Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at North Cascades Health And Rehabilitation during CMS and state inspections, most recent first.
Failure to Provide Written Bed Hold Notices at Hospital Transfer: The facility did not document providing written bed hold notices for four residents when they were transferred to the hospital or ER. One resident had anoxic brain damage, DM, and pain; another had a stage 3 sacral pressure wound, spina bifida, paraplegia, and DM2. The EHRs showed hospital transfers and anticipated return dates, but no written bed hold notice documentation. Staff said the cart nurse handled bed holds and the Administrator was unaware of the correct process.
Facility assessment failed to address the physical environment, equipment, and services needed for the identified resident smoking population. A smoking area was observed in a parking lot with a pop-up tent, fire extinguisher, metal receptacles, and smoking aprons, but it blocked an accessible parking space and was later moved to an area not compliant with the 25-foot smoking restriction. Several residents reported having lock boxes for smoking materials but no keys, and the ADM was aware of smoking area location issues but not the missing keys.
Smoking policies were not implemented in accordance with Federal, state, and local requirements. A canopy smoking area was set up over one of two handicapped parking spaces near the main entrance, with smoking aprons, receptacles, and a fire extinguisher present, and two residents were observed smoking there. The area was later moved to a location within 25 feet of the entrance and nearby windows that could open, and the Administrator stated there was no definitive plan for the smoking area placement.
The facility failed to maintain sufficient and consistently deployed nursing staff, resulting in prolonged call light response times, delayed ADL assistance, missed showers and restorative programs, and untimely or improper medication administration. Multiple residents reported waiting 30 minutes to hours for help, particularly around shift changes and staff breaks, with some attempting self-care and experiencing falls or incontinence while waiting. Family members and grievances described residents found soiled, unanswered calls to the nurses’ station, and reliance on relatives to obtain assistance. Resident council reports detailed residents left on the floor after falls, walking down halls partially undressed to seek help, and staff ignoring call lights while passing meal trays. Staff interviews confirmed ongoing short staffing, frequent call-outs, lack of dedicated shower aides, restorative aides being pulled to the floor, and NACs responsible for numerous residents and multiple showers, while some nurses left medications at bedside without observing administration.
Grievances were not promptly or thoroughly resolved for multiple residents. Concerns included missing personal items, delayed call light response, showering issues, communication problems, and possible neglect or verbal mistreatment. Documentation was often incomplete, some grievances were not escalated when abuse or neglect was possible, and several findings lacked supporting interviews or audits to fully address the concerns.
Psychotropic Medications Given Without Required Behavior Monitoring: The facility failed to document behavior monitoring, target behaviors, and non-pharmacological interventions for multiple residents receiving routine and PRN psychotropic medications. Residents with diagnoses including anxiety, depression, PTSD, schizophrenia, dementia, Alzheimer’s disease, delirium, and Parkinson’s disease received medications such as buspirone, duloxetine, quetiapine, trazodone, escitalopram, lorazepam, hydroxyzine, and alprazolam, but the record lacked licensed nurse documentation showing behaviors were monitored or that non-pharmacological interventions were attempted and effective.
PASRR referrals and follow-up were not completed or documented for several residents with MH or cognitive diagnoses. A resident with schizophrenia and psychosis had no documented Level 2 request after a 30-day exemption, and other residents with positive Level 1 PASRRs lacked evidence of monthly follow-up, Level 2 documentation, or a PASRR revision when the resident’s condition was not accurately reflected. Staff reported expectations for Level 2 review and follow-up, but the records did not show that this occurred for multiple residents.
Care plans were not revised to match residents' current needs for accidents, skin issues, and ADLs. One resident with seizures, severe cognitive impairment, and repeated falls had a fall-focused care plan that did not include seizure precautions despite physician orders and documented seizure activity. Another resident with a diabetic right heel ulcer had a care plan that lacked individualized goals and interventions for wound prevention and treatment, a third resident developed MASD without a care plan revision, and a fourth resident's ADL care plan still listed assistance needs even though the resident was observed ambulating and completing tasks independently.
