Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mountain View Post Acute during CMS and state inspections, most recent first.
Failure to Prevent Resident Elopement: A resident with severe dementia and documented wandering and exit-seeking behaviors was assessed as high risk for elopement and had a Wander Guard care plan in place. Staff redirected the resident multiple times during the day, but the resident later went missing, was found by LE walking near the facility, and returned wet, cold, and with a skin tear; staff reported frequent front-door alarms and no alarm activation when the resident was discovered missing.
Failure to Protect Resident from Abuse: A resident with hemiplegia and moderate cognitive impairment was physically struck in the mouth by a roommate after a verbal dispute over TV volume. The other resident, who had anxiety and OCD but was cognitively intact, admitted to hitting the resident and said anxiety sometimes led to aggressive reactions. Staff separated the residents, assessed for injury, and notified law enforcement, and the DON stated the behavior was not acceptable.
Surveyors found inconsistent temperature monitoring for 2 kitchen refrigerators and unlabeled, undated, and expired food in a resident snack refrigerator. Staff acknowledged the missed temperature logs and the presence of food items with no dates or expired sell-by dates, including opened condiments, a snack bag, and carrot cake. A regional nurse stated kitchen staff were expected to stock and clean the snack fridge, and that food items were everyone’s responsibility to be labeled.
The facility failed to follow its Legionella WMP and respiratory device cleaning orders. The ice machine had a slimy blackish-brown substance, the filter was overdue for replacement, and required logs for hot water heaters, eye washing stations, whirlpool monitoring, and temperature checks were missing. For a resident with OSA using CPAP, the mask and tubing were observed on a nightstand and later on the floor, and staff acknowledged the equipment should have been cleaned and stored properly per orders.
The facility failed to identify multiple grievances as allegations of neglect and did not complete thorough investigations or follow-up when indicated. Grievances included residents not receiving incontinent care, meals, assistance with eating, or transport to appointments, as well as concerns about wound care and a resident left in bed after staff said they would return to assist. The Social Services Director stated grievances were to be forwarded for follow-up and neglect allegations sent to the DON for investigation, and the Regional Nurse stated the grievances should have been recognized as neglect.
The facility failed to complete thorough investigations for a resident-to-resident altercation and a fall involving residents with dementia and other medical conditions. Investigations lacked witness statements, resident interviews, and other key details needed to explain what happened, including a fall report that did not include a wheelchair check, environmental review, or follow-up documentation, and staff acknowledged the investigations were incomplete.
The facility failed to provide enough competent nursing staff to meet resident needs, resulting in missed or delayed basic care and poor care delivery. A resident waited 63 minutes for incontinent care, another had injured fingernails and poor oral hygiene, a third had a fractured finger that was not splinted as ordered, and another had a clutched hand with no ROM or splinting interventions. Grievances and staff interviews described repeated delays in assistance, and one NA reported being alone on a hall caring for 23 residents.
Unsafe and Unsanitary Environmental Conditions: Surveyors observed extensive damage and poor sanitation in multiple resident rooms, a utility room, and the kitchen. Resident room issues included missing paint, exposed drywall, splintered wood, missing closet doors, and metal plates with sharp edges; the utility room had dirty commodes, contaminated basins, and a strong urine odor; and the kitchen had dust buildup on pipes and fans, dark grout, and missing floor tiles exposing concrete. Staff acknowledged the conditions and stated some issues had been known for an extended period.
A resident who was cognitively intact, incontinent of bowel and bladder, and required total assistance for incontinent care waited 63 minutes after requesting help for a bowel movement. An LPN was notified, but the resident was told by an NA to wait until other staff were available. The resident remained in soiled brief care for an extended period and stated they felt embarrassed and upset; the DON said it was not appropriate for staff to leave the resident lying in their bowel movement.
A resident admitted for surgical repair of the left lower leg had intact cognition at discharge, but Medicare records showed no NOMNC or ABN was issued before covered services ended. The Regional Nurse stated the notices had been missed altogether and were not given before discharge.
Unresolved resident grievances and lack of follow-up. Two cognitively intact residents filed grievances about meal-related concerns, including insufficient food for long dialysis trips and late in-room meal trays affecting residents with DM. Documentation showed staff responses did not resolve the concerns, and the residents stated they were not kept updated or given a clear outcome.
A resident with Parkinson's disease, major depressive disorder, panic disorder, and severely impaired cognition received a PRN antianxiety med 12 times with no documentation that non-pharmacological interventions were attempted before administration. The PRN order was written for 30 days instead of being limited to 14 days, and there was no documented physician rationale to extend the psychotropic beyond the regulatory limit.
A facility failed to provide consistent ADL care for two dependent residents. One resident with stroke, dementia, and left-sided hemiplegia had limited showers documented, was unshaven, had foul odor, and had long fingernails embedded into the thumb with redness and scabbing. Another resident with stroke, dementia, and diabetes required total assistance and daily oral care, but repeated observations showed yellow teeth with brown grime, dry cracked lips, and foul breath; an NA said oral care was often missed due to lack of time.
Failure to maintain proper splinting and follow physician orders for a resident with Parkinson's disease and severe cognitive impairment led to poor management of a fractured finger after a fall. The resident's splint was often not in place or was documented inconsistently, staff reported it was frequently applied incorrectly, and later ortho evaluation showed the finger had healed with significant deformity and angulation, with surgery recommended.
Failure to provide ROM care for a resident with left hemiplegia and dementia. The resident had severe cognitive impairment and left-sided functional limitation, but the care plan did not address ROM, mobility, or contracture prevention. Staff observed the resident’s left hand clenched in a fist with a washcloth inside it and a foul odor present, while the RA confirmed there was no ROM restorative program for the hand and leadership acknowledged the resident was not on a ROM program.
Improper medication storage, labeling, and refrigerator monitoring were identified on an East med cart and in a med storage refrigerator. The refrigerator held vaccines and other biologicals but was only checked once daily instead of twice daily when no DDL was used. The East med cart contained a nitroglycerin bottle with a worn-off label, insulin pens without open dates, and an expired unlabeled box of ferrous sulfate that also contained multiple different meds. Staff acknowledged the labeling and dating problems.
Failure to follow through on dental referrals and routine dental care for multiple residents. A resident with dementia had not been added to the dental list or seen by a dentist after admission, another resident with impaired cognition had broken dentures and unmet orders for new dentures with no clear tracking process, and a third resident with stroke had abnormal tongue findings and denture orders that staff had not reviewed or completed.
Failure to document education and consent for flu and pneumococcal vaccines. Two residents with dementia-related cognitive impairment had incomplete immunization records: one RR refused an unspecified vaccine without documentation of which immunization was offered or education on risks, benefits, or side effects, and another resident signed for flu immunization without documented education and had no documentation for pneumococcal vaccine offer or education. The IP confirmed the correct process was not followed.
The facility failed to offer and document COVID-19 vaccine education and consent for two residents with dementia and other significant diagnoses. One resident with moderately impaired cognition and one resident with severe cognitive impairment had records showing influenza vaccine consent, but no documentation that they or their RRs were offered or educated on the risks, benefits, or side effects of the COVID-19 vaccine; the IP confirmed the correct process was not followed.
Three residents with left-sided paralysis and severe cognitive impairment did not consistently receive their prescribed ROM and splinting programs, as evidenced by missed documentation and improper splint application. Staff interviews revealed that restorative care was often not completed due to staffing shortages and lack of coverage, and one resident's splint was observed to be dirty with an odor. The DON confirmed awareness of these lapses, citing inadequate staffing as the cause.
Three residents requiring oxygen therapy were found with unclean oxygen concentrator filters and improperly stored oxygen tubing, including filters with visible dust and debris and tubing left on beds or floors without protective storage. Staff confirmed that weekly cleaning and secure storage in plastic bags were expected per facility protocol, but these procedures were not followed.
A resident with cognitive impairment and a history of anxiety and exit-seeking behaviors was not properly reassessed or monitored for elopement risk after exhibiting increased agitation and attempts to leave. Despite prior 1:1 supervision and frequent checks, staff discontinued enhanced monitoring without updating the care plan or risk assessment. The resident exited the facility unsupervised through a window, was found outside by staff from a neighboring facility, and sustained injuries requiring hospital care. Staff interviews revealed gaps in communication and documentation regarding the resident's elopement risk.
A resident with severe cognitive impairment and multiple diagnoses was administered injectable lorazepam for agitation without being given the option to refuse and without prior consent from their representative. The care plan lacked behavior management interventions, and there was no behavior monitoring documented. The DON confirmed that administering psychotropic medication without consent constituted a chemical restraint.
Staff did not follow facility policy for identifying and reporting potential abuse or neglect after a medication error involving an injected psychotropic medication for a resident with severe cognitive impairment. Despite the resident's representative raising multiple care concerns, the incident was not reported to the State Agency, and staff treated the concerns as educational rather than as possible abuse or neglect.
A resident with severe cognitive impairment experienced a medication error when a psychotropic medication was administered by injection due to a transcription error. The resident's representative raised concerns about care, but staff did not report the incident or the complaints to the State Agency, despite later acknowledgment by the DON that the incident constituted a reportable form of abuse.
A resident with severe cognitive impairment was given an injectable psychotropic medication without documentation of attempted non-pharmacological interventions or offering the oral form, and without obtaining consent from the resident's representative for the change in administration route. The nurse stated the resident could not refuse the medication due to a physician's order, and the DON confirmed this constituted a chemical restraint, violating professional standards.
