Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at North Bend Post Acute during CMS and state inspections, most recent first.
The facility failed to submit complete and accurate PBJ staffing data to CMS for Q4. The reported census was short by two days compared with the facility’s census records, and multiple days showed inaccurate census reporting. The Administrator stated payroll software did not correctly carry over certain job codes, affecting LPN and CNA hours and the reported HPRD.
Incomplete and non-resident-specific care plans were identified for several residents. A cognitively intact resident with an ileostomy had care plan entries that were incomplete and did not accurately reflect current ostomy care needs or discharge potential, while other residents with pressure injury risk or active wounds had care plans that failed to include ordered mattress settings or were not followed as written. Another resident’s discharge potential entry was also left incomplete.
Failure to provide transfer notifications and hospital reports for two residents. The DON confirmed the facility did not give written notices for hospitalizations, and one resident with respiratory disease and anxiety had multiple hospital transfers with no written transfer notice or report sent to the receiving hospital. Another resident with failure to thrive and spinal narrowing also had a hospital transfer without documentation that the resident or representative received the required written notice.
Inaccurate PASRR screenings were found for three residents. One resident admitted with anxiety had a Level I PASRR that did not identify the anxiety diagnosis or refer for a Level II eval, another resident with anxiety, depression, and PTSD had no Level I screening in the chart and an available PASRR did not capture depression, and a third resident with anxiety, depression, and an intellectual disability had a Level I screening that identified depression but missed anxiety.
Failure to Conduct Required Care Conferences: The facility did not conduct or offer care conferences for multiple residents despite policy requiring resident participation in care planning upon admission, at routine intervals, after significant change, and when requested. Several residents had intact cognition or were able to participate, while one resident had severe memory impairment and a POA involved in prior conferences. Records showed long gaps since the last documented care conference, and residents reported they had not been offered a conference or had not participated for months.
Smoking policy compliance, unsafe water temps, blocked exit, and unsecured shower room hazards. Three residents who smoked were not managed consistently with facility smoking expectations: one kept cigarettes on hand, one was still smoking despite not being listed as an active smoker, and one had no documented smoking assessment or related orders/interventions despite ongoing smoking and COPD/respiratory failure. The facility also had hot water above the safe range in multiple rooms, a fire exit corridor blocked by equipment, and an unlocked shower room with accessible razors and cleaning products.
Controlled medication counts were not accurately reconciled on the Central and South med carts. An LPN stated controlled meds had been administered earlier in the morning but were not signed out until later, and the narcotic ledgers did not match the actual counts for several residents’ antiseizure, narcotic pain, and liquid narcotic medications. The DON stated staff were expected to sign out narcotics at the time they were given.
The facility failed to follow professional nursing standards when it did not clarify unclear PRN pain orders for two residents, did not follow ordered air mattress settings for two residents, did not obtain weekly weights as ordered for a resident with nutritional risk, and left an obsolete anticoagulant monitoring order active after the medication had been stopped. The DON confirmed the unclear orders and missed care, and observations showed the mattresses were not kept at the prescribed settings.
A resident who was dependent for bathing and personal hygiene was observed multiple times with overgrown, jagged fingernails and visible soiling under the nails. Records did not show the resident received bathing as scheduled in the care plan, and the DON could not provide documentation that the resident was offered showers twice weekly or received at least one shower per week as required. Nail care was also not documented as provided during showers.
Missing orders for ileostomy care. A cognitively intact resident with an ileostomy was observed with an ostomy pouch in place, and the record showed a care plan stating nursing would complete ostomy care as ordered. The chart included an order for EBP related to the ileostomy, but there were no orders describing how to care for or monitor the ileostomy. The DON confirmed the absence of ileostomy care orders and stated the site should be checked and the wafer changed as needed.
Missing oxygen order, assessment, and care plan for a resident using portable oxygen. A resident with COPD and respiratory failure had a portable O2 tank in the room and independently used it, but the chart had no physician order for supplemental oxygen use, no respiratory assessment, and no care plan for oxygen therapy. Progress notes instructed staff to use supplemental O2 as needed to keep O2 saturation above 90%, while the DON confirmed the record lacked the required documentation.
Incomplete resident records and missing documentation for device use and PASRR records. The facility failed to keep charts complete for three residents by not documenting a lap belt assessment for a resident with stroke, dementia, paralysis, and falls, not uploading a Level I PASRR screening for a resident with anxiety and depression, and not having informed consent, a physician order, or an assessment for a scoop mattress used for a resident with severe cognitive and functional impairment.
The facility failed to ensure RN coverage for at least eight hours a day on five occasions, primarily on weekends, due to staffing challenges. This deficiency was acknowledged by the Director of Nursing and was attributed to common staff call-outs and reliance on on-call nurses who may not be RNs.
The facility failed to designate a qualified Infection Preventionist (IP) to work onsite at least part-time, as required. Staff D, a Registered Nurse, was designated as the IP but worked offsite and only visited the facility occasionally. The facility's assessment did not determine the necessary onsite hours for the IP, leading to inadequate infection control oversight.
The facility failed to investigate and resolve grievances from residents, including requests for an air mattress and missing personal items. Incomplete grievance logs and forms, along with a breakdown in the grievance process, left residents without resolutions or explanations, risking frustration and diminished quality of life.
The facility failed to provide baseline Care Plans (CP) to six residents within 48 hours of admission, as required by policy. This deficiency was identified through interviews and record reviews, revealing that residents with complex medical conditions did not receive a CP or a summary, placing them at risk for unmet care needs. Staff confirmed that it was not the facility's practice to complete or provide baseline CPs.
The facility failed to ensure residents participated in care conferences and that care plans were updated to reflect person-centered care. Three residents did not receive required care conferences, and five residents had care plans that were not updated to reflect their current needs. Staff interviews confirmed the deficiencies in documentation and the need for accurate care plans.
The facility failed to provide adequate ADL assistance for six residents, leading to poor hygiene and grooming. Observations showed residents with long fingernails, unshaven facial hair, and inconsistent shower documentation. Despite care plans indicating the need for assistance, staff did not follow through, and documentation was lacking.