Expired and unlabeled medications were found in medication and treatment carts, including an expired insulin pen, two opened insulin vials without open dates, and expired lubricating jelly and enemas. Staff also stated that nurses are responsible for checking carts for expired items, and the DON was not aware of the expired or unlabeled medications in the carts.
A facility failed to provide a nourishing, palatable, well-balanced diet that met residents’ daily nutritional and special dietary needs and preferences. Several residents reported food that was cold, dried out, terrible, or unappealing, and an observation of test trays showed uneven meal components, limited condiments, no drinks on trays, and food that was overcooked, bland, and presented in an institutional manner.
Improper Storage and Monitoring of Nourishment Refrigerators: The facility failed to keep food in 2 of 4 snack/nourishment refrigerators stored under sanitary conditions. Surveyors found expired yogurt, expired dairy creamer, undated food items, and opened salad dressing, and one refrigerator had no temperature logs while another had blank temperature and signature entries for 2 days. Staff stated they were unsure who was responsible for monitoring refrigerator temperatures and contents.
Resident Council concerns were not accurately documented or addressed in meeting minutes over several months. Minutes often stated no issues or concerns were raised, even though residents reported grievances about staff behavior, call light response, meals, maintenance, and other facility issues. The AD acknowledged concerns were escalated to grievance forms but still documented no concerns on the council minutes, and the DON stated this was not accurate.
A facility failed to comprehensively assess and monitor the use of green wedges placed under fitted sheets along the edges of two residents’ beds. One resident with severe cognitive impairment, aphasia, and a history of intracerebral hemorrhage was observed trying to climb over the wedges, crying, and later found on the floor mat; the spouse said no consent was signed for the wedges to keep the resident in bed. Another resident with profound developmental delay, autism, anxiety, depression, and a recent neck fracture was repeatedly observed with wedges lining the bed edge. Records showed no physician order, consent, care plan, or ongoing evaluation supporting restraint use.
Failure to provide grooming assistance for dependent residents. Three residents with significant care needs were observed with unshaved facial hair and/or untrimmed nails despite care plans and assessments showing dependence on staff for grooming. One resident with traumatic brain bleed, MS, and COPD was repeatedly observed with chin hairs, unkempt hair, and untrimmed nails; another resident with DM2, HF, and bladder infection reported only receiving bed baths instead of preferred showers and became tearful about not getting needed help; a third resident with dementia had dry, scaly skin, long jagged nails, and ongoing need for shaving and nail care. Staff stated grooming was typically done on shower days, while the DON stated ADLs including hair, shaving, and nail care were expected daily.
A facility failed to document assessment and monitoring after abuse allegations involving two residents, including reports of medication pressure, inappropriate toileting comments, and a resident left soiled for hours. The facility also did not carry out an ordered behavioral health consult for a resident with dementia, anxiety, depression, and delusions, and did not ensure a resident with a suprapubic catheter received the ordered catheter follow-up and change.
Failure to maintain and/or improve ROM was identified for a resident with a hx of stroke affecting the dominant right side. The resident was seen with the right hand balled into a fist, with no splint, hand roll, or other device in place, and the care plan showed no restorative program. Staff reported the resident was receiving PT only, had right-sided spasticity and limited ROM, and OT noted thickened yellow matter on the palm and stated an OT eval was needed because the hand could develop a contracture if not addressed.
The facility failed to keep fall prevention interventions in place for two residents with high fall risk and failed to consistently secure smoking materials for four residents. One resident with seizures, Parkinson’s disease, and cognitive impairment had multiple falls, but seizure precautions were not on the care plan and fall mats were delayed. Another resident with frequent falls and Parkinson’s disease sustained a head injury and a second fall before the care plan was updated. Surveyors also observed cigarettes and lighters unsecured in rooms and common areas, and residents reported lock boxes without keys or keeping smoking items in their rooms.