The facility failed to provide consistent showering care for three residents dependent on staff for ADLs. A resident with moderate cognitive impairment missed multiple scheduled showers, while another resident reported receiving a shower only once every three weeks due to staff shortages. A third resident expressed discomfort from not receiving regular showers. Staff acknowledged a breakdown in the showering process.
A resident with a history of a fractured hip and hemiplegia experienced neglect when the facility failed to perform consistent skin assessments and address a developing necrotic area on the foot. Despite policies requiring weekly checks, staff did not document or communicate changes in the resident's condition, leading to hospitalization and partial amputation. Interviews revealed lapses in care, communication, and documentation among staff.
The facility failed to maintain resident hygiene and dignity, affecting five residents. A resident had long, dirty fingernails and had not been bathed as scheduled, while another had not showered for over a week, resulting in unkempt hair and split nails. A third resident, recovering from pneumonia, had not bathed since December, and a fourth shared a room with a strong urine odor. Additionally, a cognitively impaired resident ate with their hands due to lack of staff assistance, and staff cleaned the dining area while residents were still eating, which was deemed undignified.
Residents expressed concerns about call lights not being answered timely and food not being delivered hot, but the facility failed to follow its grievance policy. The Activities Director did not ensure grievances were logged and resolved, leaving residents unaware of the grievance process and without feedback on their concerns.
The facility failed to properly review and validate PASARR assessments for four residents, leading to incomplete or inaccurate screenings for serious mental illness (SMI) or intellectual/developmental disabilities (ID/DD). This included missing or incorrect level 1 PASARR forms and the absence of required level 2 evaluations, placing residents at risk of inappropriate placement and care. Staff interviews revealed misunderstandings about the sufficiency of level 2 Invalidation Assessments without corresponding level 1 PASARRs.
The facility failed to develop and implement timely baseline care plans (BCPs) for several newly admitted residents, resulting in incomplete or missing initial goals and treatment plans. This deficiency affected residents with various medical conditions, including dementia and heart complications, and left them and their representatives uninformed about their care plans. Staff interviews revealed that a transition to a new system contributed to these omissions.
The facility failed to consistently review and revise care plans for five residents, leading to incomplete documentation of medical needs and interventions. Care plans lacked specific parameters for medical devices, medication updates, and safety measures. Additionally, care conferences did not consistently involve residents or their representatives, and nursing assistants were not included in the interdisciplinary team meetings.
The facility failed to provide adequate care for three residents, including a resident with mental health issues who did not receive necessary physician assistance, a resident with cellulitis whose IV line was not properly maintained, and a resident with paralysis who experienced skin breakdown due to inadequate monitoring. These deficiencies highlight significant lapses in care and monitoring protocols.
The facility failed to provide adequate restorative nursing services to maintain or improve ROM for four residents, leading to a deficiency. A resident with paralysis reported infrequent ROM exercises, while another dependent on staff for transfers noted inconsistency in their RA program. A third resident recovering from amputation stated their exercise program never started, and a fourth resident with a hip replacement experienced a decline in mobility without receiving prescribed exercises. Staff acknowledged the lack of program maintenance and review.
The facility failed to provide adequate nursing staff, resulting in deficiencies in resident care, including poor hygiene, inadequate medical monitoring, and insufficient restorative services. Residents reported not receiving regular showers, and staff interviews highlighted the reliance on agency staff with minimal orientation. The facility's outdated assessment of staffing needs contributed to the ongoing issues.
The facility failed to maintain proper cleaning and storage of oxygen equipment, risking infection transmission. Residents with severe cognitive impairments and respiratory issues had dirty oxygen concentrator filters, and one resident's humidifier was improperly placed on the floor. Staff interviews revealed non-compliance with scheduled maintenance and infection control practices.
The facility failed to maintain a safe and sanitary environment, with issues such as embedded dirt in hall floors, damaged tiles in the dining room, and grime in the laundry and utility rooms. Residents experienced discomfort due to temperature control issues and unclean conditions in their rooms. Staff interviews revealed that the facility was in need of repairs, with no current plans to address these deficiencies.
A facility failed to assess a wheelchair seat belt as a restraint for a resident with impaired cognition and mobility. The resident could not unbuckle the seat belt independently, and no evaluation was conducted to determine if it was a restraint or enabler. Staff interviews confirmed the oversight, and the facility's policy was not followed.
The facility failed to implement its abuse prevention policies, affecting four residents. A resident reported verbal abuse by an LPN, but no investigation was conducted. Another resident experienced rough handling by an RN, which was not logged or investigated. A third resident's refusal of care by a new NA was not properly addressed, and the NA continued working. Lastly, a resident was teased by an NA, but the incident was not reported to the state, and the NA was not removed from care duties.
A facility failed to notify the LTC Ombudsman of a resident's transfer to the hospital, as required. The resident, with heart complications and Parkinson's, was transferred without the necessary written notice. Staff interviews revealed a lack of awareness and process for such notifications.
A facility failed to issue a written notice of bed hold to a resident or their representative during a hospital transfer. The resident, with heart complications and Parkinson's, was transferred without the required notification, as confirmed by staff interviews and record reviews. The standard procedure of informing the resident or representative via phone and documenting it was not followed.
The facility failed to develop comprehensive care plans for two residents, leading to unmet care and safety needs. One resident with a urinary tract infection and catheter had improper catheter management and lacked a detailed care plan. Another resident with a history of substance abuse had no structured care plan addressing their condition, with staff acknowledging a lack of training in this area.
Two residents in the facility did not receive consistent showering and grooming care as per their care plans. One resident, with diabetes and asthma, had not been showered for nearly two weeks, resulting in strong urine odor and flaky skin. Another resident, with diabetes and a history of stroke, had not been showered for over a month, leading to oily hair and dirty fingernails. Staff interviews revealed inconsistencies in staffing and care provision.
A facility failed to assess a resident's use of chewing tobacco, risking potential interactions with medications and health concerns. The resident, admitted after surgery and on psychoactive and IV antibiotic medications, was diagnosed with nicotine dependence but was not assessed for tobacco use. The resident was observed chewing tobacco, and the Assistant DON admitted to being unaware of the resident's continued use, acknowledging the facility's policy was not followed.
A resident with hypoxia and on continuous oxygen was not using their prescribed Bipap device for about two months. The device was stored out of reach, and staff were unaware of the resident's refusal to use it. Physician orders lacked specific settings or mask type, and staff did not discuss the risks and benefits of device use with the resident.
A facility failed to administer Tacrolimus at consistent times for a resident with a heart transplant, risking organ rejection. The MAR lacked specific timing instructions, leading to multiple instances of early or late administration. Staff interviews revealed a lack of awareness about the critical timing requirements for this medication.
The facility failed to ensure residents were free of unnecessary psychotropic medications by not consistently monitoring individualized behaviors, not attempting non-pharmacological interventions, and not conducting AIMS assessments. A resident with dementia received Seroquel without a clear indication, and another with depression and bipolar disorder received Trazodone and Risperidone without proper documentation or consent. The Director of Nursing acknowledged these deficiencies, which were exacerbated by a change in ownership.
The facility failed to provide palatable and warm meals at the proper temperature for several residents. A resident with diabetes and malnutrition reported cold and unappetizing food, while others in the dining hall received meals that were described as disgusting and not appetizing. Staff explained that delays in serving contributed to the issue, and a test tray revealed flavorless and poorly prepared food. The DON expected meals to support nutrition and dignity, but the observations showed otherwise.
The facility did not update its assessment after a change in ownership and the loss of a nursing assistant training program. The assessment, dated September 2023, failed to reflect these changes, placing residents at risk for unmet care needs. The DON confirmed the program's suspension, and the new Administrator noted the previous Administrator's failure to update the assessment.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to ensure interventions were implemented to safeguard and prevent elopement for a resident with severe dementia, agitation, anxiety, restlessness, and wandering behaviors. The resident was identified as high risk for elopement on the elopement assessment, and the care plan included use of a Wander Guard device on the resident’s wrist with staff to check its functionality every shift. The resident’s comprehensive assessment showed severe cognitive impairment, with assistance needed for dressing, personal hygiene, toileting, and eating, while remaining independent with ambulation. The resident had been wandering and exit seeking throughout the day and had tried to follow families and go out when doors were open, with staff redirecting the resident multiple times. Later that night, the resident was found missing, last seen by evening shift staff and then located by local law enforcement walking east on the road near the facility before being returned. The resident was wet and cold, appeared to have fallen into a ditch, and had a skin tear to the right foot. The record also showed the Wander Guard was documented as functioning and in place after the incident, while staff stated the front door alarm frequently activated during the day, no alarms were heard when the resident was discovered missing, and current weekly testing logs for the Wander Guard system were not available.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect residents’ right to be free of abuse for 1 of 3 residents reviewed for abuse. The facility policy defined abuse as the willful infliction of injury to another person and willful as a deliberate action. Resident 1 was admitted with right-sided hemiplegia and COPD, and the comprehensive assessment dated 02/10/2026 showed moderate cognitive impairment and a need for two-person assistance with bed mobility, dressing, and transfers. Resident 2 was admitted with major depressive disorder, anxiety disorder, and obsessive compulsive disorder, and the comprehensive assessment dated 02/01/2026 showed the resident was cognitively intact and independent with transfers and mobility using a wheelchair or walker. The facility incident log documented a resident-to-resident altercation in room [ROOM NUMBER] on 04/20/2026 at 6:55 PM. The investigation found that Resident 2 became verbally aggressive toward Resident 1 over the television volume, then walked to Resident 1’s bed and physically hit Resident 1 in the mouth. Staff intervened, separated the residents, assessed for injuries, and notified local law enforcement. During interviews, Resident 2 stated they hit Resident 1 because Resident 1 was mouthing off and dared them to hit them, and acknowledged that hitting others was wrong but said anxiety sometimes caused aggressive reactions. Resident 1 stated Resident 2 yelled about the volume, approached the bed, and hit them on the left side of the face, and said they did not trust Resident 2. The DON stated Resident 2 had a history of verbal outbursts when triggered by lack of control, had been out earlier for a medical procedure, and was likely overstimulated and easily triggered, and stated the behavior was not acceptable.
