowel Management, which directed staff to offer bowel medications and non-pharmacological interventions when a resident had no bowel movement for 3 days or more, and to document provider notification and orders in PCC notes. Resident 58 was cognitively intact and reported struggling with constipation. The resident had bowel care orders for Miralax, Bisacodyl tablets, Bisacodyl suppositories, and Fleet Oil Enema. Review of the bowel record showed two separate 5-day periods without a bowel movement in December 2025, and the MAR showed facility nurses failed to administer the as-needed bowel medications as ordered and in accordance with the bowel protocol. The DNS acknowledged that on both occasions the facility nurses failed to administer the bowel medication as ordered and as directed by the bowel protocol. Resident 63 was cognitively intact, and the bowel record showed a 5-day period with no bowel movement or only one small bowel movement in February 2026, and the DNS stated the as-needed bowel medication was not administered in accordance with the physician's orders and bowel protocol. Resident 8 had memory problems and needed substantial to dependent assistance with ADLs; the bowel record showed 4 consecutive days without a bowel movement in January 2026, but the MAR documented no bowel medications were given, and staff stated the resident should have been administered bowel medications and that the bowel protocol should have been started, with refusal documented and the provider notified. Resident 12 was rarely or never understood or able to understand others; bowel records and documentation survey reports showed multiple no-bowel-movement periods, including 4-day and 5-day episodes, and progress notes showed Bisacodyl was given and ineffective during one episode, but no progress notes were found showing the bowel protocol had been initiated for later no-bowel-movement episodes. Staff also identified inconsistent bowel documentation between records and stated the documentation should have been consistent.
Fluid restriction intake not accurately monitored or totaled for two residents
Penalty
Summary
The facility failed to ensure fluid intake was accurately monitored, documented, and assessed for 2 residents with fluid restriction orders. Resident 16 had a 1500 mL/day fluid restriction with amounts divided between day, evening, and night shifts, but the order did not allot any fluids to dietary as required by the facility policy. The resident’s care plan listed the fluid restriction as an intervention, but did not include the reason for the restriction or the goals of the restriction. In the EHR, fluids with meals were documented under Nutrition-Fluids in POC and fluids provided by nursing were documented on the MAR, but there was no instruction to reconcile the two sources or a place to document the 24-hour total. When the recorded intake was reconciled for a 7-day period, the resident exceeded the restriction each day, and 5 of 21 meal entries were left blank. There was no documentation showing the 24-hour totals had been calculated or that staff identified the resident routinely exceeded the restriction. Resident 4 also had a 1500 mL/day fluid restriction with the same shift allotments, but the order did not allot any fluids to dietary. The nutrition care plan listed the fluid restriction as an intervention, but did not include the reason for the restriction or the goals. Fluids with meals were documented in POC and fluids provided by nursing were documented on the MAR, but nurses only initialed the fluid restriction and did not record the amount of fluid provided on their shift, which prevented calculation of the resident’s 24-hour fluid intake total. During interview, the DON stated the fluid restriction orders should have identified how much was allotted to dietary and nursing, nursing should have recorded the amount of fluid provided, and the person or shift responsible for reconciling intake and calculating the 24-hour total should have been identified.
Infection Surveillance Documentation Not Kept Current
Penalty
Summary
The facility failed to provide documentation and evidence of real-time analysis for its infection prevention and control surveillance program for December 2025 and January 2026. The facility policy titled Infection Surveillance, dated 11/2025, stated that monthly time periods would be used for capturing and reporting data and that line charts would be used to show data comparisons over time and monitor trends. During interview, the Infection Preventionist/RN stated she did not have a line listing for December 2025, had been behind in December, and chose to keep up with January and February because they were current. The Infection Preventionist/RN later stated she was working on the December 2025 line listing, did not have monthly summaries for December 2025 and January 2026, and did not have a surveillance map for December 2025. She explained that the monthly summaries and surveillance maps were used to document infection patterns and determine whether there were concerns about resident-to-resident transmission. The DON stated the infection control program should include monthly documentation with a line listing, surveillance map, and monthly summary, and that this documentation was important for reporting, tracking, identifying the source of infection, determining isolation duration, and when staff could return to work. The Administrator later provided monthly summaries for November 2025, December 2025, and January 2026.
