Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Rehabilitation And Care Center during CMS and state inspections, most recent first.
Failure to provide ordered compression stockings and heel boots. Two residents did not receive ordered care: one resident with orthostatic hypotension was observed without compression stockings despite a physician order, and another resident with pressure wounds was observed without heel protection boots despite orders and a care plan for foam boots/heel protectors. Staff also reported no documented refusals for either resident.
A resident with vascular dementia, a hx of falls, and a leg fracture was identified as a fall risk with interventions that included a low bed, call light within reach, and floor mats at the bedside. Despite repeated fall-related documentation and care plan directions, surveyors observed the floor mats missing and the call light repeatedly out of reach. Staff gave inconsistent accounts of the resident’s fall risk status, and the DON/Administrator stated the fall mat intervention had been discontinued without explaining how it was determined to no longer be needed.
Unlocked Medication and Treatment Carts: A medication cart was observed unlocked and unattended while an RN entered a resident room and staff walked by, and an LPN later stated the cart should be locked when unattended. A treatment cart was also found unlocked with wound care supplies, creams, cleanser, iodine, gloves, and other items inside; the LPN stated they had not recently used it and did not know it was unlocked.
Incomplete resident records for oncology appt and weekly labs. A resident with extensive stage lung CA and liver mets had an oncology visit scheduled, but the EMR lacked documentation showing whether the resident attended or why the appt was missed; staff accounts conflicted with the resident’s statement that they never canceled it. The EMR also lacked weekly lab results for extended time periods despite a physician order, and staff stated the results should have been uploaded.
A resident with metastatic lung cancer and a cognitively intact status wanted to continue planned chemotherapy, but facility and oncology records showed repeated delays, cancellations, and rescheduling of chemo and port-placement appointments. The facility told the oncology clinic it could not accommodate residents receiving chemo, cited transportation and room/bathroom limitations, and canceled appointments without documentation that the resident was notified. Interviews confirmed the resident and family believed the resident was supposed to receive six cycles of chemo and had not agreed to stop treatment.
Failure to Provide Chemotherapy Services Listed in Facility Assessment: A resident with extensive stage lung cancer and liver metastasis was not provided planned chemotherapy after admission. Interviews showed staff told the resident, caregiver, oncology clinic, and family that the facility could not manage the port, provide transportation, or accommodate chemotherapy because of quarantine precautions and the lack of a private bathroom, despite the facility assessment listing cancer treatments such as chemotherapy and radiation among services offered.
A resident with moderate cognitive impairment had their antipsychotic medication dosage increased on two occasions without the responsible party being notified, despite facility policy requiring notification within 24 hours. Both the RN and DON processed the medication changes but did not inform or document communication with the responsible party, who was known to be concerned about medications causing drowsiness.
The facility failed to complete timely and comprehensive Resident Assessment Instruments (RAI) and Care Area Assessments (CAA) for several residents, leading to incomplete evaluations of their needs and preferences. Significant Change in Status Assessments (SCSA) were also delayed for residents electing hospice services. Staff interviews revealed a lack of awareness and training regarding assessment requirements.
The facility failed to ensure accurate PASRR evaluations for residents, leading to potential risks in placement and mental health care. One resident's PASRR did not initially reflect their depression diagnosis, while another had conflicting information regarding their mental illness. Two residents were not referred for necessary level two evaluations, placing them at risk for inappropriate placement and unmet mental health needs.
The facility failed to properly monitor and document bowel movements, weights, and blood glucose levels for residents, leading to potential risks in their medical status. A resident with constipation had no documented bowel movements for several days, while another resident's weight monitoring was inconsistent with physician orders. Additionally, a diabetic resident experienced lapses in blood glucose monitoring and insulin administration, with their care plan lacking necessary diabetes management details.
The facility failed to ensure proper indications and monitoring for antipsychotic medications for several residents, leading to potential adverse effects. A resident was given Seroquel without appropriate indications, and consent was delayed. Another resident lacked individualized monitoring for Seroquel, resulting in unmonitored behaviors and a fall. A third resident was prescribed duloxetine and hydroxyzine without monitoring for adverse effects, despite being at risk for depression and mood issues.
The facility failed to maintain a safe, clean, and homelike environment, with issues such as uncomfortable sound levels, inadequate housekeeping, and insufficient living space. Residents experienced distress due to noise, cramped conditions, and unclean surroundings, with no documented intervention from the facility.
A facility failed to complete a Significant Change in Status Assessment (SCSA) for a resident who elected hospice services. Despite the requirement to perform a SCSA within 14 days of hospice enrollment, the resident's Minimum Data Set (MDS) assessments showed no SCSA was completed. Staff interviews confirmed the oversight without providing an explanation.
A facility failed to develop a baseline care plan for a resident with a hearing impairment, despite documentation of moderate difficulty hearing. The resident, admitted with paranoid schizophrenia and anxiety, had no assistive devices for hearing. Staff interviews revealed reliance on care plans to determine care levels, but the resident's hearing issue was not included, risking unmet needs and complications.