Food Storage and Refrigerator Monitoring Deficiency
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety. Surveyors found that kitchen refrigerator temperatures were not consistently monitored for 2 of 2 kitchen refrigerators, and the dietary manager acknowledged the inconsistent temperature logs and stated a sign had been posted as a reminder, but staff were still having trouble. Staff also stated they tried to remember to check temperatures daily and recognized the importance of monitoring all temperatures to ensure the integrity of the food. Surveyors also found that the nutritional refrigerator on the south hall contained unlabeled and expired foods on multiple observations. Items included an opened jar of Tostito cheese with no date opened and the manufacturer’s date rubbed off, an opened jar of marmalade with no open date, a large Ziplock bag containing a peanut butter sandwich, Ensure, and a cup of canned fruit with no dates on the contents or bag, and a piece of store-bought carrot cake that was past its sell-by date. A regional nurse stated there was an expectation for kitchen staff to ensure the nutritional fridge was stocked and cleaned, and that food items were everyone’s responsibility to have dates and names placed on them.
Infection Control Lapses in Water Management and CPAP Care
Penalty
Summary
The facility failed to implement components of its infection prevention and control precautions related to its water management program and respiratory device care. The facility’s Legionella water management program required monthly flushing of hot water heaters, weekly temperature monitoring, monthly cleaning and disinfecting of the ice machine, flushing and cleaning of unused sink eye washing stations every 30 days, and inspection and cleaning of the resident whirlpool bathtub when used. Record review showed the ice machine cleaning log was completed monthly, but there was no documentation of monthly hot water heater flushing, weekly hot water heater temperature monitoring, flushing or monitoring of unused sink eye washing stations, whirlpool bathtub monitoring, or facility-wide temperature logs for much of 2025. Observations of the facility’s eye washing stations showed multiple stations with dirty, stained, partially broken labels and a last inspection date of May 2024. The ice machine in the east hallway dining room had a slimy, wet, spotty blackish-brown substance under the main lid and on the underside of the white plastic storage retainer plate, and the water filter was labeled as last changed on 03/24/2025. Staff C stated the ice machine was cleaned monthly and deep cleaned twice a year, but also acknowledged the blackish-brown substance should not be there, that the filter had not been changed for 10 months and 26 days, and that the facility did not have documentation for several required WMP control measures. Staff A stated the substance could have been biofilm growth and that the ice machine was not clean and needed to be disinfected. For Resident 30, the medical record showed diagnoses including heart failure and obstructive sleep apnea, and that the resident required a CPAP machine. The physician order required nursing staff to clean the CPAP mask, tubing, and machine with soap and water every Thursday and to check the tubing daily for damage or non-function. During observation, the resident’s CPAP mask and tubing were seen on the nightstand across clothing, lotion, and paperwork, and later on the floor. The resident stated they had not seen staff clean the mask or machine and were unsure whether the reservoir had been cleaned. Staff H acknowledged the mask should not be on the floor and stated the CPAP mask and tubing should be cleaned and kept in a bag when not in use. Staff A stated the expectation was that care be done for all residents and physician orders and care plans be followed.
Failure to Recognize Grievances as Neglect Allegations
Penalty
Summary
The facility failed to implement its abuse and neglect policies and procedures when it did not identify multiple grievances as allegations of neglect and did not complete a thorough investigation or follow-up when indicated. Review of grievances from 12/01/2025 through 02/23/2026 showed 10 grievances that were not recognized as neglect allegations, including reports that a resident at risk for skin breakdown was ignored after requesting incontinent care, a resident was soaked in urine and had requested assistance four to five times without receiving help, and a resident did not receive a meal when going to dialysis. Other grievances described a resident not being taken to a surgical appointment, a resident’s husband requesting help for an incontinent wife who did not receive timely assistance, repeated missed meal trays, concerns about wound care frequency and handling of wound care supplies, a dialysis resident not receiving a meal, a resident not receiving lunch and not getting help with eating, and a resident who was told staff would return to assist with getting up for a meal but was left in bed. During interview, the Social Services Director stated they were the Grievance Officer and that grievances would be sent to the appropriate department for follow-up, and if the allegation was abuse or neglect, the process was to forward it to the DON for investigation. The Regional Nurse reviewed the grievances and stated the facility should have recognized them as allegations of neglect. The report also cited the definition of neglect from the Purple Book as a failure to provide goods and services that maintain a resident’s physical and mental health, and referenced WAC 388-97-0540(2)(a)(b).
Incomplete investigations for resident altercation and fall incidents
Penalty
Summary
The facility failed to ensure investigations were completed and thorough for resident-to-resident altercations and a fall involving three residents. The report states that all incidents of abuse, neglect, mistreatment, injuries of unknown source, and similar events must be thoroughly investigated, including the who, what, when, why, and how of the incident. The deficiency involved Resident 22, Resident 4, and Resident 52, with the facility’s investigations lacking required details and documentation. Resident 22 had diagnoses including dementia with agitation, anxiety, insomnia, and need for assistance with personal care, and was assessed as having moderately impaired cognition and needing supervision/touch assistance for walking. The resident was involved in a resident-to-resident altercation when Resident 52 grabbed the resident by the wrist and escorted them out of the room into the hallway. The facility’s investigation for this incident did not include witness statements, and the record showed no thorough investigation of the event. Resident 4 had diagnoses including diabetes, a recent below-the-knee amputation, and pulmonary fibrosis, and was cognitively intact but required substantial assistance with transfers, mobility, dressing, and total assist for showering. After the resident slid out of a wheelchair, the incident report documented the fall as related to wandering and impulsiveness, but there were no interviews with witnesses or the resident, no assessment of the wheelchair, no environmental assessment, and no documentation of follow-up monitoring for residual injuries. Resident 52, who had heart failure and dementia with moderately impaired cognition, was also involved in the altercation with Resident 22 and attempted to bend a staff member’s wrist and threatened to punch the staff member. The investigation for Resident 52 also lacked witness statements and interviews with other residents, and staff acknowledged the investigation was incomplete without witness statements.
Insufficient Nursing Staff and Missed Basic Care
Penalty
Summary
The facility failed to provide sufficient numbers of competent nursing staff to meet resident needs, and the report cites concerns involving resident rights, ADLs, quality of care, and prevention of loss of ROM. The facility assessment showed that 87% of residents required assistance with ADLs excluding bathing, and 45.8% required maximal assistance from two or more staff for ADLs excluding bathing. The grievance logbook also contained multiple complaints alleging delayed or missed care, including requests for incontinent care, meal assistance, and help getting up that were not answered in a timely manner. Resident 5 was not provided timely care for a bowel incontinence episode and waited 63 minutes despite having the call light on and requesting help multiple times. Staff told the resident they had to wait until staff were available, and the resident stated they were embarrassed and upset about the delay. The report also states that Resident 2 had long jagged fingernails that injured the left thumb, and Resident 3 had yellow teeth, brownish grime on the bottom teeth, foul-smelling breath, and dry cracked lips on multiple observations. An anonymous staff member stated there was not time to perform oral care for residents. Resident 35 had a left fourth finger fracture after a fall, and the record showed a splint was ordered but was not applied from 08/01/2025 through 08/26/2025. Orthopedic clinic notes stated the finger healed in a tilted fixed state and would require surgery to correct, and that the resident should have been seen earlier because the surgical outcome could have been avoided. Resident 2 was also observed with the left hand in a clutched fixed position with a strong odor from skin-on-skin contact, and the care plan showed no restorative nursing, splinting, or ROM program for the left hand. Staff interviews stated there was not enough staffing to provide even basic care, that concerns about inadequate staffing had been reported without action, and that one nursing assistant was alone on the East Hall for hours caring for 23 residents.
Unsafe and Unsanitary Environmental Conditions
Penalty
Summary
The facility failed to maintain a safe, comfortable, and sanitary environment in 8 of 12 resident rooms, 1 utility room in the East hallway, and 1 kitchen reviewed for environment. In multiple resident rooms, surveyors observed damaged walls, missing paint, exposed drywall, splintered wood on doors, missing closet doors, and metal plates pulled away from the wall with sharp edges exposed. Specific observations included bathroom doors with paneling removed and bare wood exposed, walls with deep scratches and chipped paint, missing chunks of drywall around bathroom grab bars, and clothing protruding from an open closet. Staff acknowledged that several of the environmental issues were known and that repairs were being worked on, but there was no repair schedule for the resident rooms. In the East hallway utility room, surveyors observed multiple dirty commodes stored throughout the room, basins containing yellow and brown substances on counters and in both clean and dirty sink areas, and yellow and brownish substances around the sink faucets with a strong odor of urine. In the kitchen, staff acknowledged black dirt and dust buildup on ceiling pipes and an oscillating fan, dark black/brown grout, and missing floor tiles exposing concrete. Staff stated they were unsure when the kitchen and ceiling areas were last cleaned, that maintenance handled deep cleaning, and that the flooring had been missing for two years after work had started and then stopped.
