Above 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 Mckay Healthcare & Rehab Ctr during CMS and state inspections, most recent first.
Failure to Provide Consistent Restorative ROM Services: The facility did not consistently provide ordered restorative ROM/PROM programs for residents with significant mobility limitations, including a resident with stroke, dementia, and a contracted hand, a resident with quadriplegia and contracted fingers, and a resident with persistent vegetative state and bilateral upper-extremity contractures. Documentation showed repeated omissions, and staff reported restorative aides were routinely pulled to floor NA duties, with no consistent therapy/restorative support during the period reviewed.
A resident was discharged without receiving the SNF ABN for changes in Medicare coverage. The BOM stated they were responsible for notifying residents of Medicare coverage changes but had not provided the form because they were unaware it was required. Another staff member acknowledged the form was not given and should have been.
Grievance process information was not readily available to residents or RRs, and residents were not aware they could file grievances anonymously. A resident council discussion and staff interviews showed that several residents did not know where grievance forms were located and believed staff had to complete them for them, while staff acknowledged the gap in resident awareness and that forms were kept near the CNA charting area and DON office.
A facility failed to provide consistent oral care and nail care for two dependent residents. One resident with quadriplegia and total ADL dependence was repeatedly observed with a dry toothbrush, disheveled hair, brown teeth, and a white film along the gumline, while staff admitted oral care had not been offered. Another resident with stroke, dementia, severe hand contractures, and total personal hygiene needs was observed over multiple days with long jagged fingernails, chipped nail polish, debris under the nails, and a foul odor from the hand; staff said nail care had been attempted once but not continued.
A resident with ESRD receiving dialysis had provider orders for daily weights, BP monitoring, carvedilol hold parameters, and a 1.5 L fluid restriction, but the facility did not transcribe or implement the orders. The resident had large weight gains, unmonitored fluids at the bedside, and reported SOB and swelling, while staff stated the fluid restriction was not on the MAR, they were unaware of the symptoms, and the facility did not have a policy for daily weights for dialysis residents.
Laundry Room Environmental Damage and Leak: Surveyors observed an active leak from a commercial washer with standing water behind and under the unit, along with extensive floor, ceiling, and wall damage in the laundry area. The floor was pitted and deteriorated, the ceiling had peeling paint and exposed drywall, and multiple wall sections near the washer and hopper were damaged, stained, and uncleanable. The Administrator and Maintenance Director acknowledged the conditions and the ongoing washer leak.
A resident with COPD, depression, chronic pain, polysubstance abuse disorder, and a documented moderate elopement risk required supervision with walking but had no elopement care plan in place. After a family visit with no recorded sign-out, an LPN later found the resident absent from the room, accepted the roommate’s statement that the resident went to lunch with family, did not verify this with the family, and did not initiate the missing resident/elopement protocol despite the resident not returning by the end of the shift. The resident’s absence was not formally recognized until the next day when a nurse noted the resident missing at medication time, contacted the family, and learned the resident had been dropped off in the parking lot the prior afternoon, leading to delayed implementation of the elopement protocol and the resident ultimately being found off premises and sent to the hospital for evaluation.
The facility failed to ensure dignity and privacy for three residents, including inadequate restroom privacy for two residents and neglecting vision care needs for another. Staff used a small restroom with insufficient privacy for residents requiring mechanical lifts, despite a larger option being available. Additionally, a resident's deteriorated glasses were not replaced due to a misunderstanding of palliative care policies.
A resident with Parkinson's disease expressed a desire to eat meals in their room due to noise in the dining room, but was told they had to eat in the dining room because of choking issues. The DON confirmed residents have the right to choose their dining location, but it was unclear why this resident's choice was not honored.
The facility failed to send required Level 2 PASARR referrals for two residents with serious mental illness, despite positive Level 1 screenings indicating conditions such as depression and anxiety. This oversight was acknowledged by the Social Services Director, who had not yet reviewed all resident records for compliance.
A facility failed to provide trauma-informed care for a resident with a history of severe abuse. Despite the resident's representative identifying specific trauma triggers, these were not documented in the care plan. The Social Service Assessment noted the resident's history and triggers, but this information was not communicated or incorporated into the care plan, highlighting a breakdown in the facility's process.