Failure to Honor Resident Choice for Bathing and Fluids
Penalty
Summary
The facility failed to promote and facilitate resident self-determination by not honoring resident choice related to bathing frequency and access to fluids of choice for Residents 4, 38, and 6. The facility’s policy stated residents had the right to choose aspects of their daily routine, including bathing times, and that refusals should be documented and care/treatment reoffered. However, the policy did not identify who obtained resident preferences, how they were obtained, when they were documented, or where they were documented. Resident 4 was cognitively intact and had bathing/showering marked as very important on the quarterly MDS. The resident stated they preferred two showers a week, but said the facility assigned shower days and provided only one shower a week. The care plan directed bathing once weekly if a shower could not be performed, or bi-weekly shower/bath/bed bath with shampoo and nail care. The bathing record showed bed baths on 01/16/2026, 01/23/2026, and 02/06/2026, and a refusal on 01/30/2026, with no documentation explaining the refusal or showing that bathing was reoffered the next day. Resident 38 was also cognitively intact, dependent on staff for bathing, and had bathing marked as very important. The resident stated they previously received two showers a week but now only received one, and that staff assigned shower days without asking for input. Their care plan directed bathing once weekly or as needed, with a bed bath if a shower could not be performed, but did not define what unable to perform meant. The bathing record showed bed baths on 01/14/2026, 01/21/2026, 01/28/2026, and 02/04/2026. Resident 6 was cognitively intact and dependent on staff for bathing. On multiple observations, no water or fluids were present at the bedside, and the resident stated they did not have water and would go without unless they asked for it. On one observation, the resident said they wanted water with ice, and an LPN stated he would bring it; he also said he usually brought a cup of water for medications but the resident often asked him to pour it out afterward. Staff gave conflicting explanations about responsibility for offering water, with one LPN/unit manager stating hospitality aides were responsible, another stating water should be offered when residents were not on fluid restriction, and the DON stating hospitality aides were responsible for offering water. The resident was not on a fluid restriction, and staff acknowledged water could be kept at bedside, including a pitcher of water.
Damaged Shower Room Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment in 1 of 2 shower rooms on the [NAME] Unit. During interview, a resident stated the shower room had cracks in the floor filled with caulking, damaged walls, and cracked and/or missing tiles, and said it needed to be fixed. The resident also stated they suggested staff stop using the shower room because it needed work badly. On observation, the shower room flooring was a seamless resinous epoxy surface with extensive discoloration, surface wear, and patching, including heavy uneven discoloration around the floor drain and high-traffic areas. A crack in the flooring greater than six feet long was filled with white one-inch-wide caulking. The FRP wall panel was damaged in multiple areas, including one area at the lower right corner that was cracked and partially detached, exposing the underlying substrate material. The DON observed the shower room and confirmed the degraded and heavily discolored flooring and damaged FRP panels, and stated the facility had plans to redo the shower room but had not gotten to it yet.
Care Plans Did Not Reflect Residents’ Current Needs
Penalty
Summary
The facility failed to ensure resident care plans were reviewed, revised, and accurately reflected residents’ care needs for 3 of 24 residents reviewed. The deficiency involved Resident 4, Resident 16, and Resident 38, and was identified through observation, interview, and record review. The report states these failures placed residents at risk for unidentified and/or unmet care needs and diminished quality of life. Resident 4 had an order for a 1500 mL/day fluid restriction secondary to hyponatremia, and the nutrition care plan documented the restriction. However, the care plan did not identify the goal of the restriction, how the fluid would be allotted between dietary and nursing, what action staff should take if the resident was non-adherent, or whether a water pitcher should be at bedside. The DON stated the fluid restriction care plan should have included the goals, monitoring direction, bedside pitcher guidance, and actions for non-adherence. Resident 16 had a positive COVID-19 rapid test and was placed on isolation with aerosol precautions. The COVID-19 care plan directed staff on contact/droplet precautions, psychosocial monitoring, family education, alternate communication, and activities within isolation limits, but did not include direction to assess or monitor respiratory signs and symptoms or complications. Resident 16 also had a 1500 mL/day fluid restriction for hyponatremia, but the care plan listed shift allotments without identifying the total daily restriction, the goal, actions for non-adherence, or whether a water pitcher should be at bedside. Resident 38 had diagnoses including mood disorder, anxiety disorder, delusional disorder, and personality disorder, and the Level II PASRR treatment plan directed staff to speak with family about the resident’s delusions; however, the comprehensive care plan did not identify those diagnoses as problems, did not develop goals or interventions, and did not identify what the resident’s delusions were. The comprehensive care plan also listed a 1700 mL/day fluid restriction that had already been discontinued in the electronic health record, and the Social Services Director/Case Manager stated the care plan needed to be updated.
