Above average — CMS composite of the measures below.
The next survey window likely opens around February 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 Mira Vista Care Center during CMS and state inspections, most recent first.
A resident’s POLST was mistakenly sent home with another resident’s discharge paperwork when both residents were discharged. The LPN/Resident Care Manager and RN/DON stated the facility routinely placed the original POLST in discharge paperwork, and staff acknowledged that sending one resident’s POLST with another resident’s documents was improper and a HIPAA violation. The issue was identified as a repeat citation.
The facility failed to follow IPCP and respiratory protection requirements during an influenza outbreak and across multiple rooms on TBP, contact, droplet, and enhanced barrier precautions. Staff were observed not performing hand hygiene, not wearing required PPE such as gowns, gloves, eye protection, or N95s, moving a resident with C. diff outside the room without PPE, handling meal trays and condiments without hand hygiene, and using resident care equipment without proper cleaning. The facility also had an incomplete N95 fit-testing program, with many staff expired or not tested and no documented medical evaluations.
PASRR screening and follow-up were incomplete for multiple residents. One resident with a hip fracture had only the initial Level I with a 30-day exemption in the record, another resident with dementia and behavioral symptoms had no updated PASRR despite psychotropic use and agitation, a resident with major depression and psychotic symptoms had no Level II follow-up documented after an exempted Level I, and another resident had an incorrect Level II invalidation in the record. Social services staff reported missed exemptions, missed email correspondence, and incomplete documentation.
Incomplete CNA Documentation and Delayed Weekly Skin Assessments Multiple residents had incomplete CNA charting for ADLs, bowel/bladder status, behaviors, toileting, oral hygiene, personal hygiene, and turning/repositioning across numerous shifts. Two residents also had weekly skin checks that were either missing or not completed/locked in a timely manner, despite TAR directions for routine weekly skin evaluations. Staff stated documentation was expected by the end of shift and that UDA completion should occur at the same time it was filled out.
Failure to provide Medicare coverage and liability notices. The facility could not locate required liability notices for three residents whose skilled services had ended, and it also could not locate the NOMNC for one resident who remained in the facility after the Medicare A episode ended. The Social Services Director stated a change in business office managers affected when liability notices were being issued, and the notices had not been completed.
Failure to log and resolve resident grievances: two residents reported concerns that were not entered into the grievance log or fully investigated. One resident complained that a replacement mattress was uncomfortable and did not fit the bed frame properly, while another reported missing blouses and unresolved reimbursement issues. Staff acknowledged the concerns were missed during a transition, and the grievance log contained no documentation for the clothing issue.
Unnecessary psychotropic medication use was identified for two residents. One resident with dementia, stroke history, and agitation was given Seroquel for dementia with agitation despite no clear psychosis diagnosis, and staff relied on the provider rather than consistently reviewing behavioral health notes. Another resident with dementia, depression, and behavioral disturbance received daily Seroquel for dementia with agitation even though PASRR, MDS, progress notes, and psychoactive reviews did not document psychosis; the resident also slept much of the day and staff reported no hallucinations or delusions.
Failure to Provide ADL Grooming Assistance: A resident who was dependent on staff for ADLs and had diabetes, muscle weakness, and cognitive communication deficit was repeatedly observed with greasy hair, long facial hair, and jagged fingernails with brown matter under them. Staff said diabetic nail care should be ordered and listed on the TAR, but no such order appeared on the resident’s TARs, and the resident did not refuse care.
A resident with DM, cognitive communication deficit, dysphagia, and no teeth experienced significant weight loss after poor PO intake, refusal of snacks and supplements, and a non-individualized nutrition plan. Records showed the resident ate less than 25% of most meals, had a downward weight trend, and lost 11.6% of body weight within about 2 months. During observation, the resident ate only a few bites of lunch and said fruit was too hard to eat because they had no teeth.
The facility failed to complete annual CNA performance reviews on time for 2 of 4 CNAs reviewed. Two CNA employee files showed late evaluations, and the ADON confirmed that two performance evaluations were overdue and stated there was a process and a plan to ensure evaluations were completed timely.
Incomplete Nurse Staffing Postings: The facility’s daily nurse staffing postings were not current or accurate and did not include the resident census. Observations found missing census information, missing end-of-shift totals, and weekend postings without census or hours worked. An interim scheduler/CNA stated they updated the sheets after shifts, were unaware changes had to be reflected as they occurred, and that no one updated the postings after hours or on weekends.
Unsecured Medication and Treatment Carts: A medication cart on one hall and a treatment cart on another hall were observed unlocked and unattended. The medication cart was left open while a resident was nearby, and the treatment cart contained Betadine, Santyl, hydrocortisone cream, Nystatin/triamcinolone, and other items. The DON acknowledged the unlocked medication cart, and an RN later acknowledged and locked the treatment cart.
Failure to obtain and provide routine dental services for a resident with dysphagia and poor dentition. The resident reported broken, falling-apart teeth, difficulty eating at times, and said they had not been offered a dental visit. Records showed no upper teeth, many missing and broken lower teeth, a mechanically altered diet, and a care plan noting oral/dental problems. Staff said dental needs were discussed but not documented, and no dental care documentation was found.
A facility failed to provide written bed hold notices to two residents at the time of hospital transfer, and one resident’s transfer/discharge notice was incomplete. One resident was transferred to the ER after an acute change in condition and was unresponsive; the transfer form lacked the required brief explanation for why the resident’s needs could not be met, and the record did not show the representative was notified in writing or offered a bed hold. Another resident was sent from an outside wound care visit to the ER for a wound infection, and staff could not locate any bed hold documentation; the resident later stated they had not been offered a bed hold.
A resident with paraplegia had a left thigh wound that was treated with a foam dressing, but the chart lacked a wound description, measurements, assessment, or documentation of healing. Another resident on hospice had ordered decreases in BP meds for low BP, but the facility did not implement the Lisinopril and Amlodipine changes right away, and the hospice RN had to refax the med list.
A resident experienced an acute neurological change with symptoms such as facial droop, slurred speech, arm weakness, and visual problems, but staff did not immediately notify the responsible party and did not document timely follow-up with the physician as previously instructed. Facility policy required prompt physician contact based on urgency and notification of the resident representative for changes in condition, yet progress notes lacked evidence that either emergency contact was informed when the change was first identified, and there was no documentation that the physician was called back within the specified timeframe. The resident was later transferred to a hospital, where an acute stroke was confirmed, and staff interviews acknowledged that such symptoms constituted a critical situation requiring concurrent physician and family notification.
Deficiencies were found in infection control practices, including improper PPE use and inadequate signage for residents on transmission-based precautions. Staff entered rooms of residents with infectious conditions, such as C. difficile, norovirus, ESBL, and those with PEG tubes, without donning required PPE or following organism-specific hand hygiene protocols. Observations and staff interviews revealed inconsistent understanding and implementation of facility policies and posted instructions.
Two residents prescribed antidepressant medications did not receive required monitoring for target behaviors, side effects, or depressive symptoms. One resident experienced a serious medication side effect and was started on a new antidepressant without appropriate monitoring or care plan updates. Staff confirmed that monitoring measures and non-pharmacological interventions were not implemented for either resident.