A resident with major depressive disorder and anxiety experienced a significant medication error when their prescribed anti-depressant, paroxetine, was discontinued for 18 days despite a PCP's order to continue it indefinitely. The error was not identified by the facility's staff, and the PCP was not notified, discovering the issue during a medication review.
A facility failed to maintain a current hospice agreement and did not implement a process for effective communication with the hospice provider for a resident with Parkinson's disease and heart failure. The hospice agreement was outdated and unsigned, and the resident's care plan lacked hospice-related interventions until days after enrollment. Staff interviews revealed inadequate documentation and communication processes, placing the resident at risk of not receiving necessary end-of-life care.
A facility failed to ensure agency staff proficiency in mechanical lift use, leading to a resident's fall during a transfer. The facility's policy required two staff members for mechanical lift transfers, but agency staff were not verified for proficiency. A newly trained agency NA, unfamiliar with the facility's policy, was left alone with a resident during a transfer, resulting in the resident sliding off the lift. The facility did not verify proficiency skills for agency staff prior to their assignments.
A resident with a progressive neurological condition fell during a transfer using a sit-to-stand lift due to improper use of the lift and lack of adherence to facility protocols. The resident, who required two-person assistance, was left with only one staff member present, and the safety buckle was not secured, leading to a fall and hospital evaluation.
The facility failed to maintain the scheduled bathing frequency for two residents, compromising their dignity and hygiene. One resident with Parkinson's Disease received only two out of nine scheduled showers, while another with dementia received three out of nine. Staff cited staffing shortages as a reason for missed showers, and the DON was unaware of the issue.
The facility failed to monitor blood pressure when administering medications for two residents, leading to a deficiency. One resident with Parkinson's and high BP was prescribed Lisinopril with instructions to hold if SBP was below 90, but no BP monitoring was documented. Another resident with heart disease and high BP was prescribed Spironolactone with similar instructions, yet no BP monitoring was recorded. Staff interviews revealed a lack of prompts for BP checks, and the DON acknowledged system inadequacies.
A resident with a history of sexually inappropriate behavior was not adequately supervised, leading to a non-consensual incident with a severely cognitively impaired resident. Despite the known risk, the facility did not implement one-on-one supervision, resulting in psychosocial harm to the victim.
The facility failed to report an allegation of neglect involving a resident with a neurological disorder to the State Survey Agency. The resident's representative reported suspected neglect and denial of liquids, but the Director of Nursing did not report it, believing it did not meet the criteria. This placed residents at risk for continued neglect.
Failure to Provide Consistent Restorative ROM Services
Penalty
Summary
The facility failed to ensure that residents consistently received restorative therapy services to maintain range of motion for 3 of 12 residents reviewed for ROM and mobility. Resident 24 had diagnoses including stroke, dementia, and left-sided hemiplegia, and the 03/01/2026 comprehensive assessment showed severe cognitive impairment, dependence on one staff member for activities of daily living, and a contracture to the left hand. The care plan called for a restorative nursing program for passive range of motion to the upper extremities, including left hand exercises, three days per week, but the electronic record for May 2026 documented the program as completed only 3 of 31 days, with no documentation, shift entries, or clinical justification for the remaining omissions. During observation on 05/31/2026, Resident 24 was sitting in a wheelchair with the left arm flaccid in the lap, the left hand tightly closed in a fist with the thumb over the fingers, and a foul odor coming from the hand. The resident stated the hand could not be opened because it would break and said they did not receive exercises for that hand. On 06/04/2026, a NA performed hand hygiene on the contracted left hand and the washcloth was covered with a brown substance from the palm; the palm was red and emitted a strong foul odor. Staff H stated the palm was very dirty and red. Resident 1 had diagnoses including quadriplegia, depression, and need for assistance with personal care, and the daily Kardex showed active and passive ROM programs for the upper and lower extremities. During observation, Resident 1 had limited movement to the left hand and later was observed with contracted ring and pinky fingers on the left hand; the resident stated they were not receiving therapy and did not wear a brace at night, adding that they would wear something to hold the fingers straight if provided. Resident 6 had diagnoses including persistent vegetative state and contractures of both arms and both hands, with severe cognitive impairment and dependence on staff for all mobility and care. The daily Kardex showed a daily PROM program for the upper and lower extremities, but during observation the resident had visible bilateral upper arm contractures, and the resident representative stated therapy was not enough and that they came in to do ROM every day. Staff P stated restorative programs were not completed consistently in May 2026 because restorative aides were routinely pulled to work as floor NAs, and Staff A acknowledged the facility was aware of the restorative issues and had failed to maintain the required restorative services during that time.