Failure to Provide and Reoffer Scheduled Bathing
Penalty
Summary
The facility failed to ensure bathing services were provided as scheduled, or reoffered if refused, for Resident 14, who was admitted with a diagnosis of dementia and was assessed as moderately cognitively impaired with no rejections of care on the annual MDS dated 12/29/2025. The resident’s care plan documented an ADL self-care performance deficit related to increased weakness and decreased mobility secondary to dementia, and specified that bathing/showering required 1-2 person assistance with a goal of once weekly or as needed. Observation and record review showed Resident 14 had not received a shower since 01/23/2026, which was 19 days before the review, despite the shower schedule being Fridays. On 02/10/2026 and 02/11/2026, the resident was observed with shiny, oily, unkempt hair and brown substance under the fingernails, and the resident was unsure or did not remember when the last shower occurred or whether showers were offered regularly. Staff reported the resident sometimes refused showers, but the unit manager could not find documentation of refusals or reapproaches since the last shower, and the DON was informed that the resident had not been showered since 01/23/2026 and that documentation of refusals and reapproaches was unavailable.
PRN Pain Medication Given Outside Ordered Parameters
Penalty
Summary
The facility failed to ensure Resident 3’s medication was administered within the ordered parameters for Hydrocodone-Acetaminophen, which was ordered on 02/17/2025 to be given every four hours as needed for moderate to severe pain with a pain score of 6-10. Resident 3 was admitted to the facility on [DATE], and the Quarterly MDS dated 12/23/2025 indicated the resident’s skills for daily decision making were moderately impaired. Review of the MAR showed Hydrocodone-Acetaminophen was administered 38 times outside of the ordered parameters during 01/01/2026 through 01/31/2026, with pain scores documented below 6, and four additional administrations outside of parameters during 02/01/2026 through 02/10/2026, also with pain scores documented below 6. On 02/12/2026, the Unit Manager/LPN reviewed the January and February MARs and acknowledged the medication had been given outside of ordered parameters and should not have been given that way. On 02/13/2026, the DON stated this did not meet expectations and said staff should try nonpharmacological interventions first, then other pain medications if available, and if pain was not relieved, check with the provider before giving the medication outside of parameters.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, with an observed error rate of 8% based on 2 of 25 medication administration opportunities. One error involved Resident 13, who had just finished breakfast when Staff E, RN, stated she would give ferrous sulfate, which was ordered to be taken with breakfast. Resident 13 was then observed receiving ferrous sulfate along with pantoprazole after breakfast. The order for pantoprazole, dated 11/18/2025, directed that it be taken on an empty stomach approximately 30 minutes to 1 hour before a meal, and Staff E later stated the pantoprazole should have been given on an empty stomach rather than after breakfast. The second error involved Resident 36, who was observed receiving medications from Staff F, LPN. Staff F gave Resident 36 a plastic cup containing approximately 8 ounces of liquid with polyethylene glycol dissolved in it, told the resident to keep the medication and sip on it, and then left the room, leaving the medication with the resident. When asked, Staff F said she probably should have stayed with Resident 36. The DNS stated that a resident should have a self-assessment before medication is left at bedside, and the electronic record showed a self-administration of medication document for Resident 36 was completed more than an hour after the observation.