The facility did not consistently follow physician orders for medication administration, including required blood pressure and heart rate checks, resulting in multiple instances where medications were given outside of prescribed parameters or without proper documentation. Staff interviews confirmed expectations for monitoring and documentation, but records showed repeated omissions and lack of routine auditing, affecting several residents with heart failure and hypertension.
Dietary staff did not follow required hand hygiene protocols when changing gloves and failed to wear beard nets as required by facility policy, resulting in unsanitary food preparation conditions.
Surveyors found that two residents' medical records were incomplete and not systematically organized. One resident's chart lacked required documentation for a significant change PASSR evaluation, and another resident's care plan conference note was missing key interdisciplinary team input and essential care plan elements, including hospice services. Staff interviews confirmed delays and gaps in documentation.
A resident reported being left alone in a wheelchair for six hours, but the incident was not identified or reported as abuse or neglect, nor was it investigated according to policy. Additionally, a staff member had not completed required annual abuse and neglect training, indicating lapses in both grievance handling and staff education.
A resident with multiple health conditions reported being left alone in a wheelchair for six hours, resulting in soreness. Although the grievance was documented and addressed by an LPN and marked as resolved by the Administrator, there was no evidence of a formal investigation into the allegation of abuse or neglect, as required by facility policy. Staff interviews confirmed that such an incident should have been investigated, but no documentation of an investigation was found.
A resident with a history of antibiotic-resistant UTI and DVT was not scheduled for a recommended cystoscopy and infectious disease consult, leading to ongoing discomfort. The deficiency was due to miscommunication and lack of a formal scheduling policy, with staff unaware of the need for appointments until informed by a nurse practitioner.
The facility's policy failed to address safe storage of foods brought in by visitors, prohibiting personal refrigeration units in resident rooms and not allowing outside food in facility storage. This led to residents being unable to store uneaten perishable items, impacting their quality of life.
The facility failed to ensure a clean, comfortable, and homelike environment, with observations revealing stained carpets, broken blinds, damaged walls, and dirty floors across all units. The administrator acknowledged the poor condition and mentioned ongoing repairs but lacked specific plans for addressing these issues. This was a repeat deficiency from a previous survey.
The facility failed to maintain food safety standards, with a broken refrigerator seal, moldy pickles, and improper temperatures in storage units. The kitchen had cobwebs, debris, and spills, while the freezer had ice buildup and unidentified food. Staff acknowledged cleaning issues and unlogged maintenance needs, risking food contamination.
A resident with a history of stroke and vascular disease sustained a sunburn during an outing due to the facility's failure to identify sun exposure risks and provide adequate supervision. The resident's care plan lacked sunblock use guidelines, and staff did not offer sunblock, despite its availability. The facility also lacked a policy on sunburn prevention, and staff interviews were not conducted following the incident.
The facility failed to honor food preferences for two residents, impacting their quality of life. One resident was unable to store personal food items due to facility policy, while another resident's dietary preferences were not documented or considered, leading to dissatisfaction with the facility's food offerings.
The facility failed to assist two residents in formulating Advance Directives (AD), risking their right to have medical treatment preferences honored. One resident had an incomplete Durable Power of Attorney (DPOA) document, while another expressed interest in an AD and DPOA but received no follow-up. Staff were unaware of these deficiencies, contributing to the issue.
The facility failed to provide adequate assistance with ADLs for three residents, leading to unmet care needs. A resident with multiple medical conditions struggled to eat independently due to lack of adaptive equipment and staff assistance. Another resident with cancer and COPD was unable to reach their meal tray, and a third resident did not receive consistent oral hygiene care. Staff interviews revealed a lack of awareness and compliance with care plans, highlighting systemic issues in care provision.
Facility staff failed to follow infection control practices for two residents with urinary catheters. A resident's catheter bag was emptied without cleansing the spout, and hand hygiene was not performed between glove changes. Another resident's catheter tubing was observed dragging on the ground multiple times, despite care plan instructions to secure it. These actions increased the risk of infection.
A resident reported missing personal property, including cash, after being admitted to the hospital. Despite attempts to retrieve their belongings, the facility did not log any grievances, and staff interviews revealed a lack of communication and follow-up. Eventually, some items were found, but the cash was not mentioned, highlighting the facility's failure to address the grievance timely.
A resident was discharged to a hospital and denied re-admission to the facility without receiving a written transfer discharge notice or being informed of their appeal rights. The facility also failed to notify the State Long-Term Care Ombudsman. Staff cited drug use and disruptive behavior as reasons for non-readmission, while the resident was left without support in a distant facility.
A facility failed to provide a written bed hold notice to a resident or their representative upon transfer to a hospital, as required by policy. The resident's medical records lacked documentation of the notice, and interviews with staff revealed confusion about who was responsible for providing it. The resident confirmed not receiving any information about a bed hold.
A facility failed to follow physician orders for a hospice referral for a resident with multiple health issues, including chronic respiratory failure and a history of cancer. Despite a referral being made by an ARNP, it was not acted upon by social services, leaving the resident without requested hospice support. Interviews revealed a breakdown in the facility's process for handling hospice referrals.
Resident POLST Sent With Another Resident’s Discharge Papers
Penalty
Summary
The facility failed to ensure that resident-identifiable information was not shared with the public when Resident 3’s Portable Orders for Life-Sustaining Treatment (POLST) was given to another resident’s family member at discharge. Resident 3 was discharged from the facility on 03/27/2026, and Resident 1 was also discharged on 03/27/2026. An email from Collateral Contact 1 dated 05/02/2026 stated that Resident 3’s POLST had been sent home with Resident 1’s discharge information, and the family member expressed concern and wanted the original POLST returned to the facility. During interviews, Staff B, the LPN/Resident Care Manager, stated that when a resident was discharged, the original POLST was included in the discharge paperwork. Staff A, the RN/DON, also stated that the facility placed the resident’s original POLST with discharge paperwork upon discharge. Staff B acknowledged that Resident 3’s POLST should not have been sent home with Resident 1. Staff C stated that HIPAA is meant to protect residents’ health care information and agreed that sending a resident’s POLST home with another resident’s discharge paperwork would be a HIPAA violation. The report identifies this as a repeat citation from 03/11/2026 and 06/06/2025.