Failure to Provide SNF ABN Before Discharge
Penalty
Summary
The facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) for Resident 48 before discharge from the facility. A review of the Notice of Medicare Non-Coverage dated 02/08/2026 showed that the resident had not been given the SNF ABN. During an interview on 06/01/2026, the Business Office Manager stated they were responsible for notifying residents of changes in Medicare coverage and acknowledged that they had not provided the SNF ABN because they were unaware they were supposed to give the form. In a separate interview, Staff A acknowledged that Resident 48 had not been provided the SNF ABN and stated that it should have been provided.
Grievance Process Information Not Readily Available
Penalty
Summary
The facility failed to ensure information about the grievance process was readily available to residents and resident representatives and failed to ensure residents were aware of their right to file grievances anonymously. Review of the facility policy, Resident and Family Grievances, revised 10/28/2019, showed that how to file a grievance or complaint would be available to residents. However, during observation on 06/02/2026 at 9:28 AM, there were no physical grievance forms available for resident or RR access anywhere in the facility. During interview on 06/02/2026 at 10:19 AM, Residents 26, 39, and 75 stated they did not know where grievance forms were located, were unaware they could submit forms anonymously, and believed staff members had to fill out the forms on their behalf. In interview on 06/03/2026 at 4:21 PM, the Activities Director stated grievance forms were kept on the wall near the nursing assistant charting area and the DON office, and acknowledged that if residents did not know what the forms looked like or where they were located, the facility needed to re-educate them and improve its process. In interview on 06/03/2026 at 4:42 PM, the Administrator acknowledged a gap in resident awareness regarding the grievance process and confirmed that some residents could be unfamiliar with their right to file anonymously and where to locate physical grievance forms.
Failure to Provide Oral Care and Nail Care
Penalty
Summary
The facility failed to ensure that dependent residents received needed ADL care, specifically oral care and personal grooming. The facility policy stated that care and services based on the resident’s comprehensive assessment would include grooming and oral care. Resident 1 was admitted with quadriplegia and need for assistance with personal care, and the comprehensive assessment showed the resident was dependent on staff for ADLs. The resident’s Kardex directed nursing assistants to provide mouth care and personal hygiene, yet the resident stated staff did not offer a setup to brush teeth and could not access supplies independently. Multiple observations showed the resident with disheveled, oily hair, a dry toothbrush stored on the bedside table, brown teeth, and a thick white film along the gumline, while staff acknowledged oral care had not been offered and that the resident had completely failed to receive oral care from staff. Resident 24 was admitted with stroke and dementia, had severely impaired cognition, and required one staff member for personal hygiene. The care plan identified an ADL self-care performance deficit and need for assistance with all personal hygiene. Observations showed the resident’s left hand with severe contractures, a very foul odor, long jagged fingernails with chipped nail polish, and brown substance under the nails. The fingernails remained unkempt across repeated observations, and the resident’s left hand fingernails were digging into the palm. During a later observation, staff attempted to cut the resident’s nails but stopped when the resident pulled away, and hand hygiene revealed a brown substance on the washcloth and a red, dirty palm with a strong foul odor. The Administrator stated nursing assistants were responsible for daily and as-needed nail care and acknowledged awareness of the nail care issue.