Failure to provide and document ordered fluids and fluid restriction affected three residents. One resident with severe cognitive impairment and an indwelling catheter had altered nutrition/hydration needs, required max assist, and had IV hydration orders and a nutrition eval showing high daily fluid needs, while another resident with Parkinson’s disease had low BP after a fall and family reported meals were left untouched and home water bottles were often empty. A third resident with DM and HF had a 1500 mL fluid restriction in the hospital discharge summary, but it was not entered in the orders or MAR/TAR, weights were not documented as ordered, and CNA documentation showed intake above the restriction on multiple days.
A resident with acute and chronic respiratory failure with hypoxia and COPD had an oxygen order that only directed supplemental O2 if the resident’s oxygen level was below 90%, without a documented flow rate. The resident’s care plan did not address oxygen needs, respiratory meds, or respiratory diagnoses, while staff observed the resident wearing nasal cannula O2 at varying flow rates and reported the resident always wore oxygen and had oxygen levels checked every shift.
Incomplete and inaccurate charting was identified for two residents. One resident with hereditary spastic paraplegia and bladder dysfunction had a care plan that did not specify the catheter type or catheter-specific care instructions, and the MAR/TAR showed multiple missing entries for catheter output. Another resident with DM2, a bladder infection, and HF had missing MAR/TAR documentation for medicated vaginal cream, drain output, and ear drops. An LPN/Resident Care Manager stated charting was expected to be completed by nursing staff and CNAs, with missing documentation reviewed daily, though agency staff were harder to hold accountable.
Infection control practices were not followed during wound care and medication administration. A resident with multiple pressure ulcers, osteomyelitis, hereditary spastic paraplegia, a suprapubic catheter, and EBP for wounds and an implanted device received wound care from an RN/ADNS without a gown, and the RN/ADNS did not perform hand hygiene between glove changes. In a separate observation, an LPN wore gloves without hand hygiene, cut a pill, administered the medication, removed the gloves, and touched the med cart computer mouse without observed hand hygiene.
The facility did not consistently post complete daily nurse staffing information in an accessible location for residents, families, and visitors. Surveyors observed that current staffing information was posted near the reception desk on a weekday, but the postings for the preceding weekend were missing. The staffing coordinator reported being solely responsible for completing and updating the daily staffing information and acknowledged that no one fills out the required information on weekends when they are not present, resulting in missing staffing and census data for those days.
A resident with bipolar disorder, agoraphobia, and anxiety, care-planned to feel safe and receive cares in pairs, reported that a contracted NAC provided peri-care alone, stroked the inner thigh, made the area excessively wet, and made sexually suggestive comments about the resident’s appearance and relationship status. The resident told another caregiver that the NAC’s peri-care was different, took longer, was gentle, and that the NAC’s comments made them feel very uncomfortable; the caregiver only switched room assignments and did not report the allegation or its reason to nursing staff. The allegation was not brought to the LPN/RCM and DON until the following day, contrary to the facility’s abuse policy requiring mandated reporters to immediately report allegations within two hours, allowing the NAC to continue working and to have ongoing access to residents during and after the alleged incident.
A resident with bipolar disorder, agoraphobia, and anxiety disorder, who was cognitively intact and dependent on staff for toileting and personal care, reported that a NAC made sexually inappropriate comments, touched them inappropriately, and sexually assaulted them during care. Multiple NACs learned of the resident’s allegations during their shifts and one NAC changed room assignments but none reported the suspected abuse as required by facility policy, which mandates immediate reporting of abuse allegations to authorities. The allegation was not entered into the state reporting system until the following day, and leadership later acknowledged that the report should have been made as soon as the first staff member was informed.