Infection Control and Respiratory Protection Failures
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program by not ensuring staff followed hand hygiene, PPE, transmission-based precautions, and respiratory protection requirements. The report states staff were not compliant with infection prevention and control guidelines and standards of practice across multiple halls, multiple rooms on transmission-based precautions, and for a large portion of employed staff who were expected to use N95 respirators during an influenza outbreak. The facility also failed to ensure universal resident medical equipment was cleaned and disinfected, and failed to implement its respiratory protection plan for 85 of 109 employed staff. During the influenza outbreak, a sign at the entrance notified entrants that the facility was experiencing an increase in respiratory infections and encouraged mask use. The receptionist handed out Aura 1870+ N95 respirators to individuals entering the building, even though the report notes each individual should be fit tested for the respirator. Staff D, the RN/Infection Preventionist/ADON, stated N95 respirators should not have been handed out and said the local health department directed staff to wear N95 respirators during the outbreak, with surgical masks in hallways and N95s when entering a resident room on droplet precautions. A record review showed the facility’s N95 fit test program was incomplete and outdated, and fit testing forms documented 50 staff with expired fit testing and 35 staff who had not been tested at all. The documentation provided did not include medical evaluations, and Staff A and Staff G stated no medical evaluations were documented for staff who were to wear N95 masks. The report also documented multiple failures with contact, droplet, and enhanced barrier precautions. A resident with C. diff was observed being walked down the hallway and into the reception area by a PTA without the required gown and gloves, and the PTA stated they did not understand or know about the Contact Enteric Precautions. In another room, a resident with C. diff remained on Contact Enteric Precautions while sharing a room with another resident who did not have C. diff; Staff D stated the resident had not been taken off precautions because a provider appointment had been canceled and the facility was waiting for next steps. Staff A was observed delivering a meal tray and then leaving the room, handling condiments from the meal cart, and returning to the room without performing hand hygiene. Staff C entered a room posted for TBP requiring an N95 respirator and eye protection while wearing only a surgical mask and no eye protection, and stated they should have worn the required PPE. Additional observations showed staff entering rooms on droplet precautions and enhanced barrier precautions without the required PPE or hand hygiene. Staff F left a resident room wearing a gown and placed a meal tray on the top of the dining cart before removing the gown in the hallway. In a room with droplet precautions and enhanced barrier precautions, Staff E entered wearing only a mask and no eye protection, assisted the resident with bed and linen care, and exited without gown, gloves, or eye protection. In another room with enhanced barrier precautions, Staff F entered while emptying catheters for residents but was not wearing a gown or gloves. Staff I delivered meal trays to rooms on droplet precautions wearing an N95 and goggles but no gown or gloves, and no hand hygiene was observed before entry or after. Staff J entered a room with droplet precautions and enhanced barrier precautions wearing a mask, face shield, and gloves but no gown, brought the vital sign cart into the room, then exited without the face shield or gloves and took the cart down the hall before sanitizing it later. The report also noted that room 213 lacked a trash can immediately inside or outside the room for disposal of used PPE, despite droplet precautions signage indicating PPE disposal requirements.
PASRR Screening and Follow-Up Deficiencies
Penalty
Summary
The facility failed to ensure Level I PASRR screenings were accurate, that residents were referred after the expiration of an exemption, and that PASRRs were updated for 4 of 5 residents reviewed. The facility policy stated Social Services staff were to coordinate screening for possible serious mental disorders or intellectual disabilities and make a Level II referral when indicated, but the policy did not address expiration of an exemption. Resident 2 was admitted with diagnoses including high blood pressure and a right hip fracture. Their PASRR dated 12/01/2025 showed no serious mental illness or intellectual disability and included a 30-day nursing level of care exemption from Level II evaluation. The Social Services Director stated the resident was discharged to the hospital and readmitted, but the only PASRR in the record was the initial Level I with the 30-day exemption. The director stated they had not seen the exemption, assumed a negative PASRR if the resident was not on psychotropic medications, and tracked exemptions on a computer to send to the evaluator on the 25th day. Resident 11 was admitted with diagnoses including right hip fracture, history of stroke, and unspecified dementia. The Level I PASRR dated 10/04/2025 stated the resident did not have symptoms of serious mental illness, depression, or anxiety disorder, but a psychiatric evaluation dated 10/23/2025 documented agitation, anxiety, verbal aggression, and possible depression. The record also showed psychotropic medication use and care planning notes describing agitation and aggression, yet no updated PASRR was completed. Resident 5 had major depressive disorder with psychotic symptoms and a Level I PASRR on 01/28/2026 that required Level II referral but also noted a 30-day exemption if discharge did not occur; no documentation of Level II follow-up was found. Resident 20 had diagnoses including unspecified dementia, insomnia, and anxiety; the Level I PASRR dated 08/12/2025 included a 30-day hospital exemption and required Level II if discharge did not occur, but the Level II dated 12/20/2025 incorrectly invalidated the PASRR because the resident had been discharged even though they had not. The Social Services Director documented the evaluator sent an incorrect invalidation and stated they missed an email containing a PASRR invalidation and did not document correspondence with the evaluator.
Incomplete CNA Documentation and Delayed Weekly Skin Assessments
Penalty
Summary
The facility failed to maintain complete and accurate medical records for multiple residents by not documenting CNA-provided care and resident observations as required. Review of the facility policy titled, Charting and Documentation, stated that all services provided to the resident shall be documented in the resident's medical record. Record review showed missing CNA documentation for ADLs, behaviors/interventions, meal consumption, voiding, bowel movements, toileting hygiene, oral hygiene, personal hygiene, and turning/repositioning for Residents 20, 32, 53, 92, 2, and 93 across multiple shifts and dates. Resident 20 had diagnoses including unspecified dementia, muscle weakness, dysphagia, and cognitive communication deficit, and required assistance with toileting, transferring, bed mobility, bathing, personal hygiene, dressing, and eating. The resident's MDS documented substantial to maximum assistance for oral hygiene, toileting hygiene, showering, dressing, personal hygiene, and transferring. The DSR-v2 reports for January, February, and March 2026 showed repeated missing documentation for behavior monitoring and interventions, bladder continence, bowel movement, toileting hygiene, oral hygiene, personal hygiene, and turning/repositioning on evening and night shifts. Resident 32 had diagnoses including muscle weakness, after surgical care, and heart failure, and required substantial to dependent assistance with toileting, two-person assistance for transferring, and assistance with bed mobility, bathing, and dressing. Their DSR-v2 reports also showed repeated missing documentation for behavior monitoring and interventions, bladder continence, bowel movement, oral hygiene, personal hygiene, toileting hygiene, and turning/repositioning on multiple shifts in February and March 2026. Resident 53's DSR-v2 reports showed missing documentation for ADLs, behavioral symptoms, and bowel monitoring on multiple shifts in January and March 2026. Resident 92's DSR-v2 reports showed missing documentation for ADLs, behavioral symptoms, and bowel monitoring on numerous AM, PM, and night shifts from December 2025 through February 2026. Resident 2's DSR-v2 report showed missing documentation for ADLs, behavioral symptoms, and bowel monitoring on AM, PM, and night shifts across late January through early March 2026. Resident 93's DSR-v2 report showed missing documentation for ADLs, behavioral symptoms, and bowel monitoring on the PM shift and on two day shifts before the resident was discharged to the hospital. Staff D stated there was a designated staff member who reviewed NAC documentation daily and reported it to the team, and the team was responsible for informing NACs to review and complete their daily documentation. Staff CC stated charting was expected to be completed by the end of the shift and that charting was attempted throughout the shift for meals and toileting needs. The facility also failed to ensure timely completion of weekly skin checks for Residents 92 and 53. Resident 92's TAR directed the LN to perform a skin check every seven days and complete the skin evaluation UDA weekly on Mondays, but the record showed missing documentation for two weekly skin evaluations in December 2025, and two January 2026 skin evaluations were not locked until three days after they were documented completed. Resident 53's TAR directed weekly skin checks every Friday, but the January and February 2026 skin evaluations were not locked until three days, 10 days, and 13 days after they were documented completed. Staff B and Staff AA stated the expectation was that when the LN filled out a UDA it should be completed at the same time, and they were made aware this was not done for Residents 92 and 53.