The facility failed to update care plans for two residents, one with multiple falls and another with a discontinued medication for weight loss. Despite recommendations for additional interventions after falls, these were not added to the care plan of a resident with stroke and neurocognitive disorder. Another resident's care plan was not updated after discontinuing Ozempic for weight loss. Staff interviews indicated care plans should be revised by care managers and reviewed quarterly, but this was not consistently done.
The facility failed to provide adequate assistance with ADLs for two residents, leading to deficiencies in care. A resident with stroke and neurocognitive disorder did not receive scheduled showers, while another with Alzheimer's and dysphagia was left without meal assistance for extended periods. Additionally, the latter's call light was repeatedly found out of reach, contrary to care plan directives.
A resident with pulmonary fibrosis and CHF did not receive oxygen therapy as prescribed, with the concentrator settings consistently above the ordered 3 lpm. Despite protocols to check settings every shift, the resident's oxygen levels fell below target, requiring temporary adjustment. Staff interviews confirmed the discrepancy in settings.
The facility failed to accurately complete the daily nurse staffing form with actual hours worked for each shift on multiple days. Observations showed that the posted forms did not reflect the actual hours worked, and interviews revealed that the Staffing Coordinator updated the hours the following day based on time punches, rather than in real-time. This misunderstanding of requirements placed residents and their representatives at risk of not being fully informed of staffing levels.
A resident with stroke, aphasia, and dementia exhibited repetitive yelling and distress, which the facility failed to consistently assess, monitor, or document. Despite having a care plan, there was no evidence of consistent implementation of interventions. Staff responses were inconsistent, and there was no structured system for documenting behavioral symptoms, placing the resident at risk of unmet emotional and psychosocial health needs.
The facility failed to secure and properly label medications, as observed with an LPN leaving an unlabeled insulin pen unattended on a cart. Additionally, two residents had medications accessible at their bedsides without proper authorization or assessment for self-administration. One resident had multiple medications on their nightstand, while another kept an Albuterol inhaler on their overbed table, both without a self-medication program assessment or care plan.
The facility failed to provide prompt dental services for two residents, resulting in a deficiency. One resident experienced pain and needed extractions and dentures, while another had broken teeth and had not seen a dentist since admission. Despite care plans indicating the need for dental coordination, there was no documentation of referrals or evaluations, as confirmed by staff interviews.
A facility failed to follow infection control procedures for a resident on enhanced barrier precautions, as staff did not wear gowns during high-contact care activities. Additionally, mechanical lifts were not sanitized between uses, with staff showing inconsistent understanding of disinfection protocols.
The facility failed to follow proper infection control protocols during wound care for three residents. An LPN and a provider did not change gloves or perform hand hygiene as required, risking contamination. For one resident, the LPN used the same gloves for multiple tasks, including handling soiled items. Another resident's care involved handling a glove box with unwashed hands, and for a third resident, hand hygiene was neglected between glove changes. These actions violated infection control procedures and CDC guidelines.
A resident with multiple wounds did not receive timely and appropriate wound care as per consultant recommendations. The facility delayed implementing treatment changes for the resident's wounds, including the anterior abdomen, right abdominal pannus, and buttocks, leading to a risk of complications. The Director of Nursing confirmed that there was no documentation explaining the delays or lack of implementation.
The facility failed to ensure timely administration of insulin for three residents with diabetes, leading to significant medication errors. Multiple doses were administered outside the required time frame, with some being up to four hours late. The Director of Nursing Services and the Administrator acknowledged the non-compliance but could not provide further information on the delays.
The facility failed to follow physician orders for three residents upon admission, including the use of a bipap machine for one resident and compression stockings and an abdominal binder for two residents with orthostatic hypotension. Staff interviews confirmed that these orders were missed or not documented, placing residents at risk of medical complications.
Failure to Provide Ordered Compression Stockings and Heel Boots
Penalty
Summary
The facility failed to ensure that Resident 82 received ordered compression stockings for orthostatic hypotension. Resident 82 was admitted with diagnoses including history of stroke, history of falling, and orthostatic hypotension. The MAR showed a physician order dated 01/02/2026 to apply compression stockings to both lower extremities in the morning and remove them at night. However, during observations on 01/06/2026 and 01/07/2026, Resident 82 was lying in bed with legs uncovered and no compression stockings in place. During interview, the RN found the resident wearing protective sleeves that were loose fitting and bunched around the ankles rather than compression stockings, and no compression stockings were found in the room. Resident 82 stated they would get some compression stockings. Review of progress notes from 01/02/2026 through 01/08/2026 showed no documentation of refusals to wear compression stockings. The facility also failed to ensure Resident 94 wore ordered heel protection boots. Resident 94 was admitted with diagnoses including multiple pressure wounds and failure to thrive. The hospital discharge summary dated 01/02/2026 documented that the resident was to wear sage boots to both feet to offload the heels. The TAR documented a physician order dated 01/07/2026 for daily and as needed heel protectors at all times for wound care, and the care plan documented heel and ankle ulcers with interventions including foam boots as tolerated for wound healing. During observations on 01/06/2026 and 01/07/2026, Resident 94 was lying in bed with the foam boots at the foot of the bed and not being worn. The resident stated someone had told them they should be wearing the boots all the time. Staff stated the resident had boots for their feet, but it was up to the resident if they wanted to wear them, and the DON stated there were no documented refusals for the foam boots.