Failure to Follow Physician Orders for Surgical Wound Care
Penalty
Summary
Facility staff failed to follow physician orders regarding the removal of surgical staples for a resident who had undergone a C2-T10 posterior spinal fusion and T4 corpectomy. The hospital's transfer orders specified that the staples should be removed three weeks postoperatively unless there were concerns about the incision, in which case the surgeon should be contacted. Review of the resident's electronic medical record showed no documentation that the staples were removed or that the surgeon was contacted regarding the incision. Additionally, when the resident was discharged to their prior living facility, there was no documentation sent regarding the presence of staples in the incision or instructions for their removal. Staff interviews confirmed that the order for staple removal was missed and that this information was not communicated to the receiving facility. This lapse was identified during record review and staff interviews, with no evidence that the required care was provided or communicated.
Failure to Provide Timely Assistance with Toileting and Bed Mobility
Penalty
Summary
The facility failed to provide necessary assistance with toileting and bed mobility for a resident who was admitted with cancer and pressure ulcers. The resident was cognitively intact but required staff assistance for bed mobility and was totally dependent for toileting. According to the care plan, the resident needed one-person assistance for bed mobility and maximum assistance with a bedpan for bowel movements. On the evening of 04/08/2025, staff placed the resident on a bedpan but did not inform the night shift that the resident was still on the bedpan. The night shift staff provided medication and assessment but were unaware of the bedpan and did not reposition the resident during their shift. The resident remained on the bedpan from approximately 9:15 PM until 7:15 AM the following morning, when staff discovered the bedpan during a wound assessment. As a result, the resident sustained a possible deep tissue injury on the left gluteal fold. Staff interviews confirmed that residents with pressure ulcers or at risk for them should be repositioned at least every two hours, and that this resident required assistance to turn due to pain and weakness. The failure to communicate and provide necessary assistance led to the resident remaining on the bedpan for an extended period, resulting in injury.
Inaccurate and Outdated Care Plans in LTC Facility
Penalty
Summary
The facility failed to ensure that resident care plans were reviewed, revised, and accurately reflected the residents' care needs for six of the 25 sampled residents. Resident 73's care plan inaccurately identified the diagnosis for the use of Seroquel and did not include the specific target behaviors for the medications prescribed. Additionally, the care plan did not address the use of mirtazapine for depression, and the diagnosis for Nuedexta was incorrectly documented. Staff acknowledged these inaccuracies and omissions. Resident 99's behavior care plan was incomplete, lacking details about the psychotropic medication in use, the supporting diagnosis, and the resident-specific target behaviors. Resident 81's care plan was outdated, as it still mentioned a PEG tube that had been removed, and staff confirmed that care plans should be updated with significant changes. Resident 11's care plan was not revised after being discharged from hospice, and it still included a discontinued medication, which staff acknowledged should have been updated. Resident 91's care plan incorrectly indicated the need for enhanced barrier precautions, which was not required, and Resident 8's care plan still included aerosol contact isolation that was no longer necessary. Staff interviews confirmed that these care plans did not meet expectations and needed to be updated to reflect the current care needs and conditions of the residents.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to comprehensively assess residents for the use of bed rails or mobility bars, which are considered physical restraints, for four out of five residents reviewed. This deficiency was identified through observations, interviews, and record reviews. The facility's policy, revised in September 2024, mandates a full assessment and informed consent before authorizing the use of side rails. However, the facility did not adhere to this policy, as evidenced by the lack of documented assessments and informed consent for the residents involved. Resident 11, who was cognitively intact but had documented delusions, was found to have bilateral side rails for bed mobility without a comprehensive assessment or informed consent. The resident experienced a fall and hallucinations, yet no reevaluation of the necessity and safety of the bed rails was conducted. Similarly, Residents 91, 40, and 51 had bed rails installed without documented assessments or evaluations for safety, entrapment risks, or less restrictive alternatives. These residents were unable to independently release the bed rails, indicating a lack of proper assessment and consideration of their individual needs and conditions. Interviews with staff, including the Unit Manager and Director of Nursing Services, revealed that the expected documentation and assessments were not completed. Staff acknowledged the absence of necessary evaluations and the failure to meet the facility's expectations for assessing the appropriateness and safety of bed rails. Despite requests for documentation, the facility was unable to provide evidence of completed assessments for the residents involved, highlighting a significant oversight in ensuring resident safety and compliance with regulatory requirements.