Failure to Provide Medicare Coverage and Liability Notices
Penalty
Summary
The facility failed to provide required liability notices for 3 of 3 residents reviewed for liability notices who remained in the facility after skilled services ended, and failed to provide a Notification of Medicare Non-Coverage (NOMNC) at least two calendar days before Medicare services ended for 1 of 3 residents reviewed for NOMNC issuance. Resident 28’s Medicare Part A service episode started on 11/28/2025 and ended on 12/24/2025, and the facility documented that it could not locate the NOMNC or the liability notice provided to the resident or their representative; the resident remained in the facility after the Medicare A episode ended. Resident 101’s Medicare Part A service episode started on 01/22/2026 and ended on 02/11/2026, and the liability notice could not be located. Resident 102’s Medicare Part A service episode started on 11/28/2025 and ended on 01/18/2026, and the liability notice could not be located. During an interview on 03/11/2026, the Social Services Director stated there had been a change in business office managers, who had been directing when to provide liability notices, and since that change the liability notices had not been completed.
Failure to Log and Resolve Resident Grievances
Penalty
Summary
The facility failed to initiate, log, investigate, and communicate grievances for 2 of 4 residents reviewed for grievances, involving Resident 32 and Resident 39. The facility policy titled, Grievances, revised 02/01/2017, stated the grievance process was to make prompt efforts to resolve resident grievances, with the grievance official responding to the person expressing the concern within three working days and maintaining a grievance log. Resident 32 stated their mattress was uncomfortable, felt like they were laying on metal bars, and had previously complained that the mattress had a hole in the middle before it was replaced. Resident 32 stated the replacement mattress was not fitted properly for the bed frame and the metal securement device could not be used because the mattress was too big. Staff stated the mattress had been replaced on 01/13/2026, but no grievance was completed related to the replacement. Resident 39 stated two blouses went missing, reported the missing items to staff, was told to order replacements for reimbursement, and still had not been reimbursed; one of the replacement blouses also went missing. The grievance logs from October 2025 through March 6, 2026 contained no documentation for Resident 39's missing blouses, and staff stated the concern had been handed off during an administrator transition and was missed.
Unnecessary Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that 2 of 5 residents reviewed were free from unnecessary psychotropic medications and that antipsychotic use had an appropriate indication. The report states the facility did not ensure appropriate indication for psychotropic medications, and it cites the facility policy requiring residents to be free from chemical restraints not required to treat a specific condition documented in the clinical record. Resident 11 was admitted with diagnoses including right hip fracture, history of stroke, and unspecified dementia. A PASRR evaluation showed no symptoms of serious mental illness, depressive disorder, or anxiety disorder. A psychiatric evaluation documented discussion of an antidepressant for signs and symptoms of depression, and noted agitation and anxiety with verbal aggression. Later behavioral health documentation described the resident as almost paranoid and potentially delusional due to dementia, but progress notes from 12/08/2025 through 03/05/2026 did not document monitoring for psychosis as recommended. The MAR showed Seroquel 12.5 mg at bedtime for dementia with agitation, and staff stated they did not know whether the resident had a diagnosis of psychosis and relied on the provider to discuss orders and recommendations. Resident 48 was admitted with diagnoses including dementia with behavioral disturbance and depression. PASRR documentation showed mood and anxiety disorder, while psychosis was not marked and a level II PASRR invalidation showed no symptoms of serious mental illness, depressive disorder, or anxiety disorder. The quarterly MDS showed no hallucinations, the resident was receiving an antipsychotic, and a gradual dose reduction had not been attempted. Physician orders showed Seroquel daily for dementia with agitation, and the psychotropic care plan linked the medication to agitation and dementia. Behavior monitoring was set to track psychotic behavior, but progress notes and psychoactive medication evaluations documented no paranoia, delusions, or hallucinations. Sleep monitors showed the resident slept 12 to 17.5 hours per day, and staff observed the resident asleep during multiple checks; staff also stated the resident did not see or hear things not there and that monitoring should be modified to track delusions and hallucinations.
Failure to Provide ADL Grooming Assistance
Penalty
Summary
The facility failed to provide assistance with activities of daily living, including personal hygiene and bathing, for Resident 10, who was dependent on staff for grooming. Resident 10 was admitted with diagnoses including diabetes, muscle weakness, and cognitive communication deficit. The admission MDS dated 01/09/2026 showed the resident could not perform grooming and was dependent on staff for ADLs, and the ADL care plan initiated on 01/06/2026 identified total assistance from one staff member for ADL needs including grooming. Observations from 03/05/2026 through 03/11/2026 showed Resident 10 repeatedly lying in bed with greasy hair, long facial hair, and jagged fingernails with brown matter under them. Staff interviews indicated nurses were responsible for diabetic nail care and that such care should be ordered and listed on the TAR, but Resident 10's January, February, and March 2026 TARs did not include an order for diabetic nail care. Staff also stated shaving was to be done with showers and that Resident 10 did not refuse care. On 03/11/2026, Resident 10's fingernails were observed clean and trimmed, but facial hair remained and the resident stated they would agree to be shaved.
Failure to Prevent Significant Weight Loss
Penalty
Summary
Provide enough food and fluids to maintain a resident's health was not ensured for a resident admitted with diabetes, cognitive communication deficit, difficulty swallowing, and vitamin D deficiency. The resident's care plan identified nutritional risk related to decreased intake, weakness, difficulty swallowing, lack of teeth, advanced age, diabetes, memory deficit, and vitamin D deficiency, with interventions to monitor intake, offer snacks and fluids, and have the RD evaluate and make changes as needed. The care plan was not revised after the initial period documented in the record, and the interventions listed were not individualized. The resident's MDS documented partial/moderate assistance with eating, no teeth, and coughing or choking during meals and complaints of difficulty or pain while swallowing. The dietary evaluation showed the resident was lethargic, could feed self with verbal cues, had missing teeth, ate less than 25% of most meals, and refused snacks and supplements; the evaluation stated that a prevention protocol should be initiated immediately and documented in the care plan when the score was 10 or greater. The CAA also documented variable and poor intake, use of an oral nutritional supplement for malnutrition risk, and a weight trend downward. The resident's admission weight was 157 pounds, and by early March the resident had lost 11.6% of body weight, or 18.2 pounds. A weight change note documented that the resident was receiving house supplements twice daily and that the team would review the resident if weight loss continued, but the note did not include new interventions or provider notification. During observation, the resident was in bed with lunch tray items including cottage cheese and fruit, ate only bites of the cottage cheese, and stated they could only eat the cottage cheese because they had no teeth and the fruit was too hard to eat. Staff and the RD acknowledged the significant weight loss, poor intake, and that the resident was not taking supplements often.