The facility failed to conduct thorough investigations into an alleged sexual abuse incident involving a resident with mental health diagnoses and dependence on staff for toileting, and a separate case of missing narcotic medication for another resident. In the abuse case, the DNS did not interview any day-shift staff despite documentation that the incident occurred on day shift, and did not obtain a statement from the NAC first informed of the allegation. In the narcotic case, the DNS did not review medication destruction forms, did not collect witness statements, and did not interview nurses who had recently worked the med cart, despite an RN’s report of missing narcotics and an established destruction process described by the ADON.
A resident with a seizure disorder and a lumbar fracture reported that antiseizure medications were repeatedly given late and not spaced as prescribed, with some nurses not understanding the importance of timely administration. The resident filed a grievance stating that one nurse was an hour late with evening meds, gave evening and HS antiseizure meds together, and omitted ordered pain medication. Audit review confirmed that an agency RN administered a scheduled morning dose of Divalproex DR nearly three and a half hours late, demonstrating failure to follow physician orders for medication timing.
Surveyors found that staff failed to immediately initiate CPR for two residents who were found unresponsive, not breathing, and without a pulse, despite one having a documented full-code POLST and the other having an unknown code status that, per policy, required CPR. The facility’s POLST binders were disorganized, with forms misfiled, located on the wrong floor, and containing conflicting CPR choices, and some staff believed code status was in the electronic care plan rather than the POLST binder. In one case, multiple RNs and an NP confirmed a resident had no pulse or respirations but did not start CPR, and EMS began compressions only after arriving minutes later. In the other case, an LPN and RNs did not perform CPR while two NACs without current CPR certification provided limited chest compressions, then stopped due to fatigue without nurses taking over, and EMS arrived to find CPR not in progress. These actions and inactions resulted in an Immediate Jeopardy citation under F678 for failure to provide basic life support, including CPR, prior to EMS arrival.
The facility failed to conduct a thorough investigation into an unexpected death following a fall involving a resident with serious medical conditions, including a bladder tumor, kidney disease, and vasovagal episodes. The incident report documented both a fall and an unanticipated death at the same time and stated the events were unwitnessed, despite multiple staff and a visitor providing statements that conflicted with this. Documentation lacked a clear timeline, identification of who performed CPR, duration of CPR, and names of involved staff. The DON did not notify the state hotline, was unaware that police had been called, did not review the police report, and relied on undocumented recollections and scribbled notes rather than complete written investigative records to rule out abuse or neglect.
A resident with hypertension, CKD, heart failure, vision deficit, and high fall risk experienced multiple falls and a significant injury after staff repeatedly administered antihypertensive medications outside ordered BP parameters and failed to update the fall care plan to address medication-related risks. The care plan focused on environmental and behavioral fall interventions but did not include specific strategies for cardiac BP medications despite the CAA identifying medications as a fall risk factor. Over time, the resident had several falls, including one associated with orthostatic hypotension and dehydration, and later sustained a forehead hematoma and L2 compression fracture after a fall they attributed to blood pressure issues. The MAR showed repeated administration of BP meds when diastolic BP was below the hold parameter, which staff later acknowledged as med errors. The facility’s post-fall investigation documented no injuries despite obvious facial trauma, left key assessment sections blank, lacked documentation of neuro checks, and did not analyze medications as a contributing factor, while interviews described the resident’s decline, ongoing dizziness, pain, and delayed call light response.
A resident with HTN, CKD, CHF, and a history of falls had multiple antihypertensive and diuretic medications ordered with specific BP hold parameters, but nursing staff administered these medications even when systolic or diastolic BP values were below the physician-ordered thresholds. On one such occasion, after receiving the medications despite a low diastolic BP, the resident became dizzy while standing at the sink, fell, and sustained a forehead hematoma and an acute L2 compression fracture. The resident and a representative reported ongoing problems with BP medications, including falls and dehydration, and the DON later acknowledged these administrations were medication errors that had not been identified as contributing factors during the initial fall investigation.