Dialysis Monitoring Orders Not Implemented for Resident With ESRD
Penalty
Summary
The facility failed to ensure that provider dialysis monitoring orders were transcribed and carried out for Resident 18, who was admitted with end stage renal disease and had intact cognition, required assistance with activities of daily living, and was receiving dialysis treatments. A provider encounter on 05/11/2026 included orders to obtain daily weights and notify the provider for a 2-lb weight gain in 24 hours or 5 lbs in 7 days, obtain a STAT BMP and arrange an urgent dialysis adjustment if weight gain was accompanied by dyspnea or edema, monitor blood pressure each shift, hold carvedilol for low systolic blood pressure or low heart rate, and limit fluids to 1.5 liters per day. Review of the resident’s physician orders and MAR/TAR for May 2026 showed none of these monitoring orders had been transcribed or implemented by the facility. Weight records showed a 13-lb gain over five days from 05/13/2026 to 05/18/2026 and a 25.5-lb gain over three days from 05/29/2026 to 06/01/2026, with no evidence the primary provider was notified of either significant weight gain as ordered. The resident’s active dietary orders and kitchen diet slips for May 2026 also showed no evidence that the 1.5-liter fluid restriction had been implemented or communicated to dietary staff. During observations, the resident had unmonitored fluids at the bedside, including a 32-ounce water cup with approximately 300 cc of water and a cup with approximately 180 cc of juice, and later a 32-ounce water cup containing approximately 600 cc of fluid. The resident stated the facility did not weigh them consistently and reported feeling more short of breath with swelling in the hands and leg. Staff stated the fluid restriction was not on the MAR, they were not aware of the resident’s recent shortness of breath or edema, and the facility did not have a policy to weigh dialysis residents daily.
Laundry Room Environmental Damage and Leak
Penalty
Summary
The facility failed to provide a safe and sanitary environment in the laundry room. During an environmental tour, surveyors observed an active water leak from the commercial washing machine that had caused standing water to pool behind and underneath the unit. The floor beneath and around the washing machines and chemical dispensing units showed extensive visible water damage, pitting, and structural deterioration, and the flooring beneath the liquid laundry chemical drums and intake lines was discolored and pitted to the point that it could not be properly cleaned or sanitized. Surveyors also observed water damage throughout the laundry room ceiling and walls. The ceiling had paint blistering and bubbling with sections peeled away and drywall exposed. The wall to the left of the washing machine had dark staining, bubbling and peeling paint, and holes exposing interior wall components. The wall behind the washing machines had two damaged sections measuring approximately 2 feet by 1 1/2 feet and 3 feet by 9 inches, with exposed and uncleanable material. The wall behind the hopper showed extensive water damage, rust and metal visible through broken drywall, warped trim pulling away from the wall, and heavily chipped peeling paint. The Administrator stated the damage was worse than the last time they had been in the room and acknowledged the facility process was not followed. The Maintenance Director stated they were aware of the washing machine leak and were waiting on parts, but had not been aware of the other damage.
Failure to Implement Elopement Protocol for At-Risk Resident
Penalty
Summary
The facility failed to implement its elopement protocol for a resident assessed at moderate risk for elopement, resulting in the resident being missing for an extended period before the protocol was initiated. The facility’s policy defined a suspected elopement as when a resident’s whereabouts are not immediately known and required staff to alert personnel using an internal alert code. The resident had diagnoses including COPD, depression, chronic pain, and polysubstance abuse disorder, and a comprehensive assessment showed the resident required supervision or touching assistance with walking and had intact cognition. An elopement risk assessment documented a moderate elopement risk score of five, but the resident’s care plan did not include an elopement care plan. The visitor sign-in sheet showed a family member visited the resident and signed in late in the morning, with no sign-out time for either the family member or the resident. On the day of the incident, an LPN administered the resident’s morning medications early in the day and later returned to give scheduled afternoon medications, at which time the resident was not in the room. The roommate reported the resident had gone to lunch with a family member, but the LPN did not call the family to verify this information, was unaware of any required time frame to contact the resident or family about return time, and did not implement the missing resident/elopement protocol, even though the resident did not return by the end of the LPN’s shift. Progress notes documented the resident as missing the following morning when the dayshift nurse noted the resident was not present for scheduled morning medications and then contacted the family, learning the resident had been dropped off in the facility parking lot the previous afternoon. The missing resident/elopement protocol was implemented at that time, approximately 18 hours after the resident was missing from the facility, and the administrator later confirmed that nothing had been done when the resident was first missing until the next day, when the resident was subsequently found by the water about half a mile from the facility and sent to the hospital for evaluation.