The facility failed to provide adequate care for residents with or at risk for pressure ulcers, as evidenced by improper documentation, lack of physician orders, and failure to implement specialist recommendations. A resident did not have a care plan for their high risk of PU development, another resident's wounds were not consistently measured or treated as recommended, and a wound VAC was used without proper orders. These deficiencies indicate a systemic issue in wound care management.
The facility failed to follow dietary orders and menu plans, resulting in residents receiving incorrect meal portions and components. A resident on a therapeutic diet did not receive large protein portions as prescribed, while another received meals with items they disliked and salt packets against their dietary restrictions. Staff interviews revealed a lack of awareness about correct portion sizes, impacting residents' nutritional intake.
The facility failed to serve food that was appetizing and at the proper temperature, as observed during meal services and a test tray. Residents reported the food was often cold, not well-cooked, and unappetizing. A test tray showed meatloaf at 117°F and hard, undercooked carrots at 99°F. The facility's dietician acknowledged the issue.
The facility failed to implement an effective Antibiotic Stewardship Program, leading to inappropriate antibiotic use for two residents. One resident received overlapping antibiotic courses for a suspected UTI without proper documentation, while another was treated for dysuria despite not meeting criteria for antibiotic use. The facility lacked a full-time Infection Preventionist, resulting in inadequate oversight and guidance.
The facility failed to maintain dignity during meal assistance for three residents. A staff member referred to a clothing protector as a 'bib' for one resident. Another resident experienced a delay in meal assistance, leading to frustration. A third resident was moved from their usual dining spot, disrupting their meal and social interaction.
The facility failed to provide required written transfer notices to residents and their representatives when residents were transferred to hospitals. This deficiency was identified for four residents, with staff confirming the absence of documentation and acknowledging the importance of such notifications for residents' rights.
The facility failed to provide written notification of its bed-hold policy to residents or their representatives during hospital transfers. Three residents were transferred without receiving the required information, as confirmed by the DON. This oversight occurred on multiple occasions, with no documentation of the bed-hold policy being offered.
The facility failed to ensure accurate MDS assessments for four residents, leading to potential risks for unmet care needs. A resident's MDS inaccurately reported no broken teeth and no need for oxygen therapy, despite evidence to the contrary. Another resident's MDS incorrectly coded aspirin as an anticoagulant. A third resident's significant weight loss was not reflected in the MDS, and a fourth resident's MDS failed to report functional limitations due to a stroke. These inaccuracies were confirmed by staff and observed during the survey.
The facility failed to ensure accurate PASRR assessments for residents with mental health conditions, affecting four residents. One resident with schizophrenia required a Level II evaluation, which was not found in their records. Another resident's PASRR inaccurately showed no SMI indicators despite having anxiety and depression. Two other residents had incomplete or inaccurate PASRRs, missing essential information and failing to reflect their mental health diagnoses.
The facility failed to develop comprehensive care plans for three residents, leading to inadequate care. A resident with dietary needs and skin issues lacked measurable goals and care plan details. Another resident with complex medical conditions had a care plan without measurable nutritional goals. A third resident with respiratory failure did not have their oxygen use addressed in their care plan. Staff acknowledged the need for improvements.
The facility failed to monitor behaviors of residents on antipsychotic medications, as seen with a resident who received such medication daily without documented behavior monitoring. Additionally, a nurse did not follow physician orders for wound care on another resident, and there was a lack of documentation for the release of a deceased resident's body to a mortuary.
The facility failed to implement an effective discharge planning process for two residents, risking unsafe discharge and diminished quality of life. One resident was not discharged home despite healed wounds and no updated discharge planning, while another was discharged without a physician's order or communication with the receiving facility.
A resident at risk for pressure ulcers reported a rash that was not regularly monitored by nursing staff. Despite orders for weekly skin evaluations, the last documented assessment was nearly two weeks prior, and daily evaluations did not report any skin conditions. The DON expected weekly assessments and documentation, but these were not consistently performed.
The facility failed to implement restorative programs for two residents, leading to deficiencies in maintaining their range of motion and mobility. One resident, post-stroke, was not provided with the prescribed splinting, while another resident with complex medical conditions did not receive the agreed-upon restorative therapy. Staff interviews and record reviews confirmed the lack of program implementation.
A facility failed to provide necessary social services interventions for a resident with depression who showed signs of self-harm. Despite receiving antidepressant and antianxiety medications, the resident's PHQ-9 assessment indicated thoughts of self-harm, but no further assessments or interventions were documented. The Social Services Director was unaware of the assessment, and the Director of Nursing expected further interviews and interventions, which were not conducted.
The facility failed to submit accurate direct care staffing information to CMS for Q1 2024, as required by PBJ reporting. A discrepancy of 170 census days was found between the facility's reported census and the MDS census summary. The administrator acknowledged inaccuracies and suspected a clerical error in the MDS submission.
Incomplete and Inaccurate PBJ Staffing Submission
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to CMS for Q4 PBJ reporting. Review of the facility’s PBJ submission for October 1, 2025 through December 31, 2025 showed a reported census total of 5,133, which was two days less than the correct census of 5,135. Review of the monthly census records for the same period identified multiple days with inaccurate reported census, including 11/04/2025, 11/16/2025, 11/17/2025, 11/25/2025, 11/26/2025, and 12/12/2025. During interview, Staff A, the Administrator, stated the facility had an issue with its payroll software that did not correctly carry over certain job codes, affecting the licensed nurse and CNA total hours. Staff A stated that if the codes had carried over correctly, the facility would have met the 3.4 HPRD and that correct and accurate census and staffing hours would have been reported.