Delayed Incontinence Care and Loss of Dignity
Penalty
Summary
The facility failed to ensure that a resident who was incontinent and required total assistance for incontinent care received timely help to maintain dignity. The resident was cognitively intact and had diagnoses including heart failure, chronic obstructive pulmonary disease, and diabetes. During observation and interview, the resident stated they needed assistance after having a bowel movement and had been waiting for a while while their call light remained on over the door of the room. The resident’s request for help was reported to an LPN standing at a medication cart several doors away, and the LPN stated they would take care of it. When the room was checked again, the call light was still on, and the resident stated an NA had told them they would have to wait until other staff were available to help. The resident was not assisted with bowel incontinence care until 63 minutes after requesting help, and the resident stated they felt very embarrassed and upset because they had to wait so long. The DON stated it was not appropriate for staff to have left the resident lying in their bowel movement and that staff were expected to assist residents with incontinent care in a timely manner.
Missing Medicare Non-Coverage and Liability Notices
Penalty
Summary
The facility failed to provide required liability notices for 1 of 3 residents reviewed for liability notices, specifically Resident 78. Resident 78 was admitted with a diagnosis of surgical repair to the left lower leg, and the 09/19/2025 discharge assessment showed the resident's cognition was intact. Review of Medicare documentation showed that Resident 78 was not issued a Notification of Medicare Non-Coverage (NOMNC) or an Advanced Beneficiary Notice (ABN) before discharge from covered services on 09/29/2025. During an interview on 02/20/2026, the Regional Nurse stated that the resident's records were reviewed and the notifications had been missed altogether and were not given to the resident prior to discharge.
Unresolved Resident Grievances and Lack of Follow-Up
Penalty
Summary
The facility failed to ensure resident grievances were promptly followed up on to a resolution for 2 of 5 residents reviewed, and residents were not kept updated on the progress of their grievances. The facility policy stated that each resident has the right to voice concerns and grievances and that the facility would actively seek a resolution and keep residents updated. Staff A, Regional Nurse, stated the expectation was for grievances to be appropriately followed up on to resident satisfaction and for residents to be made aware of the outcome. Resident 5 was cognitively intact and dependent on staff for transfers and mobility, with diagnoses including heart failure, end stage renal disease requiring dialysis, and diabetes. The resident filed a grievance about not receiving enough food to take on long dialysis trips, stating they became very hungry during travel and requested additional sandwiches. The written follow-up documented that staff met with the resident and informed them of what they could and could not have, but the outcome remained that the resident would only receive one sandwich, fruit, and a drink, and the resident stated the grievance was not resolved. Resident 4 was cognitively intact with diagnoses including diabetes and pulmonary fibrosis and required total assistance for toileting and showers with substantial assistance for dressing. The resident filed a grievance about in-room meal trays arriving about one hour later than usual for residents on the south hall, including residents with diabetes who needed earlier meals, but the grievance form had no additional follow-up comments or actions by nursing, and the resident stated they still had not heard back about the grievance.
Unnecessary PRN Psychotropic Use Without Documented Non-Drug Interventions
Penalty
Summary
The facility failed to ensure a resident was free from unnecessary psychotropic medication use when non-pharmacological interventions were not consistently attempted or documented before PRN antianxiety medication was given. Resident 35 was admitted with Parkinson's disease, major depressive disorder, and panic disorder, and the 01/03/2026 comprehensive assessment showed severely impaired cognition and a need for assistance from one to two staff members for ADLs. The resident received an antianxiety medication ordered PRN every 24 hours, and the January and February 2026 MARs showed 12 administrations of the medication with no documentation that non-drug interventions were attempted or used before any of those doses. The facility also failed to adhere to the 14-day limitation for PRN psychotropic medications. The PRN antianxiety order was written for 30 days and remained active beyond 14 days, and there was no documented clinical rationale from the practitioner to extend the medication beyond the regulatory limit. A later physician order instructed staff to monitor behaviors and attempt non-pharmacological interventions, but the record still did not show documentation of such interventions before administration. During interview, the Regional Nurse stated documentation of behaviors and non-pharmacological interventions, or at least refusal of those interventions, would be expected before PRN psychotropic administration, and that continued PRN psychotropic use beyond 14 days should include clear physician justification.
Failure to Provide ADL Care and Hygiene
Penalty
Summary
The facility failed to provide necessary care and services to residents who were dependent on staff for activities of daily living, including showers, incontinent care, oral care, and nail care. The deficiency involved 2 of 5 residents reviewed for ADLs. The facility policy stated that residents unable to complete ADLs independently would receive appropriate support and assistance with hygiene, mobility, elimination, dining, and communication in accordance with the plan of care. Resident 2 was admitted with diagnoses including stroke, left-sided hemiplegia, dementia, and need for assistance with personal care. The resident's assessment showed severe cognitive impairment and dependence on staff for showering, grooming care, and transfers. Physician orders required weekly fingernail and toenail checks on bath day with trimming as needed, along with weekly skin checks. However, the January and February 2026 task flow sheets showed only one documented shower in January and six days without a shower in February. During observation, Resident 2 was unshaven, had a foul odor to the left hand, and had long, jagged, yellow fingernails embedded into the thumb with redness, scabbing, abrasions, and deep indentations. Staff later observed the same condition and trimmed the nails. Resident 3 had diagnoses including history of stroke, dementia, and diabetes, and the assessment showed severe cognitive impairment with total assistance needed for all daily care activities. The care plan required daily oral care and ointment to the mouth to prevent dry cracked lips. During multiple observations, the resident's lower teeth were yellow with brown grime, the breath had a strong foul odor, and the lips were dry and cracked. An NA stated they were often unable to brush the resident's teeth or provide oral care because they did not have time. A regional nurse stated the expectation was that staff completed resident care such as brushing teeth, bathing, nail care, and repositioning, and followed physician orders and care plans.
Failure to Maintain Proper Splinting After Finger Fracture
Penalty
Summary
The facility failed to ensure proper immobilization and consistent follow-through with physician orders for a resident who had a fractured left fourth finger after a fall from bed. The resident had Parkinson's disease, severely impaired cognition, and required assistance from one to two staff members for activities of daily living. A comprehensive assessment showed no ROM impairment to the upper extremities before the injury. After the resident was found on the floor lying on the left side with the left arm trapped underneath, the resident's left hand was swollen and discolored, and an x-ray was obtained at the resident representative's request, which confirmed a fracture of the left fourth finger. A physician ordered splint placement to the left fourth finger, and the MAR directed staff to monitor splint placement every shift. However, the record showed multiple shifts in which the splint was not on the finger and additional shifts with no documentation verifying placement. Staff reported the splint was frequently applied incorrectly and parts needed for proper use were missing, making it ineffective. An orthopedic note later documented significant deformity and angulation of the finger after healing, and the orthopedist recommended surgical correction. The resident representative reported the finger had not healed correctly and that the resident had declined surgery after discussion with family members.
Failure to Provide ROM Care for Resident With Left Hemiplegia
Penalty
Summary
The facility failed to ensure care and services were provided to maintain and/or improve range of motion for one resident with left hemiplegia and dementia. The resident’s comprehensive assessment showed severe cognitive impairment and functional limitation of the upper and lower extremity on one side, and the care plan dated 12/04/2025 did not include a plan for the resident’s left hemiplegia to prevent further decrease in ROM, mobility, or development of contractures. There were no assessments, specific interventions to mitigate the risk of contractures, or restorative nursing ROM services identified for the resident’s left hand contracture. During observation on 02/17/2026, the resident was lying in bed with the left hand in a clutched position and nothing in the hand to prevent skin-to-fingernail contact, and there was a strong foul odor from the left hand. On 02/19/2026, a NA observed the resident’s left hand with a washcloth inside the clenched fist and stated they were unsure how it had been placed there and had not been instructed to do that. The restorative nursing assistant stated the resident was on a restorative program for meals but not for ROM and that no device had been placed on the left hand. The rehab director, RCM, and DNS stated they were not aware of the left hand contracture and acknowledged the resident did not have a care plan specifically for ROM to the left hand.
Improper Medication Storage, Labeling, and Refrigerator Monitoring
Penalty
Summary
Drugs and biologicals were not stored, labeled, and monitored in accordance with professional standards. The facility failed to discard expired or improperly labeled medications on one of three medication carts, identified as the East medication cart, and failed to document twice-daily temperature monitoring for one medication refrigerator in the medication storage room. The refrigerator contained three vials of Apisol, nine boxes of Fluzone Quadrivalent with 10 single-dose vials per box, and two vials of Arexvy. Temperature logs from 02/01/2026 through 02/16/2026 showed the refrigerator temperature was checked once daily on the NOC shift rather than twice daily when vaccines were stored without a digital data logger. An observation of the East medication cart showed one bottle of nitroglycerin tablets with a worn-off label that could not identify who the medication was for, when it was delivered, or when it expired. The cart also contained two Lantus insulin pens and one lispro insulin pen without dates showing when they were removed from refrigeration and opened. In addition, one box of ferrous sulfate with an expiration date of 12/2023 had no label identifying the resident, and it contained multiple different medications, including ferrous fumarate, anti-diarrhea tablets, guaifenesin, and ferrous glutamate. Staff stated insulin should be dated when opened and acknowledged the box contained different medications and should be destroyed. The DON stated central supply and pharmacy had audited the carts, and nurses were expected to review dates and ensure insulins were dated when opened.