Failure to Ensure Resident Dignity and Privacy
Penalty
Summary
The facility failed to uphold resident rights to dignity and privacy for three residents, leading to distress and embarrassment. Resident 14, diagnosed with Parkinson's disease and dependent on staff for activities of daily living, was observed waiting in a hallway for restroom use. The restroom used was small, with inadequate privacy due to a curtain that left a gap, and staff discussions about the resident's toileting needs were overheard. The resident's representative expressed concerns about the lack of privacy, noting a larger restroom was available but not used. Resident 27, with a history of stroke, kidney disease, and dementia, was also subjected to inadequate privacy during toileting. Staff used a mechanical lift to transfer the resident to a restroom where the door was not shut, and toileting activities were audible from the hallway. Staff interviews revealed a preference for using a smaller restroom for convenience, despite the availability of a larger, more private option. Resident 29, diagnosed with neurocognitive disorder with Lewy bodies and Alzheimer's disease, experienced neglect in addressing their vision needs. The resident's glasses were visibly deteriorated, obstructing vision, yet staff informed the resident's representative that vision appointments were not typically arranged for residents receiving palliative care. This decision was based on a misunderstanding of palliative care, equating it with hospice care, which led to the resident's needs being unmet.
Failure to Honor Resident's Dining Preferences
Penalty
Summary
The facility failed to honor a resident's right to self-determination regarding their dining experience. Resident 14, who was admitted with Parkinson's disease, difficulty speaking, and difficulty swallowing, expressed a preference to eat meals in their room due to the noise in the dining room. Despite being able to communicate their needs, the resident was told they had to eat in the dining room because of their choking issues. During an interview, the Director of Nursing confirmed that residents have the right to choose where they eat and that staff assistance would be provided if a resident chose to eat in their room. However, it was unclear why Resident 14's choice was not respected, indicating a failure to support the resident's right to make significant life choices, as outlined in the facility's policy on resident rights.
Failure to Complete PASARR Level 2 Referrals
Penalty
Summary
The facility failed to properly review and validate the Preadmission Screening and Resident Reviews (PASARR) for two residents, which is a critical assessment to ensure individuals with serious mental illness (SMI) or intellectual/developmental disabilities (ID/DD) are not inappropriately placed in nursing homes. Specifically, the facility did not send the required Level 2 referral for residents who had a positive Level 1 PASARR, indicating the presence of SMI. This oversight was identified for two residents, both of whom had documented mental health conditions such as depression and anxiety. Resident 31 was admitted with diagnoses including depression, restlessness, agitation, and insomnia, and was found to have a SMI of both depression and anxiety according to their PASARR. However, no Level 2 referral was sent for this resident. Similarly, Resident 26, who was admitted with depression, anxiety, and insomnia, also had a positive Level 1 PASARR indicating SMI, but no Level 2 referral was made. The Social Services Director acknowledged awareness of the requirement but had not yet reviewed all resident records to ensure compliance.
Failure to Provide Trauma-Informed Care for Resident
Penalty
Summary
The facility failed to provide trauma-informed care for Resident 29, who had a history of severe physical and mental abuse. Despite the resident's representative informing the facility of specific trauma triggers, such as fast movements and movements towards the face, these were not documented in the resident's care plan. The Social Service Assessment completed on admission noted the resident's history of abuse and identified triggers like loud noises, but this information was not incorporated into the care plan. Interviews with staff revealed a lack of awareness and communication regarding Resident 29's trauma history. Staff J, the Social Services Director, was responsible for updating the care plan with identified triggers and interventions but failed to do so. The Director of Nursing confirmed that the trauma and triggers should have been addressed in the care plan, indicating a breakdown in the facility's process for ensuring trauma-informed care.