Incomplete and Non-Resident-Specific Care Plans
Penalty
Summary
The facility failed to ensure care plans were comprehensive, resident-specific, and implemented for 4 of 17 residents reviewed. For Resident 3, who was cognitively intact and independent with mobility and personal care, the record showed diagnoses including a viral blood borne disease, an ileostomy, and puncture wounds on the lower back and pelvis. Resident 3 stated they performed much of their own ileostomy care and hoped to discharge from the facility after surgery in August 2026. The comprehensive care plan included an altered bowel elimination care plan related to the ileostomy, but the revised goal stated ostomy care would be done by nursing, and the discharge potential intervention was left incomplete. The PASRR recommendations care plan also contained an incomplete intervention that did not indicate whether PASRR identified serious mental illness. For Resident 54, the quarterly MDS showed partial/moderate assistance was needed for bed mobility and that the resident had diagnoses including a progressive blood circulation disorder, malnutrition, and a condition affecting blood sugar control, with risk for pressure injuries. Although there was an order for an air mattress on the soft setting, the care plan did not reflect that instruction. For Resident 6, the quarterly MDS showed lower body paralysis and two pressure wounds with full thickness skin and tissue loss and exposure of bone or tendon. The care plan stated the mattress setting should be checked each shift, but the mattress was observed repeatedly set three quarters of the way toward firm rather than on the soft setting. For Resident 58, the admission MDS showed intact cognition and no active discharge planning, yet the discharge potential care plan contained an incomplete intervention that did not identify the resident’s discharge potential.
Failure to Provide Transfer Notifications and Hospital Reports
Penalty
Summary
The facility failed to complete the appropriate transfer notifications for 1 of 4 residents reviewed for hospitalization, as well as for 1 supplemental resident. For Resident 48, the record showed hospital transfers on 01/16/2026, 02/21/2026, and 02/27/2026 related to a change in condition. The resident’s MDS assessments identified respiratory disease and anxiety. Review of the health record showed no report was communicated to the receiving hospital and no written transfer notifications were provided to the resident for any of these transfers. For Resident 61, the 05/05/2026 Discharge Return Anticipated MDS showed a hospital transfer related to a change in condition, with diagnoses including failure to thrive and narrowing of the spine. Record review showed no documentation that facility staff provided the resident or the resident’s representative with a written notification of the reason for transfer to the hospital. Staff B, the DON, stated the facility did not provide written notices for hospitalizations and believed the requirement applied only to planned discharges.
Inaccurate PASRR Screenings for Multiple Residents
Penalty
Summary
The facility failed to ensure Level I PASRR screenings were accurate for three residents reviewed for PASRR. For one resident admitted with a diagnosis of anxiety disorder and taking antidepressant medications, the Level I screening completed before admission did not identify the anxiety diagnosis and did not refer the resident for a Level II evaluation. During observation and interview, the resident stated they were constantly worried about not being stable enough to return home and said they could not get it off their mind. Staff stated the screening should have included the anxiety diagnosis and should have been corrected and resubmitted before admission, but it was not. For another resident with diagnoses including anxiety, depression, and PTSD, the chart did not contain a Level I screening, and the available Level II PASRR invalidation did not capture the depression diagnosis. Staff reviewed the PASRR and confirmed the depression diagnosis should have been included. For a third resident with diagnoses including anxiety, depression, and an intellectual disability, the Level I PASRR screening identified depression but did not identify anxiety. Staff stated the screening should have been accurate but was not.
Failure to Conduct Required Care Conferences
Penalty
Summary
The facility failed to conduct care conferences to ensure person-centered care for 8 of 18 sampled residents: Residents 7, 10, 41, 43, 48, 54, 32, and 29. The facility’s 2025 Care Planning-Resident Participation policy stated residents would be informed of and participate in care planning and treatment, with care plan meetings honored upon request and held at regular scheduled conferences, upon admission, at routine intervals, and after significant changes. Survey findings showed the required care conferences were not conducted or offered for these residents as documented in their records. Resident 7’s 04/07/2026 annual MDS showed severely impaired memory, inability to make own decisions, and dependence on staff for mobility, hygiene, and transfers; the resident had a medical POA who had participated in prior care conferences. Resident 10’s 04/03/2026 quarterly MDS showed no memory impairment, but the last documented care conference was 09/24/2025, and the resident stated on 05/31/2026 that they could not remember having a care conference or being offered one for a long time, though they would like to participate. Resident 41’s 05/04/2026 quarterly MDS showed clear speech and ability to understand others, yet there was no documentation of a care conference since admission, and the resident stated on 06/01/2026 that the facility had not conducted or offered one. Resident 43’s 05/01/2026 quarterly MDS showed no memory impairment, but the last documented care conference was 10/23/2025; the resident stated on 06/01/2026 that they had not participated in a care conference for almost a year and wanted the opportunity to discuss concerns with the IDT. Resident 48’s admission MDS showed clear speech and understanding of others, but no care conferences were documented since admission, and the resident expressed concern about not knowing future care plans. Resident 54, Resident 32, and Resident 29 each had intact cognition on quarterly MDS assessments, no refusal of care during the lookback period, and their most recent documented care conferences were 08/22/2025, 08/29/2025, and 07/15/2025, respectively, with no progress notes showing refusal to participate. Staff N and Staff B confirmed care conferences should occur upon admission, quarterly, with significant change, and as needed/requested, and that the records reviewed did not show the conferences were completed or offered for these residents.
Smoking policy, hot water, blocked exit, and shower room hazards
Penalty
Summary
The facility failed to ensure residents who smoked complied with the smoking policy for three residents reviewed. Resident 6 had a nicotine dependence diagnosis, was cognitively intact, and used a wheelchair independently, but stated they smoked outside the facility and kept cigarettes on their person during the day. Their smoking care plan required smoking paraphernalia to be kept in the nurse’s cart or med room and for the resident to sign out and return supplies to staff, while the smoking assessment noted decreased sensation and a medication that could affect cognition or judgment. Staff stated Resident 6 was expected to keep cigarettes locked with the nurse when not smoking. Resident 58’s record identified tobacco use, but the admission MDS stated the resident was not currently smoking. The resident stated they still smoked and kept their own cigarettes, while the facility’s smoker list did not identify them as an active smoker. No smoking assessment was found in the chart, and staff stated the resident should have been assessed on admission and monitored for smoking compliance. Resident 41 had COPD, respiratory failure, and nicotine dependence, and their care plan addressed risk for smoking relapse and smoking cessation. The resident stated they smoked and hid cigarettes from staff, and staff confirmed the resident smoked outside the facility, but the chart did not contain a smoking assessment, physician’s order, or smoking-related care plan interventions related to the ongoing smoking. The facility also failed to maintain safe environmental conditions in other areas. Hot water temperatures exceeded the policy range of 100 F to 120 F in multiple resident rooms, including readings of 124.2 F, 127.4 F, 126.5 F, and 126.4 F, and the administrator stated the temperatures were not within the acceptable range. A fire exit corridor was blocked by a mechanical lift and a large wheelchair despite a sign stating the corridor was to be kept clear at all times. In the South Unit shower room, the door was unlocked with no staff present, and hair and body cleaning products and disposable razors were stored in unlocked cabinets; staff stated the room should always be locked and noted the accessible items and safety hazard.