Failure to Implement Non-Pharmacological Interventions Before PRN Pain Medications
Penalty
Summary
The facility failed to implement non-pharmacological interventions (NPIs) before administering as-needed (PRN) pain medications for four residents, leading to potential unnecessary medication use. Resident 78, diagnosed with dementia and chronic pain, received PRN oxycodone and acetaminophen multiple times in November and December without documentation of NPIs being attempted. The Director of Nursing Services acknowledged the lack of documentation and expressed the expectation for nursing staff to document NPIs when a resident complains of pain. Resident 355, with age-related osteoporosis and a pathological fracture, received Tramadol for pain without documentation of side effects or NPIs. The Assistant Director of Nursing Services confirmed the expectation for side effect monitoring and NPI documentation on the Treatment Administration Record. Similarly, Resident 11, who was cognitively intact, received morphine and acetaminophen without documented NPIs or pain scores, despite expressing interest in alternative pain management options. Staff interviews revealed a lack of reevaluation of pain management following the resident's discharge from hospice. Resident 24, with chronic pain and moderate cognitive impairment, had an order for PRN oxycodone without documented NPIs. Staff confirmed that NPIs should be part of pain medication orders and documented on the Medication Administration Record. The report highlights the facility's failure to document and implement NPIs, potentially leading to unnecessary medication use and inadequate pain management for the residents involved.
Deficiencies in Psychotropic Medication Management and Monitoring
Penalty
Summary
The facility failed to ensure that seven sampled residents were free from unnecessary psychotropic medications. The staff did not complete the Abnormal Involuntary Movement Scale (AIMS) assessments fully for residents using antipsychotic medications, which are crucial for determining the severity of abnormal movements. For instance, Resident 11's AIMS assessments were incomplete, missing sections where the resident was supposed to perform specific tasks. Interviews with staff revealed that the expectation was to complete the AIMS assessments fully, documenting any tasks the resident could or could not perform. Additionally, the facility did not adequately monitor and document observed target behaviors and non-pharmacological interventions for residents receiving psychotropic medications. For example, Resident 11 had documented behaviors, but there was no follow-up documentation or progress notes to address these behaviors. Staff interviews indicated that CNAs were expected to report behaviors to nurses, who would then provide interventions and document them. However, this process was not consistently followed, leading to a lack of documentation and monitoring. Furthermore, the facility failed to implement non-pharmacological interventions before administering psychotropic medications. Resident 11's records showed no documentation of such interventions, despite receiving psychotropic medication and having documented behaviors. Staff interviews confirmed that non-pharmacological interventions should have been documented, but this was not done. Similar issues were found with other residents, where target behaviors were not identified, monitored, or documented, and non-pharmacological interventions were not implemented or recorded.
Inadequate Infection Control and Surveillance in LTC Facility
Penalty
Summary
The facility failed to implement proper Enhanced Barrier Precautions (EBP) for several residents, as evidenced by the absence of required signage indicating EBP status. Residents with conditions such as wounds and urinary catheters, who were supposed to be on EBP, did not have the necessary signage outside their rooms. This oversight was acknowledged by staff, including the Infection Preventionist and the Director of Nursing Services, who confirmed that the lack of signage did not meet facility expectations. Additionally, there was a mix-up in signage for residents who no longer required EBP, leading to further confusion. Infection control practices were not consistently followed, as observed in the care of residents with catheters. Staff failed to wear gowns during high-contact activities and missed multiple opportunities for hand hygiene. Furthermore, equipment such as the Hoyer lift was not cleaned between uses, contrary to standard precautions. Staff interviews revealed a lack of understanding and adherence to infection control protocols, indicating a need for further education and training. The facility's infection surveillance and Legionella Water Management Program were also found lacking. The antibiotic surveillance records were incomplete, missing critical information such as symptom onset dates and culture results. The Legionella program failed to identify internal areas of risk and did not have a comprehensive monitoring plan. Additionally, CPAP machines were not stored or cleaned according to policy, increasing the risk of contamination. These deficiencies highlight significant gaps in the facility's infection prevention and control measures.