The facility failed to accurately identify and document a resident’s legal representative despite the resident having developmental delay, impaired cognition, and being described as an intermittently poor historian. The resident was listed as their own responsible party, and an outside agency case manager was recorded as the primary emergency contact and treated as a decision maker, even though this person was not the DPOA. The resident signed their own POLST and consents, and staff sought approvals and updates from the case manager, while the actual DPOA was neither documented nor contacted about care decisions or a hospital transfer related to a catheter issue.
A resident with a documented DNR status in hospital discharge paperwork experienced a cardiopulmonary emergency during which staff could not locate a POLST or clear code status in the unit POLST binder or EMR. Following facility policy, staff searched the binder and EMR but found no POLST, and the MAR only directed them to a disaster recovery binder that did not contain the form. On instruction from 911, staff initiated CPR until another nurse located hospital paperwork indicating the resident was DNR, at which point CPR was stopped. Review of records and interviews showed that many residents on the unit lacked POLSTs in the binder, POLST binders were incomplete and not consistently audited, code status was not displayed in the EMR per company policy, and some POLSTs/ADs were awaiting scanning or stored in locations not readily accessible to nursing staff. The report states that this failure to access and follow POLST instructions or ensure POLSTs were readily available placed residents at risk for receiving unwanted CPR, avoidable trauma, and other negative health outcomes.
Surveyors found that the facility failed to maintain complete and accurate medical records for two residents. One resident experienced a syncopal episode on the toilet that was reported to an LPN, who had a NAC obtain vital signs and observed poor color and fluctuating status in the wheelchair, but did not document the event, the assessment, the vital signs, or any provider notification in the clinical record. Another resident was sent to the hospital for urinary catheter reinsertion, yet no hospital records from that visit were initially present in the chart, and the hospital dictation was only obtained later. The HIM reported that nurses were typically responsible for obtaining hospital records, and the Interim DON stated that hospital visits and adverse events should be documented and accessible in the clinical record.
A facility with more than 120 beds did not employ a qualified full-time social worker, as the acting social services director lacked the required bachelor's degree or qualifications. The previous director had left, and although two new social service staff were hired, the deficiency persisted during the review period.
A resident repeatedly voiced concerns about pest control, laundry, and meal service, but the facility failed to document, log, or address these grievances. Staff interviews confirmed ongoing complaints, yet no records were found in grievance logs or the resident's medical record, resulting in unresolved issues and lack of follow-up.
Multiple allegations of abuse and neglect involving several residents with cognitive and physical impairments were not thoroughly investigated. The facility did not identify or interview all relevant staff or witnesses, relied on incomplete or unsigned statements, and failed to ask specific questions related to the incidents. Investigations were limited to general inquiries, resulting in incomplete assessments of the reported events.
Two residents did not receive care as ordered by their physicians, including missed weekly lab tests for one resident with a pressure wound infection and lack of CPAP therapy and regular weights for another with heart failure and pulmonary hypertension. Staff failed to follow up on missing lab results and did not ensure respiratory equipment or weight monitoring was provided as ordered.
A resident with a history of pressure ulcers and a current sacral wound infection did not receive wound care in accordance with physician orders, including omission of required wound packing and improper infection control practices by nursing staff. The resident was observed in positions contrary to discharge instructions, and wound care was performed without proper hand hygiene or adherence to infection control standards, resulting in soiled dressings and increased risk of contamination.
The facility failed to conduct thorough investigations for three residents and did not log a COVID-19 outbreak, placing residents at risk for repeat incidents and injury. A resident with severe cognitive impairment suffered a fracture during a transfer, with the investigation lacking necessary statements and a root cause analysis. Another resident experienced an unwitnessed fall, with the investigation missing witness statements and a thorough neurological assessment. A third resident was found on the floor after an unwitnessed fall, with the investigation lacking a neurological assessment. Additionally, the facility did not log a COVID-19 outbreak despite being aware of the first positive case.