Controlled Medication Counts Were Not Reconciled
Penalty
Summary
The facility failed to ensure controlled medications were accurately reconciled for the South Medication Cart and Central Medication Cart. During observation and interview, the narcotic ledger on the Central Medication Cart did not match the actual medication packs for Resident 6, who had prescriptions for two controlled substances, Resident 34, and Resident 2. The ledger showed different counts than what was physically available in the packs for an antiseizure capsule and narcotic pain medications. On the South Medication Cart, the narcotic ledger also did not match the actual supply for Resident 51 and Resident 52, both of whom had liquid narcotic medications. Staff G and Staff E stated they had administered the controlled medications earlier in the morning and confirmed they should sign the narcotics out at the time of administration, but they had not done so. The DON later stated that not signing out narcotics at the time of administration was a safety concern and that staff were expected to sign them out when given.
Unclear pain orders, missed ordered care, and obsolete medication monitoring orders
Penalty
Summary
The facility failed to ensure nursing services were provided within professional standards of nursing by not clarifying physician orders when required for pain management. Resident 32 had diagnoses including a chronic autoimmune disease of the central nervous system, disc degeneration, and migraines, and the MDS noted mild pain that occasionally affected sleep and daily activities. The resident had two as-needed pain medication orders, including an over-the-counter medication and an opioid medication, but the opioid order did not show how long to wait between doses and neither order included parameters to guide nurses on which medication to give for what level of pain. The DON stated the orders needed clarification because they were unclear. The facility also did not follow physician orders for two residents’ air mattresses and one resident’s weekly weights. Resident 6 had traumatic spinal cord dysfunction, frequent severe pain, and two pressure wounds with full thickness skin and tissue loss and exposure of bone or tendon. An order directed that the resident’s air mattress be kept on the soft setting, but observations on multiple occasions showed the mattress set three quarters of the way toward firm, and the DON confirmed it was not kept at the ordered setting. Resident 54 had diagnoses including a progressive blood circulation disorder, malnutrition, and difficulty controlling blood sugar, and was at risk for pressure wounds. An order directed the air mattress to be set on the soft setting each shift, but observations showed it on the firmest setting on multiple occasions, and the DON confirmed it was not kept as ordered. Resident 10 had alcoholic liver cirrhosis, hypertension, and diuretic use, and the nutritional risk care plan directed staff to monitor and report significant weight loss. A physician’s order required weekly weights every Wednesday, but the last documented weight was obtained on 05/13/2026 and the record showed missed weekly weights. The dietitian and DON both confirmed the weekly weight order was not followed. The facility also left an obsolete order in place for Resident 29, who had high blood pressure, a history of stroke, and an enlarged heart. The resident had switched from an anticoagulant to an antiplatelet medication, but the order to monitor for anticoagulant adverse side effects remained active even after the anticoagulant was discontinued.
Failure to Provide Scheduled ADL Assistance and Nail Care
Penalty
Summary
The facility failed to provide assistance with ADLs, including bathing and nail care, for Resident 54, who was assessed as requiring substantial to maximum assistance with bathing and was totally dependent on staff for personal hygiene. The resident was also documented as always incontinent of bladder and bowel. Observations on multiple dates showed Resident 54 in bed with fingernails extending past the fingertips, uneven and jagged, with visible soiling under the nails. The facility’s nail care policy stated nails should be kept smooth to avoid skin injury, and the resident’s care plan directed staff to provide ADL care as needed, including bathing or showering at least two times per week and offering nail care during showers. Bathing documentation did not show showers or baths in May 2026 except for entries indicating refusals and one entry marked inapplicable, and April 2026 records showed only two showers, one refusal, and one inapplicable entry. Progress notes did not document refusals of bathing during that period. The DON stated the resident was scheduled for bathing twice weekly and that if a shower was refused one day, there was still an opportunity for a second shower that week. The DON later found a shower book entry showing one shower and one refusal, but could not provide documentation showing the resident was offered bathing twice weekly as required by the care plan or received at least one shower per week.
Missing Orders for Ileostomy Care
Penalty
Summary
Appropriate ileostomy care was not provided for one resident who was cognitively intact, independent with mobility and personal care, and had diagnoses including a viral blood borne disease, an ileostomy, and puncture wounds on the low back and pelvis. The resident stated they did a lot of the care and maintenance of the ostomy themself, and observation showed an ileostomy pouch extending from the abdomen. The facility’s ostomy policy stated ostomy care would be provided by licensed nurses under the attending physician’s orders. Record review showed a care plan for altered bowel elimination related to the ileostomy, with a revised goal that ostomy care would be done by nursing and that ileostomy care would be completed as ordered. The record also showed an order for Enhanced Barrier Precautions related to the ileostomy, but there were no other orders describing how to care for or monitor the resident’s ileostomy. The DON stated both nurses and the resident were responsible for ileostomy care, that the site needed to be checked and the wafer changed as needed, and confirmed there were no orders related to care and maintenance of the ileostomy in the resident’s record.
Missing oxygen order, assessment, and care plan for a resident using portable oxygen
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not ensured for Resident 41. Resident 41 was admitted with severe impaired memory, COPD, and respiratory failure. The facility’s 2026 Oxygen Administration policy stated oxygen was to be administered according to professional standards of practice, physician orders, comprehensive person-centered care plans, and resident goals and preferences. The resident’s quarterly MDS and care plan indicated respiratory needs, and the care plan stated staff would administer oxygen as ordered. Physician progress notes dated 04/01/2026, 05/02/2026, and 05/19/2026 instructed staff to use supplemental oxygen as needed to maintain oxygen saturation above 90%, but the order summary for 04/2026 and 05/2026 showed no physician order for supplemental oxygen use. During observation on 06/02/2026, a portable oxygen tank with nasal cannula was beside the resident’s bed, and the resident stated they independently used the tank before going for a walk and turned it on to two for 15 minutes when their oxygen was low. Staff J stated the resident independently operated the portable oxygen tank, and Staff K stated the resident knew how to use it and had used it when oxygen was low. The DON observed the oxygen tank in the room and stated the resident’s record had no physician order for supplemental oxygen use, no assessment, and no care plan related to supplemental oxygen therapy, but should have.