Failure to Maintain Fall Interventions for a Resident at Risk for Falls
Penalty
Summary
The facility failed to ensure that developed fall interventions, including floor mats and the call light, were in place for Resident 26 to minimize the risk for injury during a fall. Resident 26 was admitted with vascular dementia, a history of falls, and a leg fracture, and the care plan documented the resident as a fall risk with interventions that included keeping the bed low, anticipating needs, ensuring the call light was within reach, and placing floor mats at the bedside. The facility policy on fall best practices also required action plans, care plan updates, and review of interventions after newly identified fall risks. Incident reports showed multiple falls for Resident 26, and the Kardex repeatedly documented the need for bedside fall mats and education on using the call light for assistance. However, during several observations in January 2026, no floor mats were seen at the bedside and the call light was repeatedly found out of reach, including on the floor behind the bed and draped over a wheelchair several feet away. Staff interviews reflected inconsistent understanding of the resident’s current fall risk status and interventions, with some staff stating the resident was no longer a fall risk while others reported not seeing fall mats at the bedside. The Administrator stated the clinical resource manager had discontinued the fall mat intervention the day before and that the intervention was a year old, but could not explain how or when it was determined to no longer be appropriate.
Unlocked Medication and Treatment Carts
Penalty
Summary
The facility failed to ensure that treatment carts and medication carts were locked when unattended. On 01/05/2026 at 11:55 AM, Medication Cart C was observed unlocked and unattended while a registered nurse entered a resident room, and several facility staff walked by the cart before the nurse returned and locked it at 11:58 AM. The nurse stated they had not realized the cart was left unlocked and that the expectation was to keep the medication cart locked when unattended to prevent anyone from taking medication and misusing it. On 01/09/2026 at 11:17 AM, Treatment Cart 1 was observed unlocked with the top drawer containing antifungal cream tubes, alcohol preparation pads, and prescribed wound gel for a resident; the second drawer contained spray wound cleanser; the third drawer contained tweezers and wound supplies; and the fourth drawer contained bottles of iodine, gloves, and sanitizing wipes. An LPN stated they had not recently used the treatment cart, did not know it was unlocked, and that it should be locked after use.
Incomplete Resident Records for Oncology Appointment and Weekly Labs
Penalty
Summary
The facility failed to maintain complete, accurate, and accessible medical records for Resident 36, who was admitted with diagnoses including malignant extensive stage lung cancer with metastasis to the liver and was documented as cognitively intact on the 11/27/2025 quarterly MDS. For the resident’s oncology appointment, an oncology clinic note dated 10/16/2025 documented a scheduled visit for 10/29/2025 at 2:00 PM, and facility provider notes on 10/21/2025 and 10/24/2025 also documented follow-up with the oncologist on 10/29 at 2:00 PM. The oncology clinic later documented the resident was a no-show and that the clinic was not notified of the reason, while the resident’s EMR contained no documentation showing whether the resident attended or why the appointment was missed. The record also lacked weekly laboratory results required by physician order. Review of the January 2026 MAR documented a physician order for weekly laboratory testing, but review of the EMR found no laboratory results from 10/24/2025 to 11/19/2025 and from 11/21/2025 to 12/18/2025. Staff C stated the resident had gone to the appointment but there was no documentation, while later staff statements said the resident canceled the appointment because they did not feel well; the resident stated they never canceled the appointment and were not aware it had been canceled. Staff G stated all laboratory results were uploaded to the EMR, but no results were found for the identified time periods.