Failure to Follow Through on Dental Referrals and Routine Dental Care
Penalty
Summary
The facility failed to provide routine and timely dental services and failed to follow through on practitioner-ordered dental referrals for three residents. One resident with heart failure and dementia had moderately impaired cognition and needed assistance with ADLs, stated they wanted to see a dentist for a worn tooth, and reported they had not seen a dentist since admission. Staff stated the resident had not been added to the facility’s dental list on admission and had not been seen by a dentist while at the facility. Another resident with heart failure and moderately impaired cognition had upper dentures and a referral for new upper dentures, but the resident reported missing teeth, broken dentures, and difficulty eating, and stated the facility had told them they were getting new dentures but nothing had happened. Staff stated paperwork needed to be completed before the appointment could be scheduled and acknowledged there was no set process for tracking such requests. A third resident with stroke and moderately impaired cognition was edentulous, had an order for a referral to evaluate abnormal tongue findings, and an order for new upper and lower dentures, but staff were not aware of the referral or denture orders and had not reviewed the dental orders from the dentist visit as expected.
Failure to Document Education and Consent for Flu and Pneumococcal Vaccines
Penalty
Summary
The facility failed to ensure residents or their resident representatives were educated on the potential risks versus benefits when offering pneumococcal and influenza immunizations, and failed to document whether the vaccines were offered, accepted, or refused for 2 of 5 residents reviewed for infection control. The facility policy titled, "Influenza and Pneumococcal Immunizations," dated 08/01/2024, stated residents would be given the opportunity to accept or refuse the vaccines, would receive education on benefits and potential side effects, and that acceptance or declination would be documented in the medical record. Resident 22 was admitted with dementia, agitation, anxiety, and insomnia, and the 12/16/2025 comprehensive assessment showed moderately impaired cognition and that the resident was offered and declined the influenza/pneumococcal vaccines. However, the immunization informed consent document dated 12/11/2025 listed "other" for the immunization type without identifying which vaccine was offered, and showed the resident's RR refused the unknown immunization without documentation of education on risks, benefits, or side effects for either vaccine. Resident 2 was admitted with left-sided hemiplegia and dementia, and the 11/23/2025 comprehensive assessment showed severe cognitive impairment, no influenza vaccine, and that pneumococcal vaccine was offered and declined. The immunization informed consent document dated 11/17/2025 showed the resident signed for influenza immunization, but no education was documented for risks, benefits, or side effects, and there was no documentation that the resident or RR was offered or educated regarding pneumococcal immunization. The IP stated the correct process was not followed for offering, educating, and documenting resident immunizations.
Failure to Offer and Document COVID-19 Immunization Education and Consent
Penalty
Summary
The facility failed to ensure residents and/or resident representatives were educated on and offered the COVID-19 immunization, and failed to properly document the vaccination process for 2 of 5 sampled residents. The facility policy stated residents were to be offered the recommended COVID-19 immunization upon admission, with informed consent obtained and education provided regarding benefits and potential side effects, and that acceptance or declination would be documented in the medical record. Resident 22 was admitted with diagnoses including dementia, anxiety, and insomnia, and had moderately impaired cognition with COVID-19 immunization status not up to date. Their immunization informed consent document showed they were offered another type of immunization, not the COVID-19 immunization, and there was no documentation that the resident or resident representative was educated on the risks, benefits, or possible side effects of the COVID-19 immunization. Resident 2 was admitted with diagnoses including left-sided hemiplegia and dementia, had severe cognitive impairment, and was also not up to date with the COVID-19 immunization. Their immunization informed consent document showed the resident was offered and accepted the influenza immunization, but there was no documentation that the resident or a resident representative was offered or educated on the risks, benefits, or possible side effects of the COVID-19 immunization. The Infection Preventionist stated the correct process was not followed for these two residents.
Failure to Consistently Provide Range of Motion and Splinting Care
Penalty
Summary
The facility failed to provide appropriate care and services to maintain or improve range of motion (ROM) for three residents with a history of stroke and left-sided paralysis, all of whom were dependent on staff for activities of daily living. Observations revealed that one resident had a splint positioned incorrectly on their hand, with the foam meant to separate the palm and fingers placed on top of the hand instead of in the palm. Documentation review showed that the daily ROM programs for all three residents were not consistently completed, with 14 days in the month lacking signatures to indicate the programs had been carried out. Additionally, there were no directives or information regarding the use of the splint in the care plan for one resident. Interviews with staff indicated that the restorative nursing programs were often missed due to staffing shortages, with the Restorative Nursing Assistant (RNA) being pulled to work on the floor and no coverage provided during their days off or vacation. One resident's collateral contact reported that the resident's hand splint was frequently dirty and the palm had an odor, suggesting inadequate care. The Director of Nursing acknowledged awareness of the inconsistent completion of ROM programs, attributing it to insufficient staffing.
Failure to Maintain Cleanliness and Proper Storage of Oxygen Equipment
Penalty
Summary
The facility failed to maintain proper cleaning, disinfecting, and storage of oxygen care equipment for three residents who required oxygen therapy. For one resident with obstructive sleep apnea and dementia, the oxygen concentrator filter was found with a thick layer of dust, dirt, and hair, and staff were unable to clean it adequately, despite a protocol requiring weekly cleaning or replacement. Another resident with chronic obstructive pulmonary disease and congestive heart failure had an oxygen concentrator filter with visible dust and dirt, and the nasal cannula and tubing were found under the resident's back on the bed, with no plastic bag available for proper storage when not in use, contrary to facility protocol. A third resident, with a history of pulmonary embolism and respiratory failure, had oxygen tubing connected to a concentrator lying on the floor and the nasal cannula under the bed during multiple observations. There was no plastic bag provided to store the tubing when not in use, as required by the facility's standard protocol. Staff interviews confirmed that the expectation was for nurses to clean or change oxygen concentrator filters weekly and to store tubing securely in a plastic bag to prevent contamination, but these practices were not followed.
Failure to Reassess and Supervise Resident with Exit-Seeking Behaviors Resulting in Elopement and Injury
Penalty
Summary
A deficiency occurred when the facility failed to accurately assess, reassess, and provide adequate supervision and safety monitoring for a resident with moderately impaired cognition and a lack of safety awareness. The resident, who had a history of anxiety, depression, cognitive decline, and required assistance with activities of daily living, exhibited behaviors such as confusion, hallucinations, anxiety, and exit-seeking. Despite these behaviors, the resident's elopement risk assessment was not updated, and their care plan was not revised to reflect the increased risk. The facility's policy required identification and care planning for residents at risk of unsafe wandering or elopement, but this was not followed in this case. The resident was placed on 1:1 supervision and every 15-minute checks at times when they were actively exhibiting exit-seeking behaviors, but this increased supervision was discontinued when the resident appeared calmer, without a documented reassessment of risk. Staff interviews revealed inconsistent awareness and communication regarding the resident's elopement risk, with some staff unaware of the resident's status and the resident not being listed in the facility's elopement risk communication binder. On the night of the incident, the resident was able to exit the facility unsupervised through a window, and staff did not immediately recognize the resident was missing. There was no overhead emergency code called, and the resident was not located until found by staff from a neighboring assisted living facility. As a result of the lack of updated assessment, care planning, and supervision, the resident was found outside the facility, lying on the ground, cold, agitated, and with injuries including a head injury, left elbow fracture, and multiple bruises, requiring hospital evaluation and intervention. The incident report and staff interviews confirmed that the required processes for monitoring, reassessment, and communication of elopement risk were not followed, directly leading to the resident's unsupervised exit and subsequent harm.
Failure to Prevent Chemical Restraint and Unnecessary Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident was free from chemical restraints and unnecessary psychotropic medication use. A resident with severe cognitive impairment, dementia, diabetes, sleep apnea, and anxiety was admitted and prescribed multiple psychotropic medications, including donepezil, escitalopram, quetiapine, hydroxyzine, and lorazepam. The resident's care plan did not include any specific interventions for behavior management, identified target behaviors, or individualized interventions. Additionally, there were no behavior monitoring records for the resident during the relevant period. On one occasion, the resident became agitated during the night and refused oral lorazepam. The nurse obtained a telephone order for injectable lorazepam and administered it without offering the resident the option to refuse. The resident's representative was not informed of the new injectable medication order prior to its administration and stated they would not have consented. The Director of Nursing confirmed that administering a psychotropic medication without consent constituted a chemical restraint and that licensed nurses were expected to recognize and question such orders.
Failure to Implement Abuse Identification and Reporting Policy
Penalty
Summary
Facility staff failed to implement the required components of their abuse prohibition policy for a resident with severe cognitive impairment and multiple medical conditions, including dementia, diabetes, sleep apnea, and anxiety. The resident required extensive assistance with daily activities. A medication error occurred involving the administration of an injected medication, which was later determined to be a transcription error. The resident's representative raised multiple concerns about care, including medication administration, behavior management, diabetes management, activities, and provider oversight, during a meeting with facility leadership. Despite these concerns and the facility's policy identifying unauthorized chemical restraints as abuse, staff did not identify or report the incident as potential abuse or neglect to the State Agency. Staff interviews revealed that the concerns expressed by the resident's representative were treated as educational opportunities rather than allegations of abuse or neglect. The Assistant Director of Nursing and the Administrator both confirmed that the incident was not reported to the State Agency, as they did not consider it to be abuse or neglect. The Director of Nursing acknowledged that the administration of psychotropic medications as an injectable could constitute a chemical restraint and a form of abuse, as outlined in facility policy. However, the facility did not follow its own procedures for identification and reporting, resulting in a failure to protect residents from potential abuse and neglect.