Failure to Administer Anti-Depressant Medication as Ordered
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically concerning the administration of an anti-depressant medication. Resident 2, who was diagnosed with major depressive disorder and anxiety, was prescribed paroxetine to be taken daily. The physician's order, dated November 5, 2024, indicated that the medication should be administered for 90 days, with a reassessment by the Primary Care Provider (PCP) before the stop date of February 3, 2025. However, despite the PCP's order on January 28, 2025, to continue the medication indefinitely, the medication was discontinued on February 3, 2025, and not restarted until February 21, 2025, resulting in an 18-day lapse. Interviews revealed that the Director of Nursing, Staff B, acknowledged the oversight, stating that the process for reviewing medication orders was not followed, leading to the error being missed. The PCP was not informed of the discontinuation and only discovered the error during a medication review. This lapse in medication administration placed Resident 2 at risk for less than optimal therapeutic effects and potential negative health outcomes.
Failure to Maintain Current Hospice Agreement and Communication Process
Penalty
Summary
The facility failed to maintain a current hospice written agreement and did not develop or implement a process to ensure effective communication, collaboration, and coordination of care between the facility and the hospice provider for a resident receiving hospice services. The existing hospice agreement, dated 08/01/2019, had not been reviewed or updated as required, and was not signed by an authorized representative of the facility. This lack of a current agreement and process placed the resident at risk of not receiving necessary end-of-life care and services. Resident 14, who was admitted with diagnoses including Parkinson's disease and heart failure, was enrolled in hospice services on 03/12/2025. However, the resident's care plan did not include any focus area, goals, or interventions related to hospice services until 03/18/2025. Interviews with hospice and facility staff revealed that there was no established process for documenting hospice visits or communication, as evidenced by the absence of entries in the Hospice Communication Log for Resident 14. The Director of Nursing acknowledged the responsibility of the Administrator to ensure a current agreement and described the expected process for communication, which was not being followed effectively.
Failure to Verify Agency Staff Proficiency in Mechanical Lift Use
Penalty
Summary
The facility failed to ensure that four out of five sampled agency staff members demonstrated proficiency in operating mechanical lift transfers before or at the time of their assignment. This deficiency was identified through observation, interviews, and record reviews. The facility's policy required two staff members to assist with mechanical lift transfers, ensuring the resident was properly positioned and secured according to the manufacturer's guidelines. However, the facility did not verify the proficiency of agency staff in using these lifts, which placed residents at risk for falls and injuries. Resident 1, who was unable to pull themselves up to a standing position, was involved in a fall incident while being transferred using a sit-to-stand lift. The care plan for Resident 1 specified the use of a sit-to-stand lift with two-person assistance. On the day of the incident, Staff C, a newly trained agency nursing assistant, was left alone with Resident 1 in a standing position on the lift. Staff C, who had limited experience with mechanical lifts and was not familiar with the facility's policy, witnessed Resident 1 slide off the footplate and fall. Staff C did not recall seeing the lift sling buckle secured around the resident's torso, which was a safety requirement. Interviews with facility staff revealed that the facility did not receive or verify proficiency skills checklists for agency staff, including Staff C and Staff D, prior to their assignments. The Director of Nursing confirmed that no competencies or orientation were conducted for these staff members. The staffing coordinator acknowledged that the proficiency skills checklist was not reviewed or used as part of the orientation process. The facility administrator stated that agency staff proficiency should be confirmed before or at the time of their shift, but this was not done in practice.
Failure to Implement Safe Transfer Techniques with Mechanical Lift
Penalty
Summary
The facility failed to ensure the implementation of safe transfer techniques during the use of a mechanical lift, resulting in a fall incident involving a resident with a progressive neurological condition. The resident, who was severely cognitively impaired and dependent on staff for transfers, was being moved using a sit-to-stand lift by two agency nursing assistants. During the transfer, one of the assistants left the room, leaving the other to manage the resident alone. The resident subsequently fell from the lift, as the safety buckle was not secured around their torso, leading to a fall and subsequent hospital evaluation. The facility's policy required two staff members to be present during mechanical lift transfers, and the care plan specifically instructed the use of a sit-to-stand lift with two-person assistance. However, these protocols were not followed, as one staff member left the room during the transfer. The investigation confirmed that the lower waist belt was not buckled, contributing to the resident's fall. The incident resulted in the resident sustaining a bruise and a cut inside the mouth, although no serious traumatic injury was reported.