Late CNA Performance Evaluations
Penalty
Summary
The facility failed to ensure annual CNA performance reviews were completed timely for 2 of 4 employees reviewed, Staff J and Staff O, who had been employed longer than one year. Staff J was hired on 02/08/2024, and the employee evaluation in the file was completed late on 09/15/2025. Staff O was hired on 04/11/2025, and the employee evaluation in the file was completed late on 09/12/2025. During an interview on 03/11/2026 at 9:25 AM, the Assistant Director of Nursing confirmed that two of the four performance evaluations were late and stated there was a process and a plan to ensure performance evaluations were completed timely.
Incomplete Nurse Staffing Postings
Penalty
Summary
The facility failed to ensure that nurse staffing information postings were current, accurate, and included the census/number of residents in the facility. During an observation on 03/04/2026 at 8:21 AM, the daily nurse staffing posting did not contain the census, and at 4:01 PM there were no totals at the end of the shift. During another observation on 03/09/2026 at 8:50 AM, the daily nurse staffing posting again did not contain the census, and the weekend staffing postings showed no census or hours worked on Sunday 03/08/2026. In an interview on 03/09/2026 at 10:20 AM, Staff P, a CNA and interim scheduler, stated they were responsible for updating the daily staffing posting, that they added hours worked after shifts and would add the census if they knew it, that they were unaware the postings needed to be revised as changes occurred, and that no one updated the postings after hours or on weekends.
Unsecured Medication and Treatment Carts
Penalty
Summary
The facility failed to ensure that medications and biologicals were stored in locked compartments, including separately locked compartments for controlled drugs. Review of the facility policy titled, "Storage of Medications," dated April 2007, stated that all drugs and biologicals must be stored in a safe, secure, and orderly manner and that compartments containing drugs and biologicals must be locked when not in use. On 03/11/2026, the 200-hall medication cart was observed unlocked and unattended while Resident 2 was in a wheelchair across from the cart. The Director of Nursing later acknowledged the cart was unlocked. In an interview the same day, an LPN/Supervisor stated the expectation was for medication carts to be locked when a nurse walked away. On 03/05/2026, the 300-hall treatment cart was observed unlocked and unattended and contained Betadine Solution, Santyl ointment, Hydrocortisone cream, Nystatin/triamcinolone, and other items. An RN returned to the cart from a resident's room, acknowledged it was unlocked, and then locked it.
Failure to Obtain and Document Dental Services
Penalty
Summary
The facility failed to obtain and provide routine dental services for Resident 39, who was admitted with dysphagia. During an interview and observation, Resident 39 stated their teeth were falling apart, that they needed to see a dentist, and that they had a hard time eating at times. At the time of the interview, Resident 39 had no upper teeth and their lower teeth were discolored and partially broken. Record review showed the admission MDS documented no upper teeth and many missing lower teeth with obvious and likely cavities/broken teeth. The quarterly MDS documented a mechanically altered diet and no tooth, mouth, or facial pain or discomfort/difficulty with chewing. The care plan documented oral/dental problems related to no upper teeth and poor dentition with many missing and obvious/likely cavities/broken teeth related to a history of poor oral hygiene. Staff stated they did not see Resident 39 on the facility dental hygienist list or any other dental care documentation, that dental needs were discussed during care conferences but not documented, and that dental referrals offered during MDS assessments were not documented. The DON stated they would find documentation to support dental services, but later wrote that no additional documentation was located for dental services for Resident 39.
Failure to Provide Bed Hold Notices and Complete Transfer Documentation
Penalty
Summary
The facility failed to provide written bed hold notice to the resident and the resident’s representative at the time of transfer to the hospital for Resident 53 and Resident 92. For Resident 53, who was transferred to the ER on 03/08/2026 after an acute change in condition and was unresponsive, the EMR initially had no documentation or copies of a Nursing Home Transfer or Discharge Notice or a Bed Hold Notification. Staff Z stated that for an emergent transfer, the license nurse was to complete the transfer/discharge notice, give it to the resident and representative, and send it to the Ombudsman, and that a bed hold notification was also to be completed and given upon transfer. Staff Y later located Resident 53’s transfer/discharge and bed hold notices waiting to be scanned into the EMR and provided copies to the surveyor. Review of Resident 53’s transfer/discharge notice showed the reason for transfer was marked as necessary for the resident’s welfare and because needs could not be met at the facility, but the section requiring a brief explanation was left blank. The resident’s bed hold notification documented that the resident was unresponsive at the time of transfer and that the representative was called four times and was not available, but there was no further documentation that the representative was notified in writing of the transfer/discharge or offered a bed hold. For Resident 92, who was sent to an outside wound care appointment and then transferred to the ER for a wound infection, the EMR showed no documentation that a bed hold was offered, and both Staff Z and Staff Y were unable to locate a bed hold document. When interviewed at the hospital, Resident 92 indicated they had not been offered a bed hold.
Wound Documentation and Hospice Medication Order Delay
Penalty
Summary
Failure to assess, measure, and document a left thigh wound for Resident 92 occurred after the resident was admitted with paraplegia and later had a physician order for wound care to clean and apply a foam dressing every three days. Progress notes documented a wound or pre-existing injury to the left thigh with a dressing in place, but the record contained no description, size, or assessment of the wound, and no documentation was found showing when the wound healed. The resident’s skin evaluation forms also did not include documentation of the left thigh wound. Failure to implement hospice medication changes for Resident 11 occurred after hospice admission for a resident with right hip fracture, history of stroke, and unspecified dementia. The hospice comprehensive admission assessment documented low blood pressures in the prior week and an order to reduce Lisinopril and Amlodipine, but the facility did not implement the changes until several days later. A hospice RN visit note documented that the medication list was refaxed because the facility had not implemented the ordered decreases, and staff stated they were not sure why there was a delay and that there were no progress notes documenting receipt of the orders.
Failure to Immediately Notify Physician and Family of Acute Neurological Change
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify the resident’s responsible party and to update the physician timely when there was a significant change in condition for one resident who was later hospitalized with an acute stroke. The facility’s policy on change in condition, revised in April 2025, required the nurse to use clinical judgment to contact the physician based on urgency and to notify the resident representative of the change. The resident’s face sheet listed two emergency contacts. A progress note documented that at 5:30 AM on 01/04/2026 a change in condition was identified, the on‑call physician was notified, and instructions were given to monitor the resident and call back if the condition did not clear or worsened within 30 minutes. There was no documentation that the responsible party was notified at that time, nor that the physician was called back within 30 minutes as instructed. Later documentation on the same date at 10:11 AM by an RN showed the resident had acute neurological changes, including facial droop, slurred speech, left arm flaccidity, and visual problems. The note indicated the spouse arrived at 8:00 AM and was notified of the change in condition, and that the physician was notified that the family was declining transfer to the hospital, but it did not document immediate notification of either responsible party when the change was first identified. The note also recorded that the second emergency contact arrived at 9:00 AM and agreed to hospital transfer. An emergency room note from a local hospital at 9:40 AM confirmed an acute stroke. A CNA reported observing the resident at 6:00 AM with leaning to one side and inability to focus gaze and stated they summoned the RN, who assessed the resident at 6:10 AM. In interviews, the RN acknowledged that new onset arm weakness and visual problems would be a critical situation warranting physician and family notification and could not recall why the family was not called, while the Assistant DON confirmed that acute neurological changes should be a priority and that documentation did not show immediate family notification or that the physician was contacted again within 30 minutes as previously directed. The survey cited WAC 388-97-0320(1)(b-d).