Failure to Report Medication Error and Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of potential abuse and/or neglect to the State Agency as required, following a medication error involving a resident with severe cognitive impairment and multiple medical conditions, including dementia, diabetes, sleep apnea, and anxiety. The resident required extensive assistance with daily activities. On the day of the incident, a medication error occurred when a psychotropic medication was administered via injection after the resident refused the oral form, due to a transcription error by a registered nurse who failed to enter the new order correctly into the electronic health record. The resident's representative expressed multiple complaints regarding care, including medication management and provider oversight, during a meeting with facility leadership. Despite these complaints and the medication error, facility staff did not generate or report an allegation of abuse or neglect to the State Agency. Interviews with facility staff revealed that the incident was considered a transcription error with no negative effect on the resident and was therefore not reported. However, the Director of Nursing later confirmed that administering a psychotropic medication as an injection constituted a chemical restraint, which is a form of abuse, and acknowledged that the incident should have been reported. The administrator also confirmed awareness of the incident and the complaints but did not report them.
Failure to Obtain Consent and Follow Standards for Psychotropic Medication Administration
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple diagnoses, including dementia and anxiety, was administered lorazepam by injection without proper adherence to professional standards of nursing practice. The resident had an order for lorazepam by mouth as needed for anxiety, but during an episode of agitation, the nurse obtained a telephone order to administer lorazepam subcutaneously. There was no documentation that non-pharmacological interventions were attempted prior to administering the medication, nor was there evidence that the oral form was offered as required by facility policy. Additionally, the resident's representative was not given the opportunity to accept or decline the change in the medication administration route before the injection was given. The nurse involved stated that the resident could not refuse the medication because it was ordered by the physician, and the Director of Nursing confirmed that administering a psychotropic medication in a manner that prevented refusal constituted a chemical restraint. This practice did not meet professional standards and violated the resident's rights regarding informed consent and medication administration.
Inconsistent Showering Care for Dependent Residents
Penalty
Summary
The facility failed to provide consistent showering and grooming care for three residents who were dependent on staff for activities of daily living (ADL). Resident 1, who had moderate cognitive impairment and required substantial assistance with showering, missed six out of eight scheduled showers in February and four out of eight in March. During an observation, Resident 1 was found with unkempt hair and dirty nails, indicating a lack of proper hygiene care. Staff M, a Nursing Assistant, admitted to not having given any showers during their shift, despite being responsible for resident showers. Resident 3, with intact cognition but dependent on staff for personal care, missed seven out of eight scheduled showers in both January and February, and four out of eight in March. The resident reported receiving a shower only once every three weeks, usually a bed bath, due to staff shortages. Similarly, Resident 4, who also required assistance with showering, missed seven out of eight scheduled showers in January and six out of eight in March. The resident expressed discomfort and a sense of neglect due to the lack of regular showers. Staff C, the Assistant Director of Nursing, acknowledged a breakdown in the showering process, confirming the lack of regular showers for Resident 4.
Neglect in Resident Care Leading to Amputation
Penalty
Summary
The facility failed to ensure a resident was free from neglect, resulting in harm to the resident. Resident 1, who had a history of a fractured right hip and right side hemiplegia/hemiparesis, was admitted with severely impaired cognition and required assistance with personal care. The facility's policy required weekly skin assessments, but these were not consistently performed for Resident 1. The resident developed a necrotic area on the right foot and little toe, which was not promptly addressed, leading to hospitalization and partial amputation. The deficiency arose from multiple lapses in care. Staff D, the Resident Care Manager, admitted to not assessing Resident 1's right foot for 14 days, despite the policy requiring weekly checks. Staff O, an LPN, noted a small open area on the resident's foot but failed to notify anyone or document the change. Staff E, another LPN, reported that the resident refused a dressing change due to pain, yet no further action was taken. Staff F observed changes in the wound but did not document or notify the physician, and Staff H, who worked double shifts, did not perform treatments or dressing changes on weekends. Interviews with various staff members revealed a lack of communication and documentation regarding the resident's condition. Staff J, a Restorative Assistant, discovered the wound without a dressing and reported it to Staff E. The Assistant Director of Nursing confirmed that Staff F did not document the wound's condition or notify the physician. The resident was eventually transferred to a hospital, where a partial amputation was performed due to the severity of the necrotic tissue.
Deficiencies in Resident Hygiene and Dining Experience
Penalty
Summary
The facility failed to ensure that residents were bathed, free from odors, and provided a dignified dining experience, affecting five residents. Resident 13, who was alert and oriented, had long fingernails with a brown substance underneath and had not received a bed bath since 12/31/2024, despite being scheduled for showers twice a week. The resident's room had a musty urine smell, and the resident expressed embarrassment about their hygiene, especially during family visits. Staff failed to document refusals of baths and did not reapproach the resident for bathing. Resident 14, who was dependent on staff for bathing, had not had a shower for over a week, resulting in long, split fingernails with a brown substance underneath and greasy, unkempt hair. The resident expressed feeling unclean and embarrassed. Similarly, Resident 25, who was recovering from pneumonia, had not had a bath since 12/13/2024 and expressed a desire for at least a basin of water and a washcloth to feel better. The resident felt unmotivated to leave bed due to feeling unclean. Resident 27, who shared a room with Resident 13, also experienced a lack of bathing, with their last shower documented on 12/10/2024. The resident's room had a strong urine odor, and the resident expressed embarrassment about their hygiene. Additionally, Resident 7, who was severely cognitively impaired, was observed eating with their hands instead of using an adaptive spoon, which staff failed to assist with until a LPN intervened. The dining experience was further compromised by staff removing tablecloths and cleaning while residents were still eating, which was acknowledged as undignified by the Assistant Director of Nursing.
Failure to Resolve Resident Grievances Promptly
Penalty
Summary
The facility failed to ensure a prompt effort to resolve grievances as required by their policy, which placed residents at risk for unmet care needs. During a Resident Council meeting, residents expressed concerns about call lights not being answered timely and nursing assistants only addressing the resident closest to the door, regardless of who activated the call light. Additionally, residents reported that food was not consistently delivered hot, despite previous complaints. These grievances were not followed up on, and residents were unaware of the grievance process or their right to file grievances anonymously. The facility's grievance policy required the Activities Director to complete a grievance form for concerns raised during Resident Council meetings and forward it to the Social Services Director, who would then log and distribute the grievances to the appropriate department heads for resolution. However, the Social Services Director did not receive or log the grievances from the December 2024 meeting, and the Activities Director did not retain copies of the grievances. This lack of follow-through and communication resulted in residents not receiving feedback or resolution for their concerns.
Failure to Validate PASARR Assessments
Penalty
Summary
The facility failed to properly review and validate the Preadmission Screening and Resident Reviews (PASARR) for four residents, which is essential to ensure that individuals with serious mental illness (SMI) or intellectual/developmental disabilities (ID/DD) are not inappropriately placed in nursing homes. For Resident 9, the PASARR forms completed did not accurately reflect the resident's diagnoses of bipolar disorder and anxiety, and a level 2 evaluation was not referred as required. Staff E, the Social Service Director, acknowledged the oversight during an interview. Resident 263's medical record lacked a level 1 PASARR, although a level 2 Invalidation Assessment was completed, indicating no need for further psychiatric evaluation. However, the absence of a level 1 PASARR meant that the initial screening process was incomplete. Similarly, Resident 56's PASARR level 1 assessment was conducted after admission, contrary to the requirement for it to be completed prior to admission. The facility staff mistakenly believed that a level 2 Invalidation Assessment sufficed without a level 1 PASARR. Resident 4's record showed a level 1 PASARR indicating a mood disorder that required a level 2 evaluation, but no such evaluation was requested or completed. The facility's failure to ensure the completion and accuracy of PASARR assessments before admission placed these residents at risk of not receiving appropriate care and services tailored to their needs, as mandated by the Department of Social and Health Services guidelines.
Failure to Develop Timely Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement baseline care plans (BCPs) within 48 hours of admission for five newly admitted residents, which included specific initial goals and treatment plans. This deficiency was identified for residents with various medical conditions such as stroke, dementia, heart complications, Parkinson's, and mental health disorders. The absence of BCPs or incomplete BCPs meant that residents and their representatives were not informed about the initial care plans, medications, dietary instructions, or services to be provided by the facility. For instance, Resident 49, who had severe cognitive impairment and non-verbal pain indicators, did not have a BCP formulated. Similarly, Resident 62's BCP lacked initial nursing or therapy goals, and neither the resident nor their representative received a summary of the BCP. The report also highlights that some BCPs were initiated late, such as Resident 263's BCP, which was started on the third day of admission instead of within the required 48 hours. Additionally, the BCPs for Residents 263 and 48 were incomplete, lacking initial goals and failing to provide summaries to the residents or their representatives. Interviews with facility staff revealed that the transition to a new system for managing BCPs was incomplete, leading to inconsistencies and omissions in the care planning process. This situation placed residents at risk of unmet care needs and a lack of knowledge regarding their initial care plans.
Deficiencies in Care Plan Revisions and Care Conferences
Penalty
Summary
The facility failed to ensure that care plans were consistently reviewed and revised to meet the current needs of five residents. For Resident 25, the care plan lacked specific parameters for the use of a Bipap machine, including settings for oxygen use, pressure delivery, and instructions for the humidifier. Resident 30's care plan did not identify the type of IV catheter used, its size, or the treatment for its maintenance, and it lacked a complete focus on the resident's pain management. Resident 13's care plan did not reflect the administration of an antidepressant medication that was ordered, indicating a failure to update the care plan with current medication interventions. Resident 4's care plan did not address the high-risk immunosuppressive medication they were taking or the presence of untreated melanoma, which required monitoring. Additionally, Resident 17's care plan did not include the use of a seat belt restraint or enabling device for their electric wheelchair, which was necessary for their mobility and safety. These omissions in the care plans indicate a lack of comprehensive and up-to-date documentation to address the residents' medical needs and conditions. Furthermore, the facility failed to conduct care conferences with the participation of residents or their representatives. Resident 4 reported attending only one care conference since their admission, despite multiple conferences being documented. The facility did not consistently include input from nursing assistants in care conferences, and there was a lack of evidence that all required interdisciplinary team members attended these meetings. This lack of resident involvement and comprehensive team input in care planning further contributed to the deficiencies identified in the facility's care planning process.