The facility failed to complete PASRR evaluations timely for three residents, leading to potential delays in necessary mental health services. A resident with major depression and anxiety, and another with a traumatic brain injury, both required Level II evaluations after a 30-day exemption, but these were not documented. Another resident's Level I PASRR was delayed. Staff interviews revealed lapses in tracking and awareness of PASRR requirements.
A resident with severe cognitive impairment and a history of falls was not provided with the necessary assistance as per their care plan, leading to an avoidable accident. The resident attempted to return to their room with a cup of coffee without staff assistance, resulting in a fall. Interviews with staff confirmed the care plan was not followed, and there was no documentation to support that the required interventions were implemented.
The facility failed to assess and supervise two residents who engaged in smoking, leading to an unsafe environment and potential risk of injury. Despite a non-smoking policy, residents were observed smoking on the property without proper safety measures. The facility did not conduct smoking safety evaluations or develop care plans for these residents, contributing to the deficiency.
The facility did not complete annual performance reviews for six CNAs employed for over a year, potentially affecting their competency and resident care quality. The DON acknowledged the delay in evaluations.
An LPN at a facility was observed administering medications with a 91% error rate, as all medications were given more than one hour past their scheduled times. This affected multiple residents, with medications for blood sugar regulation, iron deficiency, and other conditions being administered late. Staff interviews revealed that assistance should have been sought if running late, and late administration should have been communicated to the provider and resident or POA.
A facility failed to provide a required transfer/discharge notice to a resident with congestive heart failure who was transferred to the hospital. The DON acknowledged that while a transfer form was sent to the hospital, it was not given to the resident, and no documentation of the notice was available.
The facility failed to provide written bed hold notices during hospital transfers for two residents, one with congestive heart failure and another with diabetes and an infection. The Director of Nursing and an LPN confirmed the lack of documentation and the failure to follow the process of offering and documenting bed hold notices, placing residents at risk of not being informed about their rights.
The facility failed to provide adequate assistance with ADLs for three residents, including bathing and nail care. A resident did not receive showers as per their care plan, and another resident's toenails were overgrown due to lack of proper care. Staff interviews revealed gaps in documentation and follow-up on missed care.
Two residents did not receive care according to professional standards, with one not receiving bowel medications or blood pressure medication as ordered, and another missing a CBC lab draw. The facility failed to follow protocols for medication administration and lab collection, leading to unmet care needs.
A facility failed to ensure proper communication with a dialysis center for a resident requiring dialysis services. The facility's policy required a Dialysis Transfer Form to document weights, lab results, medications, and follow-up care, but forms were often incomplete or missing. Staff interviews revealed a lack of awareness of the process for handling incomplete forms, and there was no evidence of follow-up communication with the dialysis center, placing the resident at risk for complications.
The facility failed to ensure residents were free from unnecessary psychotropic medications, lacking proper indications and consent. A resident was prescribed Olanzapine without a supporting diagnosis, another received Ativan and Risperidone without appropriate indications, and a third was given Sertraline without documentation for its use. This oversight placed residents at risk for medication-related complications.
Failure to Provide Written Bed Hold Notices at Hospital Transfer
Penalty
Summary
The facility failed to provide a written bed hold notice at the time of transfer to the hospital for 4 of 4 residents reviewed for hospitalizations and bed holds: Residents 10, 14, 33, and 52. The report states that this failure involved the required documentation or notification related to the residents' needs, appeal rights, or bed-hold policies, and that it placed the residents and/or representatives at risk of not having the necessary information to make an informed decision regarding their ability to return to the facility. Review of the facility's Bed hold policy, dated April 2025, stated that the community would provide a bed hold notice in accordance with applicable regulations and discuss the bed hold note, if applicable, with the resident and responsible party at the time of transfer to an acute hospital. For Resident 14, who had diagnoses including anoxic brain damage, diabetes, and pain, the EHR showed multiple hospital discharges with anticipated return dates, but no documentation of written bed hold information being provided at those times. Resident 33's EHR showed several hospital discharges with anticipated return dates and no documentation of written bed hold information. Resident 52's EHR showed a hospital discharge with no documentation that a written bed hold notice had been provided. Resident 10, who had diagnoses including a stage 3 sacral pressure wound, lumbar spina bifida, paraplegia, and type 2 diabetes, was transferred to the ER per physician orders, and the EHR contained no documentation of written bed hold information being provided at the time of discharge to the hospital. Staff stated that the cart nurse should do the bed hold when sending a resident to the hospital and that documentation would be in progress notes if the resident accepted it, while the Administrator stated they were unaware of the correct bed hold process.