Incomplete resident records and missing documentation for device use and PASRR records
Penalty
Summary
The facility failed to keep resident medical records complete and accurate for 3 of 17 residents reviewed. The report states that admission documents were not added to the chart in a timely manner and that device assessments were not documented, resulting in incomplete records and undocumented care. The facility policy required electronic clinical records to contain physician orders, required assessments, and care provided, and to be maintained in accordance with accepted standards of practice. For Resident 29, who had a history of stroke, dementia, one-sided paralysis, a developmental disorder, used a wheelchair, and had a history of falling, surveyors observed the resident in a wheelchair with a buckled lap belt that the resident could unbuckle. The last documented safety assessment for the lap belt was dated 09/12/2024, and the DON stated the more recent safety device assessment form did not include a place to document assessment of the lap belt, so the facility could not demonstrate the lap belt had been assessed after that date. For Resident 3, who had anxiety and depression, the record lacked the Level I PASRR screening even though a Level II PASRR Invalidation Assessment referenced it; the Admissions Coordinator stated the Level I PASRR was available but had not been uploaded to the chart. For Resident 7, who had severely impaired memory and was dependent on staff for mobility, hygiene, and transfers, surveyors observed the resident lying in bed on a scoop mattress, but the record did not contain informed consent, a physician order, or a facility assessment related to the mattress, and the DON confirmed those documents were absent.
Failure to Provide RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least eight hours a day for five days within a 31-day period. This deficiency was identified through a review of the facility's Daily Nurse Staff Documentation, which showed that on specific dates, there was no RN present for the required duration. The absence of an RN on these days, which were weekends, placed residents at risk for delays in assessments, identification of changes in condition, and provision of care that exceeded the scope of practice for Licensed Practical Nurses (LPNs). Interviews with facility staff revealed that the staffing coordinator was responsible for scheduling and finding substitutes when staff called out, which was a common occurrence on weekends. The Director of Nursing acknowledged the difficulty in meeting the RN requirement on weekends and confirmed the facility's failure to provide the necessary RN coverage. The reliance on an on-call nurse who may not hold an RN license further contributed to the inability to meet the federal regulation requiring RN supervision for eight hours daily.
Failure to Designate Onsite Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified staff member to serve as the Infection Preventionist (IP) and ensure that the IP worked onsite at least part-time, as required by the Facility Assessment. This deficiency was identified during an interview and record review, where it was revealed that Staff D, a Registered Nurse, was designated as the IP but worked offsite and only visited the facility occasionally. The Director of Nursing, Staff B, confirmed that Staff D had completed the CDC Nursing Home Infection Preventionist Training Course but did not fulfill the onsite work requirement of at least 20 hours per week based on the facility's census. Further investigation showed that the facility's assessment, dated 08/28/2024, did not determine the necessary amount of time the IP needed to be onsite to meet the infection control needs of the residents. The Administrator, Staff A, acknowledged that Staff D only visited the facility once a month, with the last visit being on 02/17/2025 for eight hours. This lack of consistent onsite presence by the IP placed residents at risk for unmet infection control issues and inadequate oversight of staff infection control practices.
Failure to Resolve Resident Grievances
Penalty
Summary
The facility failed to thoroughly investigate and resolve grievances identified through resident council meetings, affecting several residents. Resident 35 repeatedly requested an air mattress since admission but was not informed of the facility's decision or the reason for denial. The Director of Nursing stated that Resident 35 was not eligible for an air mattress due to the lack of an appropriate condition, but this was not communicated to the resident after the initial discussion. Additionally, the grievance was not logged, and the resident was left without a resolution or explanation. Resident 14 reported damage to personal electronic items caused by a housekeeper, but despite an initial acknowledgment and partial resolution, the resident did not receive updates or a complete resolution for over a month. The grievance form for this incident was incomplete, lacking follow-up documentation and a resolution date. Similarly, Resident 39's grievance about missing black leggings was not logged or resolved, leaving the resident uncertain about the status of their concern. The facility's grievance logs and forms from late 2024 to early 2025 were incomplete, with many grievances not assigned for investigation or concluded. Staff A acknowledged a breakdown in the grievance process due to changes in staff responsibilities, resulting in incomplete documentation and unresolved grievances. This failure to address grievances promptly and effectively placed residents at risk for frustration and a diminished quality of life.
Failure to Provide Baseline Care Plans to Residents
Penalty
Summary
The facility failed to provide baseline Care Plans (CP) to six residents within 48 hours of their admission, as required by the facility's policy. This deficiency was identified through interviews and record reviews, which revealed that Residents 23, 25, 7, 58, 40, and 55 did not receive a baseline CP or a summary of it. The absence of these care plans meant that the residents and/or their representatives were not informed of the initial plan for their care and services, placing them at risk for unmet care needs. The facility's policy mandates that a baseline CP be developed within 48 hours of admission and that a written summary be provided to the resident or their representative in an understandable manner and language. Interviews with staff, including the Director of Nursing, confirmed that it was not the facility's current practice to complete or provide baseline CPs to residents or their representatives. This lack of documentation and communication was evident in the records of the six residents, who had various complex medical conditions requiring skilled nursing care. For instance, Resident 23 was admitted after surgery, Resident 25 had multiple complex diagnoses including heart failure and respiratory failure, and Resident 7 had pressure ulcers and a spinal cord injury. The failure to provide baseline CPs was a systemic issue affecting the facility's ability to meet the immediate needs of newly admitted residents.