Deficiencies in Resident Care and Monitoring
Penalty
Summary
The facility failed to provide appropriate care and obtain necessary physician assistance for a resident with a history of mental health and substance use disorder. Resident 263, who was admitted with a right foot ulcer, bipolar disorder, and depression, exhibited significant behavioral issues, including hallucinations, delusions, and suicidal tendencies. Despite these behaviors and the resident's lack of sleep, the facility staff did not notify the medical provider or seek further interventions. The resident's wound vac was turned off due to their behavior, and the facility did not have specific training on substance use disorder, which contributed to the inadequate care provided. Another deficiency involved Resident 28, who was admitted with cellulitis and required IV antibiotic treatment. The facility failed to properly maintain and monitor the resident's peripheral IV line. The IV dressing was not changed for over a week, and the line was not flushed or maintained as per standard protocol. The orders for flushing and monitoring the IV site were not included in the Medication Administration Record, leading to the peripheral IV line becoming clogged and dirty. Resident 13, who was admitted with a stroke and left-sided paralysis, experienced skin breakdown due to inadequate repositioning and monitoring. The resident reported soreness and skin issues, but the facility staff failed to conduct regular skin assessments. The last documented skin check was on 12/28/2024, and no assessments were conducted in the first week of January 2025. The resident was later found to have Moisture Associated Skin Dermatitis due to prolonged exposure to moisture from wearing a brief and bowel incontinence.
Deficiency in Restorative Nursing Services for ROM
Penalty
Summary
The facility failed to provide adequate treatment and services to maintain or improve the range of motion (ROM) for four residents, leading to a deficiency in restorative nursing services. Resident 13, who had a history of stroke and paralysis, was supposed to receive ROM exercises for their left shoulder, elbow, and wrist six times a week. However, the resident reported that the exercises were infrequent and not part of a structured therapy program. Similarly, Resident 14, who was dependent on staff for transfers and had a prescribed RA program involving TheraBand exercises, reported that the program was inconsistent and had not been conducted for at least ten days. Resident 30, who was recovering from a partial foot amputation and sepsis, was supposed to engage in an exercise program involving TheraBand and weights. However, the resident stated that the program never commenced after their discharge from physical therapy. The care plan indicated a six-day-a-week exercise regimen, but there was no documentation to confirm that these exercises were being performed. Staff D, responsible for the restorative nursing program, admitted to not reviewing the residents' programs for maintenance and acknowledged the lack of quarterly reviews. Resident 42, who had undergone a left hip replacement and had a contracture, was supposed to perform active ROM exercises for bed mobility. However, the resident reported a decline in their ability to move their right leg and had not participated in exercises for some time. Staff O, who had been working in restorative care, confirmed that no exercises had been conducted for Resident 42 and could not provide documentation of any refusals by the resident. The Director of Nursing Services acknowledged that the restorative nursing programs for the 37 residents were broken and needed review.
Staffing Shortages Lead to Multiple Deficiencies in Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, resulting in multiple deficiencies across various aspects of care. Observations and interviews revealed that residents were not receiving adequate assistance with activities of daily living (ADLs), such as bathing and grooming, leading to poor hygiene and dignity issues. For instance, several residents reported not having received showers for extended periods, and their physical appearance, such as long, dirty fingernails and unkempt hair, reflected this neglect. Additionally, the facility's grievance process was not effectively implemented, as residents' complaints about issues like cold food and delayed call light responses were not adequately addressed. The facility also failed to provide necessary medical care and monitoring, as evidenced by the lack of ongoing assessment and treatment of skin conditions and peripheral intravenous (IV) line care. One resident had a purple discoloration on their skin that had not been assessed since late December, and another resident's IV line had not been flushed or had its dressing changed for over a week. Furthermore, the facility did not ensure that residents received appropriate restorative nursing services to maintain their range of motion and mobility. Residents expressed dissatisfaction with the lack of physical therapy and exercise programs, which were either not provided or inadequately implemented. Staffing issues were a significant contributing factor to these deficiencies. The facility relied heavily on agency staff who received minimal orientation, leading to inconsistent care. Interviews with staff members revealed that they were often overworked, with nursing assistants being pulled from their assigned duties to cover shortages in other areas. This resulted in incomplete care tasks, such as showers and restorative exercises, and increased workloads for the remaining staff. The facility's assessment of its staffing needs was outdated and did not reflect the current situation, further exacerbating the problem.
Inadequate Maintenance of Oxygen Equipment
Penalty
Summary
The facility failed to maintain proper cleaning, disinfecting, and storage of oxygen care equipment, which led to potential risks of infectious disease transmission among residents. Resident 1, who was admitted with obstructive sleep apnea and dementia, had an oxygen concentrator with a filter covered in dust, dirt, and hair, despite physician orders for weekly changes. Observations on two separate dates confirmed the filter remained uncleaned. Similarly, Resident 36, with a history of bronchitis and severe cognitive impairment, also had a dirty oxygen concentrator filter, with no records indicating the filter had been changed as required. Resident 35, who had bronchitis and heart failure, was observed with an oxygen concentrator filter similarly covered in dust, dirt, and hair. Unlike the other residents, there were no physician orders for changing the filter, indicating a lack of protocol for maintaining the equipment. Staff interviews revealed a lack of adherence to scheduled maintenance, with a Licensed Practical Nurse acknowledging the weekly schedule but not performing the task. Resident 25, who required continuous oxygen due to heart failure and respiratory issues, had their oxygen humidifier bottle placed on the floor due to tubing length issues, contrary to infection control practices. The oxygen tubing was also observed on the floor, and staff interviews confirmed these practices were not compliant with infection control standards. The Director of Nursing Services expected staff to follow physician orders and maintain infection control, but observations and interviews indicated these expectations were not met.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, comfortable, and sanitary environment across multiple areas, including the East and West halls, East dining room, shower room, specific resident rooms, laundry room, utility rooms, and the conference/activities room. Observations revealed that the floors in the East and West halls had embedded dirt and grime that could not be cleaned by regular sweeping and mopping. The East dining room had split tiles with black substances and a damaged base heater, posing potential risks to residents. The shower room had a black tar-like substance on the walls and tiles, stained toilets, and dusty vents, indicating poor maintenance. In specific resident rooms, issues such as deep gouges in walls, stale urine smells, and temperature control problems were noted. Residents expressed discomfort due to excessive heat in their rooms, which was difficult to regulate. The laundry room and utility rooms had black and brown grime that could not be cleaned, and damaged countertops and cabinets were observed. The conference/activities room had chipped tiles, a large hole in the floor, and a damaged door, all of which were potential safety hazards. Interviews with staff revealed that the facility was old and in need of repairs, with no current repair plans in place. The floors were overdue for waxing and stripping, contributing to the uncleanable conditions. The administrator acknowledged the expectation to maintain a clean and comfortable environment, but the facility's current state did not meet these standards, placing residents at risk for potential accidents and exposure to contaminants.
Failure to Assess Wheelchair Seat Belt as a Restraint
Penalty
Summary
The facility failed to comprehensively assess and monitor the need for a physical restraint for a resident using a seat belt in their electric wheelchair. The resident, who had moderately impaired cognition and mobility impairments, was unable to unbuckle the seat belt independently, which was confirmed by staff interviews. Despite the facility's policy requiring an evaluation to determine if a device acts as a restraint or enabler, no such evaluation was conducted for the wheelchair seat belt. Observations showed the resident leaning to one side in the wheelchair, indicating a potential risk of injury. Interviews with various staff members, including nursing assistants and the Assistant Director of Nursing Services, revealed a lack of awareness and adherence to the required assessment process for determining the use of the seat belt as a restraint. The staff acknowledged that the resident could not unbuckle the seat belt independently, and the necessary evaluation to classify the seat belt as a non-restraint was not performed. The facility's administrator and Director of Nursing Services admitted that the correct process for assessing the need for a physical restraint was not followed for the resident.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement its abuse prohibition policy and procedures, which include components of resident protection, identification, reporting, and investigation. This deficiency was evident in the cases of four residents who were reviewed for abuse and neglect. For Resident 41, the facility did not conduct an investigation into allegations of verbal abuse by a Licensed Practical Nurse (LPN), despite the resident's grievance being submitted. The resident reported being yelled at and having their smoking supplies demanded by the LPN, yet the staff member continued to work with the resident after the allegations were made. Resident 28 experienced rough handling by a Registered Nurse (RN) during care, which resulted in pain and the need for a diagnostic image. Although the incident was reported to the Assistant Director of Nursing Services, it was not logged or investigated. Similarly, Resident 42's refusal of care by a new Nursing Assistant (NA) was not properly addressed, as the NA continued to work additional shifts without an investigation being conducted. Resident 27 reported being teased and called gay by an NA, which was documented in a grievance. However, the incident was not reported to the state agency, and the NA was not removed from resident care pending an investigation. The facility's failure to follow its own policies and procedures for abuse prevention and response placed residents at risk for continued exposure to abuse and neglect.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to provide a written notice of transfer or discharge to the representative of the Office of the State Long Term Care Ombudsman for a resident reviewed for transfer/discharge notice requirements. This deficiency was identified for a resident who was admitted with heart complications and Parkinson's disease and was transferred to the hospital due to a change in their baseline status. The resident's medical records indicated a moderately impaired cognition, and the transfer occurred without the required notification to the Ombudsman. Interviews with facility staff revealed a lack of awareness and process for notifying the Ombudsman of resident transfers or discharges. The Social Service Director, who started working at the facility after the incident, was unaware of the requirement to provide such notifications. The Administrator and Director of Nursing Services acknowledged that the correct process was not being followed, and a written notice should have been provided to the Ombudsman regarding the resident's transfer to the hospital.