Chemotherapy Appointments Canceled and Delayed Without Resident Notification
Penalty
Summary
The facility failed to honor Resident 36’s rights related to receiving chemotherapy treatment. Resident 36 was admitted and later readmitted with diagnoses including malignant extensive stage lung cancer and metastasis to the liver, and the quarterly MDS identified the resident as cognitively intact. The resident stated they wanted to continue chemotherapy and were not aware that the facility had canceled chemotherapy appointments or told them the facility did not take care of residents receiving chemotherapy. Record review showed the oncology plan called for six cycles of chemotherapy over up to six months, with treatment every 21 days for the initial three days of each cycle, and follow-up for port placement. Facility and oncology notes documented multiple attempts to schedule chemotherapy-related appointments, including labs, infusions, and port placement. However, the oncology clinic documented that the facility called and canceled appointments, requested that chemotherapy be pushed back until after discharge, and later declined available appointments because of transportation availability or because the facility stated it could not accommodate residents receiving chemotherapy. The record also showed no documentation that the resident was notified of the appointment cancellations or changes. Interviews with the resident, family, caregiver, oncology clinic staff, and facility staff consistently reflected that the resident wanted chemotherapy and had not received the planned outpatient treatments while in the facility. Facility staff stated the resident could not have chemotherapy while residing there because of quarantine, private room and bathroom needs, transportation limitations, and the facility’s inability to care for residents after chemotherapy. The administrator also stated the resident did not want full treatment and did not want to go out for appointments prior to discharge, while the resident later stated they had always wanted chemotherapy and had never declined it. The report documents that the resident’s chemotherapy appointments were repeatedly delayed or canceled while the resident remained in the facility.
Failure to Provide Chemotherapy Services Listed in Facility Assessment
Penalty
Summary
The facility failed to identify and provide the resources needed to care for residents competently during day-to-day operations, including chemotherapy services listed in its facility assessment. The facility assessment for the 82-resident facility stated that services and care offered based on residents’ needs included cancer treatments such as chemotherapy and radiation, yet the facility did not provide chemotherapy care and treatment for one resident with extensive stage lung cancer and liver metastasis. The resident was cognitively intact and had a hospital consultation note stating chemotherapy was planned in six cycles over up to six months, with treatment potentially given every 21 days for the initial three days of each cycle. Multiple interviews showed the resident, the caregiver, oncology clinic staff, and family members were told the facility could not take care of the resident during chemotherapy, could not manage a port, could not provide transportation, and could not accommodate the treatment because the resident was in a three-person shared room without a private bathroom. Staff stated chemotherapy could not be provided due to quarantine precautions and the lack of a private bathroom, and one admission coordinator said chemotherapy had been paused with the plan to resume after discharge. The resident stated they were supposed to have chemotherapy, were not told before admission that chemotherapy could not be done, and were not aware the facility canceled the appointments.
Failure to Notify Responsible Party of Antipsychotic Medication Change
Penalty
Summary
The facility failed to notify the responsible party when a resident's antipsychotic medication order was changed. Specifically, a resident with moderately impaired cognitive ability was admitted on risperidone, and the dosage was increased on two separate occasions. There was no documentation in the clinical record that the responsible party had been notified of these medication changes, as required by facility policy, which states that notification must occur within 24 hours of a change in treatment. Interviews with the Resident Care Manager/Registered Nurse and the Director of Nursing Services confirmed that both processed the medication order changes but did not notify the responsible party or document any such notification. The responsible party was known to be particularly concerned about medications that could cause drowsiness, yet was not informed of the changes to the resident's antipsychotic regimen.
Deficiency in Timely and Comprehensive Resident Assessments
Penalty
Summary
The facility failed to complete the Resident Assessment Instrument (RAI) and Care Area Assessments (CAA) within the required timeframes and with comprehensive summaries for several residents. This deficiency was observed in the cases of nine residents, where the assessments lacked thorough analysis of the residents' needs, strengths, goals, and preferences. For instance, Resident 70's admission MDS assessment did not include comprehensive summaries for psychosocial well-being, activities, and return to community CAAs. Similarly, Resident 179's annual MDS assessment lacked comprehensive summaries for psychotropic drug use, cognitive loss, and mood CAAs. Additionally, the facility did not complete Significant Change in Status Assessments (SCSA) within the required 14-day period for residents who elected hospice services. Resident 4 and Resident 62 had their SCSA completed 33 and 31 days after starting hospice services, respectively. Furthermore, Resident 66's admission MDS assessment and Medicare discharge assessment were completed late, as were Resident 61's comprehensive admission assessment and Resident 55's quarterly MDS assessment. Interviews with facility staff revealed a lack of awareness and training regarding the completion of CAAs and MDS assessments. Staff H, an LPN/MDS Coordinator, was unaware of the requirement to fill out CAAs, while Staff G, responsible for cognition, psychotropic meds, and psychosocial well-being CAAs, identified issues with the CAA process and acknowledged incomplete assessments for several residents. The Director of Nursing and Staff H confirmed the late completion of assessments for multiple residents.