Inaccurate Drug Information Provided to Residents
Penalty
Summary
The facility failed to provide accurate information regarding the risks and benefits of proposed drug therapies for two residents, impacting their ability to make informed decisions. Resident 11, who was diagnosed with depression and PTSD, was receiving Abilify, an antipsychotic medication. However, the consent form incorrectly listed Abilify as an antidepressant. Interviews with staff revealed that the consent process did not accurately reflect the drug class and associated risks, which should have been communicated as antipsychotic rather than antidepressant. Resident 73, who was cognitively impaired and diagnosed with anxiety, depression, and agitation, was prescribed Nuedexta for pseudobulbar affect. The consent form inaccurately identified Nuedexta as an antipsychotic and mood stabilizer, with incorrect indications for use such as calling out, yelling, and dementia with behaviors. Staff acknowledged that the resident was provided with inaccurate drug information, including the drug class, indications for use, and potential adverse side effects.
Failure to Document and Assess Use of Potential Restraints
Penalty
Summary
The facility failed to obtain an assessment, orders, consent, and develop a care plan for the use of potential restraints for Resident 91, who was reviewed for physical restraints. Resident 91 was readmitted to the facility and was noted to be dependent on mobility, rarely/never understood, and moderately impaired for daily decision-making. Observations revealed that body pillows were placed on both sides of Resident 91's bed under the fitted sheet, without any documentation in the Electronic Health Record regarding an assessment, consent, orders, or care plan for the use of these pillows. Staff interviews indicated that the pillows were placed to prevent Resident 91 from falling out of bed, as the resident moved back and forth and could turn themselves. Staff acknowledged that the pillows should not have been placed under the fitted sheet and that necessary documentation and assessments were lacking. The Unit Manager and Director of Nursing Services confirmed that an assessment, consent, orders, and a care plan should have been completed for the use of body pillows, but these steps were not taken.
Inaccurate MDS Assessments for Residents with Catheter and Mental Health Needs
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two residents, which placed them at risk for unmet care needs. Resident 54, who had a suprapubic catheter due to urinary retention and neuromuscular dysfunction of the bladder, was inaccurately documented as always incontinent on their Annual MDS. The correct option, indicating the presence of a catheter, was not selected. This discrepancy was acknowledged by the Director of Nursing Services (DNS) and the MDS nurse, who confirmed that continence should be coded as 'not rated' when a resident has a urinary catheter for the entire assessment period. Resident 11, diagnosed with depression, anxiety, and post-traumatic stress disorder, was also affected by an inaccurate MDS assessment. The Significant Change MDS failed to document the resident's Level 2 Preadmission Screening and Resident Review (PASRR), which is crucial for identifying serious mental illness or intellectual disability. The MDS Manager acknowledged the error, noting that the Level 2 PASRR should have been included. The DNS confirmed that the omission did not meet the facility's expectations.
Inaccurate PASRR Assessment and Lack of Level II Evaluation
Penalty
Summary
The facility failed to ensure that a Pre-Admission Screening and Resident Review (PASRR) assessment accurately reflected a resident's mental health diagnoses and that Level II PASRR evaluations were timely referred and completed. Specifically, for one resident, the Level I PASRR assessment documented only an anxiety disorder and did not include the resident's depressive disorder or dementia with behaviors/agitation diagnoses. This oversight necessitated a referral for a Level II PASRR evaluation, which was not documented as completed in the resident's electronic health record. The resident in question was admitted to the facility with severe cognitive impairment and had diagnoses of non-Alzheimer's dementia with agitation, anxiety, and depressive disorders. A mental health evaluation confirmed these active diagnoses. However, the Level I PASRR assessment was inaccurate, and no documentation was provided to show that a Level II PASRR evaluation referral was made or completed. This failure placed the resident at risk for inappropriate placement and not receiving timely and necessary mental health services.
Deficiencies in Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to review, revise, and implement comprehensive care plans for five residents, leading to deficiencies in individualized care. Resident 59, who was admitted with sleep apnea, had a care plan that did not include information on how to contact the vendor or pulmonologist for CPAP concerns. Additionally, the care plan lacked details about aerosol-generating procedures (AGP) related to CPAP use. Resident 51, also on CPAP, did not have an AGP care plan. Resident 78, admitted with chronic pain, had a care plan that did not include non-pharmacological interventions tailored to the resident's needs. Resident 91, who had dysphagia and protein-calorie malnutrition, had a care plan that did not reflect the correct diet and lacked specific information for social and sensory stimulation activities. The care plan inaccurately documented the resident's diet as general, regular texture thin fluids, which did not align with the physician's orders for a dysphagia ground texture diet. Resident 11, diagnosed with depression and PTSD, had a pain management care plan that did not include narcotic usage or non-pharmacological interventions. The psychotropic medication care plan also lacked non-pharmacological interventions. These omissions in the care plans resulted in a failure to provide appropriate and individualized care for the residents, as the plans did not accurately reflect their assessed needs or provide clear direction to staff.