Failure to Maintain Scheduled Bathing Frequency
Penalty
Summary
The facility failed to provide care in a dignified manner by not adhering to the scheduled bathing frequency for two residents, leading to a deficiency in maintaining their dignity. Resident 1, who has Parkinson's Disease, moderate cognitive impairment, and requires assistance for personal hygiene, was scheduled for showers twice a week. However, over a 30-day period, Resident 1 only received assistance with a shower two out of nine scheduled times. This resulted in a noticeable body odor, as reported by a Resident Representative, indicating a lack of proper hygiene care. Similarly, Resident 2, diagnosed with dementia and moderate cognitive impairment, was also scheduled for showers twice a week but only received assistance three out of nine scheduled times in the same period. Interviews with nursing assistants revealed that showers were often marked as 'Not Applicable' due to staffing shortages, and the Director of Nursing was unaware of the issue. This lack of adherence to the bathing schedule compromised the residents' dignity and hygiene.
Failure to Monitor Blood Pressure with Medication Administration
Penalty
Summary
The facility failed to monitor the effectiveness of medications affecting blood pressure for two residents, leading to a deficiency in medication management. Resident 1, who has Parkinson's Disease, dysarthria, and high blood pressure, was prescribed medications including Lisinopril with instructions to hold administration if the systolic blood pressure (SBP) was less than 90. However, the Medication Administration Records (MARs) for June, July, and August 2024 showed no documentation of routine blood pressure monitoring when administering Lisinopril. Similarly, Resident 3, with diagnoses including heart disease and high blood pressure, was prescribed Spironolactone with instructions to hold administration if the SBP was less than 100. The MARs for the same period also lacked documentation of routine blood pressure monitoring for this medication. Interviews with staff revealed that blood pressure readings were only taken if prompted by the order, and the Director of Nursing acknowledged the system's inadequacy in handling medication orders with parameters.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a severely cognitively impaired resident, Resident 2, from non-consensual sexual abuse by another resident, Resident 1, who had a known history of sexually inappropriate behaviors. Resident 1, who was cognitively intact, was observed interacting with Resident 2 in a non-consensual sexually inappropriate manner in the dining room. Despite Resident 1's history of inappropriate behavior, the facility did not provide adequate supervision, which led to Resident 2 experiencing psychosocial harm. Resident 2, who was diagnosed with Alzheimer's disease, anxiety, and insomnia, was severely cognitively impaired and dependent on staff for personal care. The resident was unable to make healthcare decisions or give informed consent. During an incident, Resident 1 maneuvered their wheelchair to block Resident 2, making physical contact in a manner that was inappropriate and non-consensual. Staff observed this behavior but did not intervene in a timely manner to prevent the incident. Resident 1 had a documented history of sexually inappropriate behavior towards female residents, including making inappropriate comments and gestures. Despite this, the facility did not implement one-on-one supervision for Resident 1, which could have prevented the incident. Staff interviews revealed that Resident 1's behavior was known, yet the facility's response was inadequate, failing to protect Resident 2 and potentially placing other residents at risk.
Failure to Report Alleged Neglect
Penalty
Summary
The facility failed to ensure an allegation of neglect was reported to the State Survey Agency as required. This deficiency involved a resident with a neurological disorder who was able to make their needs known. The resident's representative reported to the facility that they felt the resident was being neglected and denied liquids. Despite an investigation initiated by the facility, the allegation was not reported to the State Agency. The Director of Nursing stated that neglect was not suspected, so they did not think it met the criteria for reporting. This failure to report alleged neglect placed the resident and other residents at risk for continued neglect and poor quality of life.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Soap Lake
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Columbia Basin Hospital | 5.6 mi | ★★★★★ | 25 | 0 |
| Lake Ridge Center | 20.9 mi | ★★★★★ | 11 | 0 |
| Columbia Crest Center | 21.6 mi | ★★★★★ | 32 | 0 |
| Colonial Vista Post-acute & Rehab Center | 38.4 mi | ★★★★★ | 0 | 0 |
| Regency Wenatchee Rehabiliation & Nursing Center | 39.3 mi | ★★★★★ | 3 | 0 |
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