Deficient Infection Control Practices and PPE Compliance
Penalty
Summary
Multiple deficiencies were identified in the facility's infection prevention and control practices, specifically related to the use of personal protective equipment (PPE) and appropriate signage for residents requiring transmission-based precautions. For a resident with recent norovirus and Clostridium difficile infections, the posted contact precautions signage did not specify the need for soap and water hand hygiene, which is required for enteric organisms. Staff interviews confirmed that signage should have included these organism-specific instructions, and observations revealed that contract staff entered the resident's room without donning PPE, stating they had not noticed the sign. Another resident with a newly placed PEG tube was ordered to be on Enhanced Barrier Precautions (EBP), but no EBP signage was displayed on the door during multiple observations. Staff were observed providing high-contact care, such as administering medication via the PEG tube, without donning appropriate PPE. Staff interviews confirmed that EBP should have been implemented upon the resident's admission, but this was not consistently followed. A third resident, readmitted with an ESBL-resistant infection, had contact enteric precautions signage posted, instructing staff to gown and glove upon room entry. However, staff were observed entering the room and handling items such as lunch trays without wearing PPE, stating they believed PPE was only necessary when providing direct care. Interviews with staff revealed a lack of understanding regarding the requirement to don PPE upon room entry, as indicated by the posted signage and facility policy.
Failure to Monitor Psychotropic Medication Use and Side Effects
Penalty
Summary
The facility failed to ensure that two residents received appropriate medication-specific monitoring for psychotropic medications, specifically antidepressants. One resident, with a history of depression and anxiety, was admitted and subsequently hospitalized after experiencing a side effect from their antidepressant medication, resulting in Syndrome of Inappropriate Antidiuretic Hormone (SIADH) and low sodium levels. Despite the resident's history and diagnosis, there was no depression symptom monitoring in place upon admission, and after a new antidepressant was started, there was no implementation of target behavior monitoring, side effect monitoring, or updates to the care plan. The resident had also initially denied depression symptoms but later disclosed ongoing depression, which was confirmed by a standardized screening tool, yet no monitoring was initiated following this disclosure. Another newly admitted resident with a diagnosis of depression was prescribed two different antidepressant medications without any associated behavior monitors, medication side effect monitors, or non-pharmacological interventions. Staff interviews confirmed that these monitoring measures were not in place for this resident. The lack of monitoring and care plan updates for both residents was acknowledged by facility staff, who stated that these components had been missed.
Failure to Adhere to Medication Administration Parameters and Documentation Standards
Penalty
Summary
The facility failed to follow professional standards of practice in medication administration for three residents with diagnoses including congestive heart failure (CHF) and hypertension (HTN). For one resident, there was no documentation that blood pressure (BP) or heart rate (HR) were monitored prior to administering eight of eleven doses of Carvedilol, despite physician orders requiring these checks. Staff interviews confirmed that vital signs should be checked and documented before administering medications with parameters, but records showed missing documentation for multiple doses. Another resident received Carvedilol and Hydralazine outside of the physician-ordered parameters on several occasions, with missing documentation of HR for five of nine doses and administration of medications when vital signs were outside the specified limits. Staff acknowledged the expectation to document and review vital signs before medication administration, but also stated that there was no routine audit for medications given outside parameters, and errors were only addressed if discovered incidentally. A third resident was administered Metoprolol and Midodrine outside of the established parameters, as evidenced by the medication administration record (MAR) showing doses given when systolic blood pressure was below or above the ordered thresholds. Staff confirmed that medications had been administered outside of parameters but were unable to fully review all relevant dates due to difficulties navigating the electronic record system. These failures to adhere to physician orders and document required assessments led to the identified deficiencies.
Failure to Ensure Sanitary Food Preparation and Staff Hygiene
Penalty
Summary
Facility staff failed to adhere to safe and sanitary food preparation practices in the kitchen, as observed during meal tray assembly. Specifically, two dietary staff members with beards were not wearing beard nets, contrary to the facility's dress policy requiring hair and beards to be effectively restrained with appropriate hair restraints, including beard nets. Staff N, the Dietary Supervisor, stated that beard nets were not necessary if beards were trimmed short, despite both staff members having facial hair. Additionally, multiple instances were observed where Staff N did not perform proper hand hygiene when changing gloves. Staff N was seen putting on gloves without washing hands prior to food preparation, removing gloves without washing hands, and repeatedly donning new gloves without handwashing in between tasks. In interviews, Staff N acknowledged the facility's process required handwashing before applying new gloves and when changing tasks, but did not follow these procedures during the observed meal preparation activities.
Incomplete and Disorganized Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete, accurate, and systematically organized medical records for two residents. For one resident with a history of depression and anxiety, the electronic chart contained two Preadmission Screening and Resident Reviews (PASSR). The second PASSR indicated an evaluation was required for a significant change, but there was no documentation of such an evaluation in the resident's chart or in the progress notes. Staff interviews revealed uncertainty about the follow-up on the PASSR, and no notes were found regarding the required evaluation. For another resident admitted with hospice enrollment, the care plan documentation was incomplete. The care plan conference note indicated only social services attended, and key elements such as disease diagnosis, health and skin conditions, special treatments, medication reconciliation, and various care plans were left blank. There was also no documentation regarding hospice care services. Staff interviews confirmed that the care conference documentation was not completed in a timely manner, with the responsible staff still working on it ten days after the conference.
Failure to Identify and Report Abuse Allegation; Lapse in Staff Training
Penalty
Summary
The facility failed to identify and respond appropriately to a grievance that constituted an allegation of abuse or neglect for one resident. Specifically, a resident with diagnoses including orthostatic hypotension, cellulitis, dementia, and malnutrition reported being left alone in a transport wheelchair for six hours, resulting in significant discomfort. The grievance, documented by the facility, indicated the resident was left unattended from 1:00 PM to 7:00 PM. Despite this report, the incident was not escalated as an allegation of abuse or neglect, nor was it reported to the state agency or investigated as required by facility policy and regulatory standards. Interviews with staff revealed uncertainty about the process for handling such grievances, with some staff indicating they would notify a nurse or administrator, but no clear action was taken to treat the report as a potential abuse or neglect case. Additionally, the facility failed to ensure that all staff received annual abuse and neglect training as required. Review of training records showed that one staff member had not completed the required training within the past 12 months. Staff interviews confirmed that annual training was expected, but there was a lack of clarity regarding the last training dates. These failures in both grievance handling and staff training placed residents at risk for abuse, neglect, and associated harm.