PASRR Deficiencies in Resident Evaluations
Penalty
Summary
The facility failed to ensure the Pre-Admission Screening and Resident Review (PASRR) accurately reflected the current status for two residents and failed to refer two residents for level two evaluations. Resident 50 was admitted with diagnoses including depression and a genetic condition, but their PASRR did not initially reflect these conditions. The PASRR was reviewed by the Social Services Supervisor and Administrator, who noted that the diagnosis of depression was added after admission, and a new PASRR was completed to address this. Resident 45's records showed no completed level one PASRR initially, and conflicting information was found regarding their diagnoses and indicators of serious mental illness. The PASRR was eventually uploaded, showing the resident was discharged to a different facility. Resident 56 was admitted with a diagnosis of depression and was taking an antidepressant, but their PASRR indicated a need for a level two evaluation, which was not completed prior to admission. Staff A confirmed that no level two evaluation was done. Resident 5 was referred for a PASRR level two evaluation 19 days after initial admission, and Staff A mentioned an invalidation for the level two PASRR. These failures placed the residents at risk for inappropriate placement and not receiving timely and necessary services to meet their mental health care needs.
Deficiencies in Monitoring and Documentation of Resident Care
Penalty
Summary
The facility failed to ensure proper monitoring and documentation of bowel movements, weights, and blood glucose levels for several residents, leading to potential risks in their medical status and quality of life. Resident 20, who was admitted to the facility, had physician orders for laxatives and stool softeners due to constipation. However, there was no documentation of bowel movements for several days, and no abdominal assessments or new orders were documented until a week later. Staff interviews revealed that the electronic health record system was supposed to alert nurses when a resident had not had a bowel movement for three days, but this was not effectively followed. Additionally, Resident 20 had orders for weekly weight monitoring, but there were multiple instances where weights were not documented as required. Staff interviews indicated a lack of consistent communication and adherence to weight monitoring protocols. Similarly, Resident 5's weight monitoring was not conducted according to the physician's orders, with weights not being taken on consecutive days as required upon admission. Resident 50, diagnosed with Type II Diabetes Mellitus, had issues with blood glucose monitoring and insulin administration. There were numerous days without documented blood glucose levels, and insulin was not administered as ordered. The care plan for Resident 50 did not address their diabetes management, and staff interviews highlighted a lack of clarity and adherence to protocols for insulin management and blood glucose checks. The facility's failure to follow these protocols and document necessary information placed residents at risk of unmanaged medical conditions.
Inadequate Monitoring and Indications for Antipsychotic Use
Penalty
Summary
The facility failed to ensure adequate indications for the use of antipsychotic medications for several residents, leading to potential adverse side effects. Resident 179 was administered Seroquel for agitation without appropriate indications, as the consent form listed confusion, anxiety, and depression, which are not suitable reasons for antipsychotic use. Additionally, the consent for Seroquel was obtained 23 days after administration, and the consent for Hydroxyzine lacked a diagnosis or indication for use. Observations showed Resident 179 frequently asleep or restless in their wheelchair, indicating possible adverse effects from the medication. Resident 380, diagnosed with paranoid schizophrenia and anxiety, was prescribed Seroquel without individualized monitoring for target behaviors. The care plan did not direct staff to monitor the efficacy of the antipsychotic medication, and behaviors such as crying and paranoia were not documented for monitoring purposes. A fall incident occurred when the resident became agitated and was not effectively de-escalated, highlighting the lack of proper behavior monitoring and documentation. Resident 45, with diagnoses including PTSD and major depressive disorder, was prescribed duloxetine and hydroxyzine without monitoring for adverse consequences or behaviors. The care plan indicated a risk for depression and mood problems, but there was no documentation of monitoring for side effects or effectiveness of the medications. The facility's failure to implement proper monitoring and documentation for these residents' psychotropic medication use put them at risk for adverse side effects and ineffective treatment.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by multiple observations and interviews. Residents were subjected to uncomfortable sound levels, particularly in a three-bed room where one resident, who was cognitively impaired, frequently yelled and disrupted the other two residents. Despite the distress caused, there was no documentation of resident preferences related to personal space or privacy curtains, and no grievances were logged regarding these issues. The facility also failed to provide adequate housekeeping and maintenance. Observations revealed sticky floors, dusty light fixtures, and walls with exposed drywall and nail holes. The hallways and utility room doors were dusty and discolored, and there were reports of gnats in the nurse's station and resident rooms. Bathrooms were found to be unclean, with rust stains, clogged drains, and unlabeled personal items scattered around. Privacy curtains were visibly soiled with brown stains and particulate matter, and there was no clear protocol for their regular cleaning or replacement. Additionally, the facility did not ensure residents had adequate living space, as some rooms did not meet the required square footage for a homelike environment. Residents in three-person rooms were cramped, with privacy curtains reducing their personal space. Interviews with staff and residents highlighted a lack of intervention from the facility to address these issues, leading to a diminished quality of life for the residents.
Failure to Complete Significant Change in Status Assessment for Hospice Resident
Penalty
Summary
The facility failed to identify a Significant Change in Status Assessment (SCSA) for Resident 229, who was reviewed for hospice services. According to the Long-Term Care Facility Resident Assessment Instrument, a SCSA is required within 14 days when a resident enrolls in a hospice program. The facility's policy also mandates that significant change in status assessments be completed within 14 days of identification. Resident 229 elected their hospice benefit on December 20, 2024, but a review of their Minimum Data Set (MDS) assessments since admission showed no SCSA had been completed. During interviews, both the Licensed Practical Nurse/MDS Coordinator and the Director of Nursing confirmed that Resident 229 was on hospice and acknowledged that a SCSA had not been performed, with no explanation provided for the oversight.