Facility Assessment Did Not Address Resident Smoking Needs
Penalty
Summary
The facility failed to ensure its facility assessment addressed the physical environment, equipment, services, and other physical plant considerations necessary to care for its identified resident smoking population. The facility assessment dated [DATE] documented that the resident population included 8 residents identified with tobacco use, but it did not include further documentation regarding the physical environment, equipment, or services related to resident smoking. Review of the facility policy titled, Resident Smoking Safety, updated January 2025, stated that smoking was not allowed on facility grounds except in designated areas, and that smoking areas were to be provided with metal cannisters for disposal of smoking materials, a portable properly rated fire extinguisher, and a suitable number of code compliant smoking aprons. On 04/07/2026, a resident smoking area was observed in the front parking lot with a canopy style pop up tent, a fire extinguisher, metal smoking receptacles, and smoking aprons, and the tent was blocking one of two accessible handicapped parking spaces. On 04/08/2026, the smoking area and items were observed relocated to another area of the parking lot that was out of compliance with state and local requirements prohibiting smoking within 25 feet of entrances or windows that open. During a resident group interview, three residents stated they kept their own smoking materials and had lock boxes in their rooms but did not have keys for their lock boxes. The Administrator stated awareness of issues regarding the location of the smoking area and was not aware that residents did not have keys for their locking boxes.
Smoking Area Placement Did Not Comply With Policy or Regulations
Penalty
Summary
The facility failed to ensure its smoking policies were implemented in accordance with applicable Federal, state, and local laws and regulations regarding smoking areas and smoking safety. The facility policy titled, "Resident Smoking Safety," updated January 2025, stated that no smoking was allowed on the facility grounds, including parking lots, except in designated areas. During an observation on 04/07/2026 at 11:00 AM, two handicapped accessible parking spaces were present in the front parking lot to the left of the main entrance, and a pop-up canopy style tent had been set up over one of those spaces. A wooden post with a fire extinguisher was placed next to the canopy, and smoking aprons and smoking receptacles were observed in the area. Two residents were observed sitting under the canopy smoking. During an interview on 04/07/2026 at 1:30 PM, Resident 83 stated they were a smoker, had been in the facility since January 2026, and had been concerned that the smoking area was in the parking lot and blocking one of the handicapped parking spaces. On 04/08/2026 at 2:00 PM, the smoking area had been relocated, but it was then observed to the right of the facility entrance within 25 feet of the entrance and nearby windows that could open. During an interview on 04/13/2026 at 2:00 PM, the Administrator stated they were aware there were issues with the location of the smoking area and that there was not a definitive plan regarding the smoking area or its placement.