Failure to Investigate Alleged Abuse/Neglect Following Resident Grievance
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of abuse or neglect for a resident who reported being left alone in a wheelchair for six hours, resulting in extreme soreness. The resident, who had diagnoses including orthostatic hypotension, cellulitis of the left leg, dementia, malnutrition, and required assistance with personal care, filed a grievance stating they were left unattended from 1:00 PM to 7:00 PM. The grievance was documented and addressed by a Licensed Practical Nurse and marked as resolved by the Administrator, but there was no evidence of a formal investigation into the allegation as required by facility policy. Record review showed no documentation in the resident's progress notes regarding the grievance or any investigation on the relevant dates. Interviews with facility staff confirmed that such a report should have been escalated and investigated as a potential abuse or neglect case. Despite requests for further documentation, no additional information was provided to demonstrate that an investigation took place, indicating a failure to follow the facility's abuse prevention and investigation policy.
Failure to Schedule Recommended Medical Appointments
Penalty
Summary
The facility failed to coordinate and schedule necessary medical appointments and procedures for a resident who was readmitted after hospitalization for antibiotic-resistant urinary tract infection and deep venous thrombosis in both legs. The resident's Urology After Visit Summary recommended a cystoscopy evaluation and a referral to an infectious disease provider, but these were not scheduled 39 days after the recommendation. The resident continued to experience discomfort, as noted by ongoing complaints of burning when urinating. The deficiency was attributed to a lack of coordination and communication among staff. Staff B, an LPN/Supervisor, stated that scheduling was part of Staff C's duties, but the after-visit summary was misplaced, and Staff C was unaware of the need for scheduling until informed by a nurse practitioner. Despite attempts by the urology clinic to contact Staff C, no communication was received due to a change in phone. The facility lacked a formal policy for scheduling follow-up appointments, contributing to the oversight.
Deficiency in Policy for Storing Outside Food
Penalty
Summary
The facility failed to ensure their policy regarding foods brought in from outside sources included provisions for safe storage and clear distinction from facility food. The policy, titled 'Resident/Personal Food Storage' and dated July 2024, allowed residents to receive food from visitors but prohibited personal refrigeration units in resident rooms due to electrical load concerns. Additionally, the policy did not permit the storage of outside food in facility pantries or refrigeration units, requiring that any perishable food not consumed on the day of opening be discarded. During an interview, the Administrator confirmed that residents were not allowed to store outside food in facility refrigerators and were required to dispose of uneaten perishable items, as personal refrigerators were not an option. This policy placed residents at risk of decreased quality of life by limiting their ability to have food items of their choice safely stored in the facility.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment across all three units observed, as evidenced by stained carpets, broken blinds, damaged walls, and dirty floors. Observations on specific dates revealed dirty and sticky floors in resident rooms, scattered wrappers, and dirty paper towels. Additionally, the facility's hallways had missing baseboards, carpet seams pulling apart, and various dark stains on the carpets, including large stains near specific rooms. The wainscot in one hallway was marked with drip-like staining and scraped areas, and there were rips in the carpet in another hallway. Further observations noted broken blinds in several rooms, with some slats completely missing. Walls in certain rooms had large gouged areas and exposed sheetrock. During an interview, the facility's administrator acknowledged the poor condition of the carpets and mentioned that bids for new flooring had been obtained, but no replacement timeline was scheduled. The administrator also stated that repairs and housekeeping were ongoing but did not provide specific plans to address the other issues. This deficiency was a repeat from a previous survey conducted in July 2023.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that resident meals were prepared and stored in accordance with professional standards of food safety. During observations, the walk-in refrigerator was found with a broken door seal and a temperature of 45 degrees Fahrenheit, while the temperature log inaccurately recorded it as 38 degrees Fahrenheit. An opened and undated bucket of pickles with mold was found inside the refrigerator. The walk-in freezer had a three-inch layer of ice on the door and contained unidentified food with unclear dating. The freezer temperature was 9 degrees Fahrenheit. The kitchen preparation area was observed with cobwebs, debris, and black particles, and the flooring had black markings and discoloration. The unit refrigerator also had a temperature of 45 degrees Fahrenheit, with sticky spills and debris inside. Interviews with staff revealed that the kitchen was cleaned daily, but deep cleaning occurred only every six months. The Dietary Manager acknowledged the mold on the pickle bucket and the broken refrigerator seal, which had been reported to maintenance but not logged. The Maintenance Staff confirmed the broken seal and ice buildup, noting that the repair was not logged. The Administrator stated that the refrigerator seal was broken by a delivery person and was awaiting replacement. These deficiencies left residents at risk for food contamination and foodborne illnesses.
Failure to Prevent Sunburn During Resident Outing
Penalty
Summary
The facility failed to identify the risk of sun exposure and provide adequate supervision and interventions to prevent a sunburn for a resident who was cognitively intact but required assistance with dressing and had impaired range of motion. The resident, who had a history of stroke, high blood pressure, and peripheral vascular disease, sustained a first-degree sunburn on their forehead and arms during an outing. The resident's care plan did not address sunblock use or sunburn prevention prior to the incident, and the facility lacked a policy related to sunblock use or sunburn prevention. The Medication Administration Record (MAR) indicated that sunblock was only available from the 15th of each month, and the resident was not offered sunblock during the outing. Staff interviews revealed that the resident was not aware of the availability of sunblock, and there was no documentation of staff offering sunblock. The facility's incident report did not include interviews with staff who worked during the weekend of the incident, and there was no evidence of staff education on offering sunblock to residents. The Director of Nursing Services was unable to determine why the sunblock order was revised after the incident.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor and facilitate resident preferences for food storage and dietary choices, impacting two residents. Resident 43, who has been at the facility since 2021 and is cognitively intact, expressed frustration over the inability to store personal food items, such as salad dressing, in the facility's refrigerators. The facility's policy prohibits residents from storing personal food in facility refrigerators or having personal refrigeration units in their rooms, leading to the disposal of Resident 43's perishable items. This policy was confirmed by the facility's administrator, who stated that residents must consume perishable items immediately or dispose of them, as the facility does not allow storage of outside food items. Resident 28, admitted with conditions including high blood pressure and a broken leg, reported dissatisfaction with the facility's food, describing it as bland and lacking flavor. The resident stated they had not been interviewed about their food preferences since admission, and their electronic medical record lacked documentation of their dietary likes or dislikes. The dietary supervisor admitted to not having met with Resident 28 to discuss their preferences, despite the facility's protocol to do so within 72 hours of admission. This oversight resulted in Resident 28 not having their dietary preferences considered, as evidenced by an inaccurate menu without meal choices.