Failure to Address Hearing Impairment in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident with a hearing impairment, which is necessary to provide effective and person-centered care. Resident 380, who was admitted with diagnoses including paranoid schizophrenia and anxiety, was documented to have mild cognitive impairment and moderate difficulty hearing without any assistive devices. Despite this, the resident's care plan did not address their hearing impairment, as confirmed by the nursing staff and the Resident Care Manager. The lack of a focus area for the resident's hearing impairment in the care plan was evident from the nursing admission assessment and progress notes, which consistently noted the resident's difficulty hearing. Interviews with staff revealed that the baseline care plan was supposed to be individualized based on the nursing admission assessment and other relevant information. However, the nursing manager responsible for starting the baseline care plan did not include the resident's hearing impairment. Staff members, including Nursing Assistants and the Resident Care Manager, indicated that they rely on the care plan to determine the level of care needed for each resident. The failure to include the hearing impairment in the care plan placed the resident at risk of not being informed of their initial plan for care and services, leading to potential unmet needs and complications.
Failure to Revise Care Plans for Falls and Nutrition
Penalty
Summary
The facility failed to review and revise care plans for two residents, leading to potential risks for unmet care needs. Resident 179, who was admitted with conditions including stroke with hemiparesis and neurocognitive disorder, experienced 15 falls since admission. Despite fall investigations recommending additional interventions such as checking the resident's position and incontinence status at specified intervals, these interventions were not incorporated into the resident's care plan. This oversight occurred on multiple occasions, including after falls on 07/01/2024, 08/31/2024, and 10/12/2024. Resident 20, admitted with a diagnosis of diabetes, was receiving Ozempic for weight loss from 10/24/2024 until it was discontinued on 12/12/2024. However, the care plan for expected weight loss was not updated to reflect the discontinuation of the medication. Interviews with staff revealed that care plans were supposed to be revised by resident care managers and reviewed as needed and quarterly, but this process was not adequately followed, resulting in deficiencies in care plan management.
Deficiencies in ADL Assistance and Call Light Accessibility
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for two residents, leading to deficiencies in care. Resident 179, who was admitted with conditions including stroke with hemiparesis and neurocognitive disorder, required maximum assistance for bathing twice a week. However, records showed that Resident 179 did not receive showers as scheduled between 12/30/2024 and 01/07/2025, receiving only one shower during this period. The facility's administrator stated that showers should be provided at least once a week, indicating a discrepancy between the care plan and actual care provided. Resident 4, diagnosed with Alzheimer's Disease and dysphagia, required assistance with eating. Observations revealed that Resident 4 was left without assistance for extended periods during meals, with their breakfast tray left unattended from approximately 7:30 AM until 8:55 AM on one occasion. Staff interviews confirmed that Resident 4 needed one-on-one feeding assistance due to shaky hands, yet the care plan only indicated set-up assistance. Documentation showed that Resident 4 was dependent on staff for eating in 14 out of 24 opportunities, highlighting inconsistencies in the care plan and actual needs. Additionally, Resident 4's call light was repeatedly found out of reach, clipped to the pillowcase or on the floor, contrary to the care plan directive that it should always be within reach. This oversight was observed on multiple occasions, indicating a failure to ensure the resident's ability to call for assistance. Staff interviews confirmed that the call light should be accessible, yet it was not consistently positioned as required, further contributing to the deficiency in care provided to Resident 4.
Failure to Adhere to Prescribed Oxygen Therapy
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for a resident with pulmonary fibrosis and congestive heart failure. The resident was admitted with a physician's order for oxygen therapy at 3 liters per minute (lpm) via nasal cannula. However, observations revealed that the oxygen concentrator settings were consistently set higher than the prescribed 3 lpm, with settings observed at 3.5 lpm and 3.25 lpm during different checks. The resident reported not adjusting the settings themselves, and the concentrator was placed in the bathroom to reduce noise. Staff interviews indicated that the oxygen settings should be checked every shift to ensure compliance with the physician's order. Despite this protocol, the settings were not maintained as ordered, and the resident's oxygen saturation levels were recorded below the target, at 85%, necessitating an increase to 4 lpm temporarily. The facility's failure to adhere to the prescribed oxygen therapy placed the resident at risk for unmet needs and potential negative outcomes.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure the daily nurse staffing form was accurately completed with actual hours worked for each shift on five out of six days reviewed. Observations on multiple days revealed that the posted daily nursing staffing forms did not reflect the actual hours worked by the nursing staff. Interviews with Staff C, the Staffing Coordinator, indicated that the actual hours worked were updated the following day based on time punches, rather than at the beginning of each shift as required. Staff C was unaware of the requirement to update the actual hours worked section in real-time after each shift. Further interviews with Staff A revealed a misunderstanding of the requirement, as they believed the staffing posting was updated every 12 hours due to some staff working 12-hour shifts. However, during the survey period, no updates to the daily staffing sheet were observed, and the staffing coordinator did not understand the requirement to update in real-time after each shift. This failure placed residents and their representatives at risk of not being fully informed of the current staffing levels.