Deficiencies in Care Conferences and Care Plan Updates
Penalty
Summary
The facility failed to ensure that residents participated in care conferences and that care plans were updated and revised to reflect person-centered care. Specifically, three residents did not receive or participate in care conferences as required. Resident 23, who was admitted to the facility, reported not having any care conferences since admission, with the last documented conference occurring six months prior. Resident 58, admitted with complex medical diagnoses, had no documentation of a care conference since admission. Resident 20 had only one care conference documented over a six-month period, despite expectations for quarterly conferences. Additionally, the facility did not update or revise care plans for five residents to reflect their current needs and conditions. Resident 7's care plan lacked specific directions for mobility devices and assistance levels, despite requiring a two-person assist and mechanical lift for transfers. Resident 25's care plan did not specify the resident's broken teeth, which were known to staff since admission. Resident 53's care plan failed to specify the resident's drug allergies, and Resident 58's care plan did not reflect the resident's NPO status, despite a physician's order. Resident 8's care plan was not updated to include the presence of an indwelling catheter, which was observed during multiple assessments. Interviews with staff, including the Social Services Director and Director of Nursing, confirmed the expectations for care conferences and care plan updates. Staff acknowledged the deficiencies in documentation and the need for care plans to accurately reflect residents' current conditions and care requirements. These failures left residents at risk for unmet care needs and inappropriate care.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADLs) for six residents, specifically in the areas of cleanliness and grooming. Residents who were dependent on staff for assistance with shaving, bathing, and nail care were observed with long fingernails, unshaven facial hair, and in some cases, long toenails. These observations were made over several days, indicating a pattern of neglect in personal hygiene care. Resident 8, who had impairments and required assistance, was observed multiple times with long fingernails and unshaven. Resident 22, with right-sided weakness, was also observed with long fingernails and toenails, and unshaven, despite requiring assistance. Resident 41, who had paralysis and required extensive assistance, was similarly observed with long fingernails and unshaven. These residents did not exhibit behaviors of rejecting care, yet their care plans were not followed. Resident 27, with severe cognitive impairment, was observed with long facial hair and had not received a shower since a specific date, despite only two documented refusals. Resident 55, with moderate impairment, was observed with long, broken, and dirty fingernails, and the documentation for nail care was incomplete. Resident 37, who was totally dependent on staff for bathing, had discrepancies in shower documentation, indicating a lack of consistent care. Staff interviews confirmed expectations for care were not met, and documentation was lacking.
Deficiencies in Pressure Ulcer Care and Management
Penalty
Summary
The facility failed to provide necessary care and services for four residents at risk for or with existing pressure ulcers (PUs), as per professional standards of practice. Resident 49, who was at high risk for PU development, did not have a care plan in place addressing this risk. Despite being assessed with a Stage 1 PU, there were no documented physician orders for prophylactic treatment, and the wound was not properly documented or included in the discharge summary. Additionally, the resident's collateral contact reported an open area on the tailbone upon transfer to another facility. Resident 14, who had multiple PUs and a diabetic foot ulcer, did not receive consistent wound measurements or follow-up care as recommended by a wound specialist. The facility failed to implement the specialist's recommendations, such as using an air loss mattress and ensuring proper footwear. Observations showed the resident without an air loss mattress and wearing gym shoes instead of diabetic shoes, with the resident reporting worsening wounds. Resident 7 had a wound VAC ordered but lacked proper physician orders for its settings once supplies were received. The VAC was observed in use without documented orders. Resident 25's wound care was not performed according to physician orders, with incorrect application of treatments and a lack of timely wound measurements. These deficiencies highlight a systemic failure in the facility's wound care management, placing residents at risk for deterioration in their skin conditions.
Failure to Follow Dietary Orders and Menu Plans
Penalty
Summary
The facility failed to adhere to its own policies regarding meal preparation and serving, which resulted in residents not receiving meals that met their prescribed dietary needs. Observations and interviews revealed that the facility did not follow the planned breakout menus during meal service, leading to residents receiving incorrect portion sizes and meal components. For instance, Resident 53, who was on a therapeutic diet with large protein portions due to recent weight loss, was served meals that did not align with the dietary orders, such as receiving only one piece of plain fish instead of the specified Panko crusted fish with large portions. Additionally, Resident 25, who had dietary restrictions including no added salt and double protein portions, was served meals that included items they disliked, such as tomatoes, and received salt packets contrary to their dietary orders. This resident expressed frustration with the kitchen service, highlighting ongoing issues with receiving meals that did not meet their dietary preferences and restrictions. Similar issues were observed with other residents, such as Resident 30 and Resident 40, who also received meals that did not comply with their dietary orders, including incorrect portion sizes and the inclusion of salt packets when not allowed. Interviews with staff, including the Director of Nursing and the Dietary Supervisor, confirmed the expectation that menus should be followed to maintain residents' nutritional status. However, the staff was unaware of the correct scoop sizes to use for large portions, indicating a lack of training or communication regarding dietary requirements. The Registered Dietician also emphasized the importance of following menus to ensure accurate nutrition calculations for residents. These failures placed residents at risk for inadequate nutritional intake and unmet dietary needs.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to serve food that was appetizing in appearance, palatable, and at the proper temperature, as observed during meal services and a facility test tray. Interviews with four residents revealed consistent complaints about the food being cold, not well-cooked, and unappetizing. Resident 25 reported that the food was almost always cold, while Resident 23 stated that the food was not cooked well and was cold upon delivery. Resident 12 mentioned that the food was not appetizing, with issues such as toast being either too hard or not toasted enough, and meals not being served hot. Resident 45 described the food as horrible and noted that staff sometimes could not identify the food being served. A test tray observation on March 4, 2025, showed that the meatloaf was served at 117 degrees Fahrenheit, and the buttered carrots were at 99 degrees Fahrenheit and were very hard and undercooked. The facility's registered dietician, Staff P, acknowledged awareness of resident concerns regarding cold food and indicated that the facility was working to address the issue. These findings indicate a failure to provide meals that meet the required standards for temperature and palatability, potentially affecting residents' nutritional intake and satisfaction with meals.