Failure to Provide Written Bed Hold Notice During Hospital Transfer
Penalty
Summary
The facility failed to provide a written notice of bed hold to a resident or their representative at the time of the resident's transfer to a hospital. This deficiency was identified during a review of the medical records for a resident who was admitted with heart complications and Parkinson's disease and was transferred to the hospital due to a change in their status. The comprehensive assessment indicated that the resident had moderately impaired cognition, which underscores the importance of ensuring that the resident or their representative is informed about the bed hold policy. Interviews with facility staff revealed that the standard procedure was to inform the resident or their representative about the bed hold policy during a phone conversation, which should then be documented in the resident's medical records. However, in this case, the staff member responsible for the resident's case management acknowledged that the notice of bed hold was not completed with the resident's representative at the time of the hospital transfer. The Director of Nursing Services confirmed that if the notification was not documented in the medical record, it was not completed, indicating a lapse in the facility's adherence to the required notification process.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, resident-centered care plans for two residents, leading to unmet care and safety needs. Resident 21, who was admitted with a urinary tract infection and urine retention, had a severely impaired cognition and required a retention catheter. Observations revealed improper management of the catheter, with tubing touching the floor and the leg bag positioned at the same level as the bladder. The comprehensive care plan for Resident 21 lacked measurable goals, interventions, and specific information related to their urinary system, urinary tract infections, and activities of daily living. Staff interviews confirmed the absence of a comprehensive care plan for Resident 21's catheter use and urinary tract infections. Resident 56, admitted with a history of substance abuse, had a moderately impaired cognition. Observations showed Resident 56 appeared confused and expressed a desire to smoke, indicating a lack of a structured care plan addressing their substance use disorder (SUD). The care plan for Resident 56 did not include specific goals or interventions for assessing risks associated with SUD, monitoring for overdose, or preventing relapse. The Social Services Director acknowledged the absence of a care plan for SUD and admitted to lacking training in this area, which contributed to the deficiency.
Inconsistent Showering and Grooming Care for Residents
Penalty
Summary
The facility failed to provide consistent showering and grooming care for two residents, leading to unmet care needs. Resident 37, who has diabetes and asthma, was supposed to receive assistance with showering twice a week, as per their care plan. However, interviews and observations revealed that Resident 37 had not received a shower for nearly two weeks, resulting in strong urine odor, disheveled hair, and flaky skin. The shower book indicated that the last recorded shower was on 12/30/2024, and no showers were documented in the shower tasks from 12/08/2024 to 01/08/2025. Similarly, Resident 22, who has diabetes and a history of a cerebral vascular accident with right hemiparesis, was dependent on staff for showering and grooming. Despite being scheduled for weekly showers, Resident 22 had not received a shower since 12/10/2024, over a month ago. This lack of care resulted in flat, oily hair, long and dirty fingernails, and untrimmed facial hair. Staff interviews confirmed that the assigned nursing assistants were responsible for completing the residents' showers and nail care, but staffing inconsistencies were noted.
Failure to Assess Resident's Chewing Tobacco Use
Penalty
Summary
The facility failed to assess a resident who used chewing tobacco, which was necessary to prevent potential interactions with medications and health concerns. The resident, who was admitted after surgery for an infection and partial foot amputation, was on psychoactive and intravenous antibiotic medications. Despite being diagnosed with nicotine dependence to chewing tobacco, the resident was not assessed for tobacco use upon admission. During an observation and interview, the resident was found chewing tobacco at their bedside and stated that no one had inquired about their tobacco use since admission. The Assistant Director of Nursing Services admitted to being unaware of the resident's continued use of chewing tobacco and confirmed that the facility's policy to assess all residents for tobacco use was not followed in this case.
Failure to Ensure Proper Use of Bipap Device for Resident
Penalty
Summary
The facility failed to ensure proper respiratory care for a resident who required a Bipap device. The resident, who was on continuous oxygen and diagnosed with hypoxia, was supposed to use the Bipap device nightly. However, the resident had not used the device for about two months and it was found stored in a location they could not reach. The resident mentioned the need to return the device to the medical supply store. The physician orders from September did not specify the settings or type of mask for the device. Staff responsible for the resident's care were unaware of the resident's refusal to use the device and had not discussed the risks and benefits of using or not using the device with the resident.
Failure to Administer Tacrolimus Timely for Transplant Resident
Penalty
Summary
The facility failed to ensure the timely administration of the immuno-suppressive medication Tacrolimus for a resident who had undergone a heart transplant. The medication administration record (MAR) lacked specific instructions indicating the importance of administering Tacrolimus at the same time every day to maintain steady blood levels and reduce the risk of organ rejection. This oversight resulted in the medication being administered either too early or too late on multiple occasions, with deviations ranging from 40 minutes to over four hours outside the prescribed 12-hour interval. Interviews with facility staff revealed a lack of awareness regarding the critical timing requirements for Tacrolimus administration. The Resident Care Manager and a Licensed Practical Nurse were unaware of the necessity for strict adherence to administration times, and the Director of Nursing Services expected nurses to be knowledgeable about the medications they administer. The transplant pharmacist emphasized the importance of administering Tacrolimus precisely 12 hours apart to prevent organ transplant rejection, highlighting the risk posed by the facility's failure to adhere to these guidelines.
Failure to Monitor and Implement Non-Pharmacological Interventions for Psychotropic Medications
Penalty
Summary
The facility failed to ensure residents were free of unnecessary psychotropic medications, as evidenced by the lack of consistent monitoring of individualized targeted behaviors, failure to attempt non-pharmacological interventions prior to administering psychotropic medications, and the absence of assessments for abnormal involuntary movements (AIMS). For Resident 21, who was admitted with dementia without behavioral disturbance, the facility administered Seroquel without a clear indication for its use. The resident's care plan lacked specific goals and documentation of behaviors, and no non-pharmacological interventions were implemented. Additionally, a pharmacy review indicated that Seroquel was inappropriately prescribed for insomnia, and no AIMS assessment was conducted. Resident 263, admitted with depression and bipolar disorder, also received psychotropic medications without proper monitoring or non-pharmacological interventions. The resident's medication administration record showed orders for Trazodone and Risperidone, but there was no documentation of targeted behaviors or non-pharmacological interventions. Informed consent forms were incomplete, lacking signatures and specific non-pharmacological approaches. The care plan for Resident 263 was generic, with no resident-specific goals or monitoring of sleep patterns, and no AIMS assessment was completed. During an interview, the Director of Nursing Services acknowledged that informed consent and AIMS assessments should have been completed before administering the first dose of medication. The director also noted that the monitoring of targeted behaviors and non-pharmacological interventions was disrupted during a change of ownership and had not been properly documented. These deficiencies placed residents at an increased risk for medication-related adverse side effects and unmet care needs.
Failure to Provide Palatable and Warm Meals
Penalty
Summary
The facility failed to provide palatable and warm meals at the proper temperature for several residents, which was observed during a survey. Resident 4, who has diagnoses including diabetes and malnutrition, reported that the food was often served cold and unappetizing, making it difficult to eat. During an observation, Resident 4's breakfast consisted of cold, hard eggs and a grayish potato patty, which the resident found unappetizing. In the East Dining Hall, Resident 23 received a pureed diet that was described as disgusting and not appetizing, with no alternative offered by the nursing assistant staff. Resident 41 was served cold chicken strips and French fries and requested a warm plate, but the replacement was still not hot, and ranch dressing was unavailable. Resident 48 loudly expressed dissatisfaction with the food, describing it as garbage. Staff T, a nursing assistant, explained that residents who complained of cold food were served last from the hall cart, which took at least 15 minutes to reach the East Dining Room. A test tray observation in the West Dining Room revealed that the mechanical soft diet lacked flavor, with teriyaki beef not tasting like teriyaki, flavorless rice pilaf with a gummy consistency, and overcooked, brownish broccoli. The Director of Nursing Services stated that they expected meals to support residents' nutrition and dignity, but the observations indicated that the food served was not palatable or appetizing.
Failure to Update Facility Assessment After Ownership Change and Program Loss
Penalty
Summary
The facility failed to update its facility-wide assessment following a substantial change in ownership and the loss of access to a nursing assistant training program. The assessment, dated September 2023, did not reflect the change in ownership that occurred on August 1, 2024. Additionally, the facility did not update the assessment to account for the loss of the nursing assistant training program, which previously helped fill nursing assistant vacancies. During interviews, the Director of Nursing Services confirmed the suspension of the nursing assistant program, and the new Administrator acknowledged that the previous Administrator did not update the Facility Assessment after the change in ownership. These oversights placed residents at risk for unmet care needs.
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 13 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 Ellensburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Yakima Valley School | 22.5 mi | ★★★★★ | 13 | 0 |
| Good Samaritan Health Care Ctr | 25.9 mi | ★★★★★ | 17 | 0 |
| Landmark Care And Rehabilitation | 26 mi | ★★★★★ | 2 | 0 |
| Crescent Health Care | 26.3 mi | ★★★★★ | 19 | 0 |
| Summitview Rehab And Health Center | 26.6 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.