Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Mckay Healthcare & Rehab Ctr during CMS and state inspections, most recent first.
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 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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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near 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 | ★★★★★ | 12 | 0 |
| Columbia Crest Center | 21.6 mi | ★★★★★ | 31 | 0 |
| Colonial Vista Post-acute & Rehab Center | 38.4 mi | ★★★★★ | 38 | 0 |
| Regency Wenatchee Rehabiliation & Nursing Center | 39.3 mi | ★★★★★ | 3 | 0 |
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