Failure to Address Behavioral Health Needs
Penalty
Summary
The facility failed to adequately address the emotional and psychosocial well-being of a resident, identified as Resident 53, who was admitted with diagnoses including stroke, aphasia, and dementia without behavioral disturbance. The resident exhibited repetitive yelling and distress, which was not consistently assessed, monitored, or documented by the facility staff. Despite having a care plan that included monitoring for signs of depression and obtaining mental health consultations as needed, there was no evidence of consistent implementation of these interventions. Observations and interviews revealed that Resident 53 frequently yelled out in a distressed manner, causing disruption to themselves and their roommate. Staff responses were inconsistent, and there was no documentation of specific interventions attempted to address the resident's behaviors. The facility's records showed instances of target behaviors related to the resident's antidepressant medication, but these were not specified or accompanied by corresponding progress notes detailing the behaviors or interventions. The lack of a structured system for nursing assistants to document behavioral symptoms further contributed to the deficiency. Interviews with staff indicated that while they were aware of the resident's behaviors, there was no clear protocol for documenting or addressing these issues. The facility's failure to implement a consistent approach to managing Resident 53's behavioral health needs placed the resident at risk of unmet emotional and psychosocial health needs, as well as a decreased quality of life.
Medication Security and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure the security and proper labeling of medications, as observed with one of four medication carts. During an observation, an LPN left an insulin pen unattended on the cart under the computer screen. The pen contained medication but was not labeled with a resident's name. Upon returning, the LPN attempted to identify the pen by checking the insulin lids in the drawer to find the missing lid and subsequently placed the pen in the drawer with a resident label. Additionally, the facility did not secure medications for two residents, which were accessible at their bedsides without proper authorization or assessment for self-administration. One resident had multiple medications, including artificial eye drops, nasal spray, oral throat spray, antifungal powder, and Diclofenac Sodium External Gel, on their nightstand. These medications were not prescribed or assessed for self-administration, and there was no care plan in place. The resident stated that they used the Diclofenac gel for knee pain relief. Another resident kept an Albuterol inhaler on their overbed table, stating they needed it frequently and did not want to wait for staff assistance. Despite staff advising the resident to store the inhaler away, the resident insisted on keeping it nearby. There was no self-medication program assessment, physician order, or care plan for this resident either. Interviews with staff confirmed that no residents were on a self-medication program, and the expectation was for medications to be safely stored and residents assessed for self-administration programs.
Failure to Provide Prompt Dental Services
Penalty
Summary
The facility failed to ensure prompt dental services for two residents, leading to a deficiency in care. Resident 33, who was admitted with obvious dental issues, expressed pain and the need for dental care. Despite a care plan indicating the need for dental coordination, there was no documentation of a referral for teeth extractions or dentures, as recommended by a consulting dentist. Interviews with staff revealed a lack of documentation and follow-up on the resident's dental needs. Similarly, Resident 56, admitted with broken teeth, had not seen a dentist since admission. The resident reported dental issues to several staff members, yet there was no documentation of a dental evaluation or appointment. The care plan for Resident 56 also included coordination for dental care, but staff interviews confirmed the absence of any documented assistance or follow-up regarding the resident's dental condition.
Infection Control Deficiencies in Resident Care and Equipment Sanitation
Penalty
Summary
The facility failed to ensure staff adhered to infection control procedures for a resident on enhanced barrier precautions (EBP). During an observation, staff members providing incontinent care to a resident in a shared room did not wear gowns as required by the EBP sign posted outside the room. The sign indicated that gloves and gowns were necessary for high-contact activities, but staff only wore gloves. Interviews with the staff confirmed their awareness of the requirement, yet they did not comply during the care of the resident. Additionally, the facility did not properly disinfect resident care equipment between uses. Observations revealed that mechanical lifts used for resident care were not sanitized after use, as required. Staff members were observed moving the lifts from one room to another without cleaning them, and some staff were unsure of the proper sanitation procedures. Interviews with various staff members, including nursing assistants and licensed practical nurses, highlighted inconsistencies in understanding and implementing the required disinfection protocols for equipment.