Deficiencies in Documentation, Order Clarification, and Medication Security
Penalty
Summary
The facility failed to ensure services met professional standards of practice for three residents. For Resident 73, the facility did not document the flow rate of oxygen administered over a six-week period, despite having an order for oxygen to maintain saturation levels. The Unit Manager acknowledged that the nurses failed to document the oxygen dose and did not clarify or correct the incomplete order. Resident 51's care was compromised due to incomplete CPAP orders that lacked specific pressure settings and instructions for humidifier maintenance. Additionally, there was a delay in carrying out laboratory orders for Resident 51, as labs ordered on December 2 were not drawn until December 11. The Assistant Director of Nursing Services admitted that the delay was not in line with expectations, especially given the medication changes. The facility also failed to secure medications properly. A medication cart was left unlocked and unattended for 13 minutes, and Resident 40 had a bottle of anti-itch lotion at their bedside without a self-administration assessment. The Unit Manager and Director of Nursing Services confirmed that medications should not be left at the bedside and should be stored securely.
Failure to Provide Adequate Bathing Assistance
Penalty
Summary
The facility failed to provide adequate assistance with bathing for Resident 90, who was admitted with severe cognitive impairment and required supervision for activities of daily living (ADLs). According to the Quarterly Minimum Data Set dated 09/04/2024, Resident 90 needed assistance with ADLs. However, a review of the Point of Care documentation, the 'Shower Book,' and the 'Marina Daily Shower' sheets revealed that Resident 90 only received showers on three occasions: 11/17/2024, 12/02/2024, and 12/08/2024, over a 30-day period. The care plan for Resident 90, dated 11/29/2023, indicated an ADL self-care performance deficit and included an intervention to offer a bed bath if a shower could not be performed. Staff E, the Unit Manager/LPN, confirmed that Resident 90 did not receive a shower during the week of November 24th because the shower aide was reassigned to other duties. Staff B, the Director of Nursing Services, acknowledged that staff call-outs contributed to the issue and confirmed that a bed bath should have been offered in the absence of a shower aide.
Deficiencies in Bowel Management and Hospice Coordination
Penalty
Summary
The facility failed to implement care and services in accordance with accepted professional standards for three residents, specifically in the areas of bowel management and hospice services. For Resident 82, the facility did not document non-pharmacological interventions despite the resident not having a bowel movement for several days, as required by the facility's bowel management policy. The Assistant Director of Nursing Services (ADNS) confirmed that the expectation was for nurses to document both pharmacological and non-pharmacological interventions, which was not done in this case. Resident 11, who was dependent on staff for care and receiving opioid pain medication, did not have bowel movements for multiple days without documentation of non-pharmacological interventions or administration of as-needed medications. The Unit Manager confirmed that the bowel protocol was not followed, and there was no documentation of attempts at non-pharmacological interventions. Additionally, Resident 99, who was receiving hospice services, did not have a current hospice plan of care in their electronic health record, and staff were unsure of the hospice services the resident was to receive.
Improper Pressure Relieving Device Settings for Resident
Penalty
Summary
The facility failed to ensure that a pressure relieving device was functioning correctly for a resident with pressure ulcers. Resident 81, who was admitted with Guillain-Barre Syndrome and malnutrition, was observed multiple times lying in bed with a pressure relieving mattress set at level 5, contrary to the care plan which specified a setting of level 3 due to the resident's weight of 107 pounds. The care plan, revised in October 2023, directed that the air mattress should be set at level 3 and checked for proper functioning each shift. Staff interviews revealed that the air mattress settings were based on the resident's weight and should be monitored for accuracy each shift. However, the resident's weight had not been updated since November 29, 2024, and the mattress was incorrectly set at level 5. The Assistant Director of Nursing Services confirmed that the mattress should have been set at level 3 for maximum effectiveness and noted that the setting should be recorded on the Treatment Administration Record for monitoring by nurses each shift.