Failure to Assist Residents in Formulating Advance Directives
Penalty
Summary
The facility failed to obtain and/or offer assistance to residents and/or their representatives to formulate Advance Directives (AD) for two residents, which placed them at risk of losing their right to have their stated preferences and decisions honored regarding medical treatment and end-of-life care. Resident 26 was admitted with diagnoses including stroke, high blood pressure, and peripheral vascular disease. The facility had a one-page Durable Power of Attorney (DPOA) document for Resident 26 that lacked a date and signature. Staff involved in the admission process were not aware of the incomplete documentation, as the admission occurred before their employment. Resident 28, admitted with high blood pressure, atrial fibrillation, and a broken right leg, signed an Advanced Directive receipt indicating interest in formulating an AD. However, there was no documentation in the medical record regarding the formulation, coordination, or execution of an AD. Social Services staff acknowledged that Resident 28 expressed interest in an AD and a DPOA but had not followed up to develop these documents. This lack of follow-up contributed to the deficiency noted in the report.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for three residents, leading to unmet care needs and diminished quality of life. Resident 11, who has multiple medical conditions including Multiple Sclerosis and hemiplegia, was observed struggling to eat independently due to limited range of motion and lack of adaptive equipment. Despite the care plan indicating the need for one-person assistance during meals, staff did not provide the necessary help, leaving the resident to attempt eating without success. Additionally, Resident 11 reported not receiving regular showers or being turned in bed as required, which was corroborated by staff interviews. Resident 33, diagnosed with lung cancer, leukemia, and COPD, also experienced neglect in meal assistance. Observations showed that their lunch tray was out of reach, and they were unable to consume their meal without help. Despite the care plan indicating the need for setup assistance, staff failed to provide the necessary support, leaving the resident dependent on their roommate to voice their need for help. Staff interviews revealed a lack of awareness regarding the residents' needs for meal assistance, highlighting a systemic issue in the facility's care provision. Resident 28, with a history of high blood pressure and a broken leg, was found to have inadequate oral hygiene care. Despite being able to brush their teeth independently when sitting up, observations indicated that their hygiene products were not within reach and showed no signs of recent use. Staff interviews confirmed that oral care was not consistently offered or provided, contradicting the care plan's directives. This deficiency was noted as a repeat issue from the previous year, indicating ongoing non-compliance with care standards.
Infection Control Deficiencies in Catheter Care
Penalty
Summary
Facility staff failed to adhere to proper infection control practices during catheter care for two residents. Resident 222, who was admitted with Parkinson's disease, urinary retention, and a history of falls, was observed having their catheter bag emptied by a nursing technician without the spout being cleansed before or after the procedure. Additionally, the staff member did not perform hand hygiene between changing gloves. This oversight was acknowledged by the staff member, who admitted that an alcohol wipe should have been used to cleanse the spout. Resident 43, who has a long-term urinary catheter due to neurogenic bladder, was observed multiple times with their catheter tubing unsecured and dragging on the ground. This occurred both outside the facility and within the facility, as the resident self-propelled in their wheelchair. The care plan for Resident 43 included an intervention to secure the catheter to prevent kinking and accidental removal, but this was not followed, leading to the tubing dragging on various surfaces, which poses a risk for infection.
Failure to Resolve Resident Grievance on Missing Personal Property
Penalty
Summary
The facility failed to resolve grievances related to missing personal property for a resident who was cognitively intact and had been admitted to the facility. The resident's inventory of personal effects included items such as a belt, cash, a hat, a necklace, a suitcase, shoes, and a knee brace. After being admitted to the hospital, the resident reported missing property, including cash and other personal items, to the State Hot Line. Despite the resident's attempts to retrieve their belongings, the facility did not log any grievances regarding the missing items in their grievance logs for May, June, and early July. Interviews with facility staff revealed a lack of communication and follow-up regarding the resident's missing items. The Interim Director of Nursing Services and Social Services Staff were aware of the situation but had not resolved it. The Business Office Manager indicated that a grievance form would not be completed if the resident had discharged. Eventually, the Director of Admissions found the resident's items in the Boiler room, including some of the missing items, but the cash was not mentioned. The facility's failure to address the resident's grievance in a timely manner placed residents at risk for unresolved missing personal property.
Failure to Provide Transfer Discharge Notice and Ombudsman Notification
Penalty
Summary
The facility failed to provide a written transfer discharge notice to a resident who was discharged to a hospital and subsequently refused re-admission to the facility. This deficiency involved a resident who was cognitively intact and had been admitted with multiple medical conditions, including type 2 diabetes, high blood pressure, and complications from a left below-knee amputation. The resident was sent to the hospital following a wound care clinic appointment due to issues with their amputation. Despite the facility's policy requiring written notice of transfer or discharge, the resident did not receive such notice, nor were they informed of their appeal rights. Interviews with facility staff revealed that the decision not to readmit the resident was made by the prior Director of Nursing Services, with input from the admissions department. The resident expressed confusion and distress over the refusal of re-admission, as they had no prior issues with the staff and were forced to relocate to a distant facility, away from their support system. Additionally, the facility failed to notify the Office of the State Long-Term Care Ombudsman about the discharge, further compounding the deficiency. The hospital case worker indicated that the facility cited drug use and disruptive behavior as reasons for the non-readmission, while a nursing supervisor mentioned the resident's demanding nature and medication hoarding as contributing factors.
Failure to Provide Bed Hold Notice
Penalty
Summary
The facility failed to provide a written bed hold notice to a resident or their representative at the time of transfer to a hospital or within 24 hours of the transfer. This deficiency was identified for one of the three residents reviewed for hospitalizations. The facility's policy, dated November 2016, requires that residents or their representatives be informed in writing of their right to a bed hold when transferred to a general acute care hospital. However, a review of the medical records for the resident in question showed no documentation of a bed hold notification being provided. Interviews with facility staff revealed a lack of clarity regarding the responsibility for providing the bed hold notice. The Director of Admissions indicated that nursing staff typically completed the bed hold form and forwarded it to medical records for uploading into the electronic medical record. However, the form was not found in the resident's records. Additionally, a Licensed Practical Nurse/Nurse Supervisor believed that Social Services would handle the bed hold notification after a resident was sent to the hospital. The resident confirmed that they did not receive any information or sign any documents regarding a bed hold.
Failure to Follow Hospice Referral Orders
Penalty
Summary
The facility failed to follow physician orders to obtain a hospice referral for a resident who was experiencing a change in condition. This oversight involved a resident who was admitted with multiple diagnoses, including adult failure to thrive, chronic respiratory failure, thrombocytopenia, a history of cancer, heart disease, depression, and anxiety. A hospice referral was made by an Advanced Registered Nurse Practitioner (ARNP) on 05/28/2024, which was intended to be placed in the Social Services box for further action. However, the referral was not acted upon, leaving the resident without the hospice support they and their spouse had requested. Interviews with facility staff revealed a breakdown in the process of handling hospice referrals. The ARNP, who initiated the referral, was unaware of why the order was not followed, despite having discussed hospice care with the resident and their spouse. The Social Services Manager stated they had not seen the referral in their box and therefore did not proceed with the hospice referral. The Interim Director of Nursing Services confirmed that the facility's process was to pass hospice referrals to social services for implementation but could not explain why this particular referral was not processed. This failure placed the resident at risk of not receiving necessary end-of-life support.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 122 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Mount Vernon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Center Of Mount Vernon | 1.4 mi | ★★★★★ | 9 | 0 |
| Life Care Center Of Skagit Valley | 6.6 mi | ★★★★★ | 19 | 0 |
| Josephine Caring Community | 12.4 mi | ★★★★★ | 28 | 0 |
| Soundview Rehabilitation And Health Care Inc | 14.4 mi | ★★★★★ | 32 | 0 |
| Arlington Health And Rehabilitation | 18.3 mi | ★★★★★ | 16 | 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.