Inadequate Infection Control During Wound Care
Penalty
Summary
The facility failed to implement proper infection prevention and control measures during wound care for three residents. Observations revealed that a Licensed Practical Nurse (LPN) and a provider from a consulting wound clinic did not adhere to hand hygiene protocols. For Resident 1, the LPN and the provider did not change gloves or perform hand hygiene after removing a soiled dressing and before applying a new one. The LPN also used the same contaminated gloves to handle various items and perform incontinent care, further risking contamination. For Resident 2, the LPN did not change gloves or perform hand hygiene after cleansing a wound and before applying a clean dressing. Additionally, the LPN contaminated a box of gloves by handling it with unwashed hands. In the case of Resident 3, the provider and the LPN failed to perform hand hygiene after removing gloves and before applying new ones during wound care. These actions were contrary to the facility's infection control procedures and the CDC's hand hygiene guidelines, placing residents at risk for germ transmission and potential wound infections.
Failure to Implement Wound Care Recommendations
Penalty
Summary
The facility failed to follow consultant recommendations for a resident reviewed for wound clinic visits, which placed the resident at risk of complications. The resident, who was admitted to the facility on 05/30/2024, had wounds on the anterior abdomen, right abdominal pannus, left buttock, and right buttock. A wound clinic consult note dated 10/09/2024 recommended specific treatment changes for these wounds. However, the Treatment Administration Record (TAR) for October 2024 showed that the treatment changes for the anterior abdomen and right abdominal pannus wounds were not implemented until 10/12/2024 and were ordered three times a week instead of every other day. Additionally, there were no treatment order changes for the right and left buttock wounds. Further review revealed that a subsequent wound clinic note dated 10/16/2024 indicated an infection in the buttock wounds and recommended a change in treatment. Despite this, the TAR showed that the treatments for the buttock wounds were not initiated until 10/21/2024. Interviews with the Director of Nursing confirmed that consultant notes should be followed up within 24-48 hours, and there was no documentation explaining the delays or lack of implementation of the recommended treatments.
Significant Medication Errors in Insulin Administration
Penalty
Summary
The facility failed to ensure that three residents with diabetes (Residents 4, 2, and 5) were free from significant medication errors related to the administration of insulin. The facility's policy required insulin to be administered within one hour before or after the scheduled time. However, multiple doses of insulin were administered outside this time frame, placing the residents at risk of abnormal blood sugar levels. For instance, Resident 4 received several doses of lispro, glargine, and detemir insulin more than one hour late, with some doses being administered up to four hours late. Similarly, Resident 2 had instances where insulin was either not given or administered significantly earlier or later than scheduled. Resident 5 also experienced delays in receiving both aspart and NPH insulin doses. During interviews, it was revealed that the facility staff, including the Director of Nursing Services and the Administrator, were aware of the policy but failed to adhere to it. Staff B, the Director of Nursing Services, acknowledged the multiple instances of non-compliance but could not provide further information on why the insulin was administered late. Staff A, the Administrator, admitted to not having reviewed the administration times of insulin before. This lack of oversight and adherence to the facility's medication administration policy contributed to the significant medication errors observed. The report highlights that the facility's failure to administer insulin within the required time frame compromised the residents' diabetes management. The documented instances of late insulin administration for Residents 4, 2, and 5 indicate a systemic issue in the facility's medication administration process. The facility's inability to ensure timely insulin administration as per their policy resulted in significant medication errors, as confirmed by the surveyors' findings.
Failure to Follow Physician Orders on Admission
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for three residents upon their admission. Resident 1, who was admitted with acute and chronic respiratory failure, sleep apnea, and lung disease, did not have an order for a bipap machine in their admission orders despite it being prescribed in the SNF transfer orders. The resident reported that the bipap mask was missing and that staff did not obtain a replacement for the first 10 days of their stay. Staff interviews confirmed that the bipap orders were missed during the admission process, and the second nurse reviewing the orders only checked medications, not treatment orders. Resident 2, admitted with orthostatic hypotension, had physician orders for compression stockings and an abdominal binder to be worn when out of bed or during therapy sessions. These orders were not included in the resident's admission orders, care plan, or Kardex. The resident's family member reported that the resident was not wearing the prescribed items, and therapy notes showed no documentation of their use. Staff interviews revealed that the orders were not entered correctly, and there was no documentation to confirm the application of the compression stockings or abdominal binder. Resident 3, also admitted with orthostatic hypotension, had similar physician orders for compression stockings and an abdominal binder. These orders were also missing from the resident's current physician orders and Kardex. Staff were unable to provide documentation that the prescribed items were being used. The deficiency in following physician orders for these residents placed them at risk of medical complications and a decline in health status.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 510 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Marysville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Marysville Care Center | 0.8 mi | ★★★★★ | 23 | 0 |
| Bethany At Pacific | 4.5 mi | ★★★★★ | 0 | 0 |
| Everett Transitional Care Services | 5.6 mi | ★★★★★ | 8 | 0 |
| View Ridge Care Center | 7.4 mi | ★★★★★ | 16 | 0 |
| Madison Post Acute | 8 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.