Deficiency in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to establish an effective Antibiotic Stewardship Program, which is crucial for promoting appropriate antibiotic use and reducing unnecessary prescriptions. The program's policy required nursing staff to monitor antibiotic initiation and conduct a review within 48-72 hours to assess the response and review lab results. However, the policy lacked specific criteria for determining appropriate antibiotic usage. The facility did not have a full-time Infection Preventionist, relying instead on an offsite Infection Preventionist who visited monthly. This setup led to inadequate oversight and guidance on antibiotic use. For Resident 8, the facility's records showed that the resident was prescribed multiple courses of antibiotics for a suspected urinary tract infection (UTI) without proper documentation or adherence to McGeer's criteria. The resident received antibiotics from 12/14/2024 to 12/19/2024, and again from 12/17/2024 to 12/21/2024, despite the lack of documentation to justify the continuation of the first antibiotic course. The final urine culture report indicated an infection, but the facility failed to document the rationale for overlapping antibiotic treatments. Resident 35 was prescribed a seven-day course of antibiotics for dysuria, but the facility's records showed that McGeer's criteria were not met. A urinalysis conducted on 12/24/2024 revealed no infection, yet there was no documentation of staff consulting with the provider to discontinue the antibiotics. The offsite Infection Preventionist acknowledged that Resident 35 did not meet the criteria for antibiotic treatment and that staff failed to review the order appropriately. This oversight highlights the facility's deficiency in managing antibiotic prescriptions effectively.
Failure to Maintain Dignity During Meal Assistance
Penalty
Summary
The facility failed to maintain and promote dignity during meal assistance for three residents. For Resident 27, a staff member referred to a clothing protector as a 'bib' while assisting the resident to the dining room for lunch. This terminology is considered undignified and does not respect the resident's right to a dignified existence. Resident 112 experienced a delay in receiving assistance with their meal. After being served, the resident attempted to access their food but was unable to do so as staff moved the tray out of reach, promising to return after passing other trays. This left the resident frustrated and attempting to get out of their wheelchair to reach the tray. Assistance was not provided until nearly 10 minutes later. Additionally, Resident 57 was moved from their usual dining spot to a different table, facing away from others, disrupting their meal and social interaction. These actions collectively demonstrate a failure to uphold the residents' dignity and self-determination during dining services.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide required written notices to residents and their representatives at the time of transfer or discharge to an acute care hospital, as mandated by their policy. This deficiency was identified for four residents who were transferred to hospitals with the anticipation of return. The facility's policy required that the transfer/discharge notice be provided in a language and manner understandable to the resident and their representative, including the specific reason for the transfer, the effective date, and information on how to obtain an appeal form. However, the facility did not adhere to this policy, as evidenced by the lack of documentation of written notifications for Residents 9, 1, 41, and 37. Interviews with facility staff, including the Social Services Director and the Director of Nursing, confirmed the absence of written discharge notices for these residents. Staff acknowledged the importance of providing such notifications to uphold residents' rights. Despite the facility's policy stating that notices should be provided as soon as practicable in cases of urgent medical needs, there was no evidence that this was done for the residents reviewed. This oversight placed residents at risk of being discharged without proper communication regarding their care and preferences.
Failure to Provide Bed-Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of its bed-hold policy to residents or their representatives at the time of transfer to a hospital or within 24 hours, as required by policy. This deficiency was identified for three residents who were transferred to acute care hospitals. Resident 9 was transferred on November 7, 2024, but there was no documentation indicating that the resident or their representative received the required bed-hold policy information. Staff B, the Director of Nursing, confirmed this oversight during an interview. Similarly, Resident 1 was discharged to a hospital on June 8, 2024, and there was no record of a bed-hold notification being provided. Staff B acknowledged the lack of documentation and stated that nursing staff should have offered and documented the bed-hold notification. Resident 37 was transferred to a hospital on two occasions, April 2, 2024, and May 28, 2024, without any progress notes or documentation of a bed-hold offer. Staff B confirmed that the bed-hold policy was not offered for these discharges.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) accurately reflected the status of four residents, leading to potential risks for unmet care needs and diminished quality of life. For Resident 25, the MDS inaccurately reported no broken teeth and no need for oxygen therapy, despite observations and records indicating otherwise. The resident had broken teeth prior to admission, which were not documented, and was observed using oxygen continuously, contrary to the MDS report. Resident 53's MDS inaccurately coded aspirin as an anticoagulant medication, although the resident was not receiving any anticoagulant during the assessment period. This discrepancy was confirmed by the MDS Nurse, who acknowledged the error upon reviewing the resident's records. Similarly, Resident 1's MDS failed to reflect significant weight loss, as the resident had lost almost 48 pounds over six months, a fact that was known to the Director of Nursing and the dietitian. For Resident 41, the MDS inaccurately reported no functional limitations in range of motion, despite the resident having right-side weakness and contractures due to a stroke. Observations and interviews confirmed the resident's inability to move their right arm and leg, contradicting the MDS report. The Rehab Director and Director of Nursing both acknowledged the inaccuracies in the MDS, highlighting the need for accurate assessments to plan appropriate care.
Inaccurate PASRR Assessments for Residents with Mental Health Conditions
Penalty
Summary
The facility failed to ensure accurate Pre-Admission Screening and Resident Review (PASRR) assessments for residents with mental health conditions, leading to deficiencies in the care provided to four residents. Resident 23, who had diagnoses of anxiety, depression, and schizophrenia, was identified as needing a Level II evaluation due to Serious Mental Illness (SMI) indicators, but no such evaluation was found in their records. Similarly, Resident 53's Level 1 PASRR inaccurately indicated no SMI indicators, despite the resident having anxiety and depression requiring medication. Staff C acknowledged the inaccuracies and the need for updated assessments. Resident 1's PASRR also failed to identify SMI indicators, despite the resident's diagnoses of anxiety and depression and the use of related medications. Additionally, Resident 27's PASRR was incomplete, lacking any indication of mood or anxiety disorders, and was missing essential information such as the name of the person completing the form and the date. Staff C confirmed the inaccuracies in these assessments, which were not updated as required, leading to a failure in meeting the residents' mental health needs.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents, which placed them at risk for inadequate care. Resident 53 required assistance with eating, was on a therapeutic diet, and was at risk for pressure ulcers. However, the care plan did not include measurable goals for nutritional status or address the resident's skin picking behaviors, recurrent lesions, or dental issues. Despite a physician's order to monitor skin conditions, these aspects were not incorporated into the care plan. Staff B acknowledged the need for measurable goals and the inclusion of the resident's dental and skin conditions in the care plan. Resident 58, who was admitted with complex medical diagnoses and required a feeding tube, also had a care plan lacking measurable goals for nutritional status. Similarly, Resident 25, diagnosed with respiratory failure and requiring continuous oxygen, did not have a care plan addressing their respiratory status and oxygen use. Staff B confirmed the expectation that care plans should include goals and interventions for identified conditions, which was not met for these residents.