Deficiencies in Respiratory Care Documentation and Equipment Maintenance
Penalty
Summary
The facility failed to provide respiratory care in accordance with accepted professional standards for three residents. Resident 73, who had severe cognitive impairment and heart failure, was observed receiving oxygen via nasal cannula. However, the facility did not document the amount of oxygen administered, nor did they include instructions to check and replace the humidifier bottle or clean the oxygen concentrator's external filter weekly, as per facility policy. This lack of documentation and adherence to policy placed the resident at risk for ineffective assisted ventilation. Resident 51, with severe cognitive impairment and obstructive sleep apnea, required CPAP therapy. The facility's orders for CPAP did not include the prescribed pressure settings, nor did they instruct staff to check and refill the humidifier chamber with distilled water or disinfect it weekly. This omission in the CPAP orders could lead to improper use of the device and inadequate respiratory support for the resident. Resident 81, who was moderately cognitively impaired and had respiratory failure, was observed with a nebulizer machine. The care plan did not include treatments via the nebulizer or care of the associated equipment. The MARs lacked documentation for lung sounds or cleaning of the equipment, and there were no directions on how to clean, replace, or store the equipment. This oversight in documentation and care planning could compromise the resident's respiratory health.
Failure to Promptly Notify Provider of Lab Results
Penalty
Summary
The facility failed to promptly notify the ordering provider of laboratory results that fell outside of clinical reference ranges for Resident 73, who was reviewed for unnecessary medications. Resident 73, who had severe cognitive impairment and diagnoses of diabetes and heart failure, was on medications including metformin and spironolactone. A provider note indicated that Resident 73 had elevated blood glucose levels and required an A1C test, among other lab tests, to be conducted as part of a three-month blood draw. However, the A1C test was delayed by 41 days, and the elevated result was not communicated to the provider until 34 days after it was available. Additionally, other lab tests that were ordered to be drawn every three months, such as TSH, B12, vitamin D, BNP, CBC, and CMP, had not been conducted as of the date of the report. Staff members, including the Unit Manager and Assistant Director of Nursing Services, confirmed the delays and acknowledged that the notification of the provider did not meet the facility's policy for prompt notification. This failure placed residents at risk for delayed treatment and potential negative outcomes.
Failure to Adhere to PPE Protocols for COVID-19 Positive Residents
Penalty
Summary
The facility failed to ensure that three staff members adhered to CDC guidelines for using personal protective equipment (PPE) when caring for residents with confirmed COVID-19 infections. Staff A, a Certified Nursing Assistant (CNA), entered the room of a COVID-19 positive resident wearing a N95 respirator, gown, and gloves but without eye protection. After providing care, Staff A removed their gown and gloves, performed hand hygiene, but did not remove or discard the N95 respirator before exiting the room and continued to interact with other residents. Similarly, Staff B, another CNA, entered the same resident's room with appropriate PPE, but after exiting, they failed to perform hand hygiene before donning a new N95 respirator. Staff C, a Licensed Practical Nurse (LPN), also failed to remove and discard their N95 respirator after caring for a different COVID-19 positive resident, exiting the room and proceeding down the hallway. The Infection Preventionist confirmed that both residents were on isolation due to their COVID-19 positive status and that staff were expected to remove and discard PPE, including N95 respirators, after each care encounter. The failure to follow these protocols placed both residents and staff at risk of contracting and spreading COVID-19.
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What surveyors actually found near you
We read the 849 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Poulsbo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Northwoods Lodge | 4.6 mi | ★★★★★ | 9 | 0 |
| Bainbridge Island Health & Rehab Center | 9.5 mi | ★★★★★ | 23 | 0 |
| Bremerton Trails Post Acute | 10.6 mi | ★★★★★ | 55 | 0 |
| Belmont Terrace | 10.7 mi | ★★★★★ | 22 | 0 |
| Port Washington Post Acute | 12 mi | ★★★★★ | 15 | 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.