Failure to Monitor Antipsychotic Use and Document Care Procedures
Penalty
Summary
The facility failed to monitor and document the behaviors of residents receiving antipsychotic medications, as observed in the cases of three residents. Resident 8, who was admitted with conditions including non-Alzheimer's dementia, depression, and anxiety, received antipsychotic medication daily without any documented monitoring of behaviors related to the medication. Staff interviews revealed that there was no documentation to justify the use of antipsychotic medication for Resident 8, and staff acknowledged the importance of monitoring behaviors but failed to do so. Additionally, the facility did not clarify physician orders for wound care for Resident 25, who was at risk for pressure ulcers. During an observation, a nurse applied castor oil ointment incorrectly, not following the physician's order. Furthermore, for Resident 61, who was on hospice and passed away in the facility, there was no physician order obtained to release the body, nor was there documentation of the release to a mortuary. Staff interviews confirmed these documentation lapses, indicating a failure to adhere to required procedures.
Deficient Discharge Planning for Two Residents
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process for two residents, leading to potential risks for unsafe discharge and diminished quality of life. Resident 23, who was admitted for short-term care with a surgical wound, expressed frustration about not being discharged home after their wound healed. Despite the resident's desire to return home and the healing of their wound, there was no documentation of a quarterly care conference or any updated discharge planning in their records. The Social Services Director acknowledged the lack of documentation and stated that guardianship services were being pursued for Resident 23, but no records confirmed this action. Resident 60 was discharged to a home/community setting without a physician's order, and there was no documentation of communication with the receiving facility to ensure continuity of care. The Director of Nursing confirmed the expectation for a physician's order and progress notes documenting communication with the receiving facility, but these were absent in Resident 60's records. This lack of proper discharge documentation and communication highlights the facility's failure to adhere to its discharge policy, potentially compromising resident safety and care continuity.
Failure to Monitor and Document Skin Condition Changes
Penalty
Summary
The facility failed to monitor and identify changes in a resident's skin condition in a timely manner, specifically for a resident who was at risk for developing pressure ulcers and had existing pressure ulcers upon admission. The resident, who was cognitively intact, reported having a rash under their right-side abdominal fold and right armpit for a couple of weeks. During a wound care observation, a Licensed Practical Nurse (LPN) noted large areas of red, inflamed skin with drainage, but the resident indicated that nursing staff only checked the rash areas when prompted by the resident. The resident's medical records showed a previous order for antifungal powder, which was discontinued after the rash was resolved, and an order for weekly skin evaluations to prevent skin breakdown. However, the last documented skin assessment was nearly two weeks prior, and there was no documentation of a scheduled skin check. Additionally, daily skilled evaluation forms completed by staff did not report any skin conditions. The Director of Nursing (DON) stated that it was expected for nursing staff to complete and document weekly skin assessments and notify the DON and provider if new areas were identified.
Failure to Implement Restorative Programs for Residents
Penalty
Summary
The facility failed to provide a restorative program for two residents, leading to a deficiency in maintaining or improving their range of motion and mobility. Resident 41, who had a stroke resulting in paralysis on one side of their body, was observed multiple times without the prescribed splint on their contracted right hand. Despite being discharged from occupational therapy with a referral for a restorative nursing program, the staff did not implement the recommended splinting schedule. Interviews with the Rehab Director and Director of Nursing confirmed that the restorative program was not executed as required. Resident 23, with complex medical conditions including an infection and amputation, was assessed to have functional limitations in their lower extremities and required a wheelchair for mobility. Although a restorative program was discussed and agreed upon, there was no documentation of an evaluation or initiation of such a program. Despite physician orders to evaluate and start restorative therapy, the facility did not follow through, as confirmed by staff interviews and record reviews.
Failure to Address Self-Harm Risk in Resident with Depression
Penalty
Summary
The facility failed to provide necessary social services interventions for a resident who was reviewed for unnecessary medications. The resident, who had a diagnosis of depression and was receiving antidepressant and antianxiety medications, showed multiple symptoms of depression according to the PHQ-9 assessment. The assessment indicated that the resident had thoughts of self-harm for two to six days during the 14-day look-back period. However, there was no documentation of further assessments, monitoring, or interventions related to the positive response to self-harm, nor was there any indication that the provider was notified. Interviews with staff revealed that the Social Services Director, who was new to the position, was unaware of the assessment and did not conduct the necessary follow-up. The Director of Nursing stated that they expected staff to further interview the resident about any self-harm statements and implement appropriate interventions, but this was not done. Observations showed the resident lying in bed with eyes closed on multiple occasions, and the resident expressed a desire to go home but acknowledged an inability to care for themselves.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) for the first quarter of 2024, as required by the Payroll Based Journal (PBJ) reporting system. The discrepancy was identified through a review of the PBJ data submitted by the facility, which showed a reported census total of 5235. However, the CASPER Report 1704S - Daily Minimum Data Set (MDS) Census Summary indicated a total census sum of 5065, revealing a discrepancy of 170 census days. The inconsistency was noted on multiple days across January, February, and March 2024, indicating that the facility's reported census did not match the MDS census summary on several occasions. During an interview, the facility's administrator, Staff A, acknowledged that the PBJ submission was managed at a corporate level and admitted to inaccuracies in the census numbers. Staff A suggested that the facility's electronic health records provided a more accurate census total compared to the MDS reported numbers, suspecting a clerical error in the MDS census submission. This failure to provide accurate staffing information potentially impacted the accuracy of the nursing home's staffing level data collected by CMS, which could affect the provision of resident care and services.
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Illustrative
What surveyors actually found near you
We read the 451 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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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near North Bend
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avamere Rehabilitation Of Issaquah | 12.1 mi | ★★★★★ | 0 | 0 |
| Marianwood Health And Rehabilitation | 12.9 mi | ★★★★★ | 22 | 0 |
| Briarwood At Timber Ridge | 13.3 mi | ★★★★★ | 27 | 0 |
| Bellevue Post Acute | 18.5 mi | ★★★★★ | 66 | 0 |
| Cedar River Healthcare Center | 19.4 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.