Insufficient Nursing Staff Leading to Delayed Call Responses, Missed Care, and Medication Issues
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient and qualified nursing staff to meet residents’ needs, resulting in prolonged call light response times, delayed assistance with activities of daily living (ADLs), missed or delayed restorative and shower care, and untimely medication administration. The facility assessment dated 04/01/2026 identified a need for 5 RNs, 5 LPNs, 5 NACs, and 2 restorative aides but did not include shower aides. Review of staffing patterns for the prior 31 days showed wide variation in NAC coverage, with only 4 or 5 NACs on duty for 6 of 31 days. Restorative aides reported being pulled from restorative programs to work the floor, and staff interviews confirmed ongoing short staffing, frequent call-outs, and the absence of dedicated shower aides, leaving floor staff responsible for multiple showers in addition to caring for 10–11 residents each. Multiple residents reported long call light response times, particularly around shift changes and staff breaks. One resident stated they routinely waited over 30 minutes at shift change and described slipping in the bathroom after deciding not to wait any longer for help, then contacting their surgeon for an x-ray due to foot pain. Another resident reported experiencing falls and described call light waits longer than 30 minutes during staff breaks, leading to fear of incontinent episodes. Several residents described waiting 20–60 minutes or longer for assistance, including one who said they waited hours when they first arrived, and another who stated that if they were having a heart attack, the long wait at shift change would not be good. Observations by surveyors showed a call light activated at 9:50 AM with multiple staff walking past it; the light did not receive a response until 10:12 AM and was turned off at 10:14 AM. Family members and grievances corroborated these concerns. One family member reported finding their spouse covered in bowel movement and waiting about 40 minutes after activating the call light. Several family members stated there were noticeably more staff present when state surveyors were in the building and that staffing dropped significantly after surveyors left, describing the facility as a “ghost town.” Another family reported having a relative from another floor come up to check on a resident because they did not receive enough help, and described calling the nurses’ station multiple times with no answer, then calling the resident’s cell phone and using speakerphone so the resident could call for help. Grievances documented residents waiting 40 minutes to two hours for call light responses, including one resident who reported being told by a NAC that they had been on break and that there was no other NAC to cover, and another who reported that full urinals were not emptied, resulting in them wetting their pants. Resident council minutes and a resident council meeting further detailed the impact of insufficient staffing. Residents reported call lights not being answered timely, residents falling and remaining on the floor for extended periods, and residents pulling call lights out of the wall or walking down the hall partially undressed to get help. One resident described hearing another resident yelling for help and finding them hanging off the bed with their head nearly to the floor; they held the resident’s head until staff arrived, who then stated the resident was not their assignment. Residents also reported that staff passing meal trays did not respond to call lights and said they could not provide care until everyone was done eating, and that one resident remained soiled and in a wheelchair from 6:00 PM to 9:00 PM before being changed. Medication administration and restorative care were also affected. One resident reported that nurses gave their dinner and bedtime medications together despite their objections, and several residents stated that both agency and facility nurses left medications at the bedside without observing ingestion. A restorative aide reported that there were many more restorative programs now, but restorative staff were frequently pulled to work the floor, especially in the prior month, resulting in missed restorative programs. Staff confirmed that showers were missed due to the lack of shower aides and that NACs were expected to complete multiple showers in addition to their regular assignments. During an interview, the RCM stated the facility was still short staffed, that call-outs were a problem, and that staff morale was down after schedule changes. When asked if the QAPI committee was aware of staffing issues, the Administrator initially responded, “Really?” and then said, “Let’s move on,” without providing additional information.
Grievances Not Promptly or Thoroughly Investigated
Penalty
Summary
The facility failed to ensure resident grievances were reviewed promptly and thoroughly resolved with supporting documentation for multiple residents, including concerns involving call light response, missing personal property, showering practices, communication with staff, and possible neglect or verbal mistreatment. The grievance policy stated the administrator was the designated grievance official and that grievances were to be resolved immediately when possible or routed promptly when not possible, but the record showed several grievances were not fully investigated, were not clearly documented, or were not escalated when the allegations involved possible abuse or neglect. Resident 105, who had diagnoses including major depressive disorder and anxiety, reported that the facility lost blankets and clothing, including a black blanket given by a deceased son. The resident stated the missing items had been reported to laundry without follow-up and that reimbursement had not been offered. Record review showed the resident’s inventory listed several blankets, but staff interviews reflected confusion about which blanket was missing and whether it had been inventoried. Staff also stated the resident had been told the facility would not reimburse the item because it was not on the initial inventory list, and a later interview showed a new grievance was completed for the missing blanket. Several other grievances lacked complete investigation or documentation. Resident 122’s shower grievance documented a missed shower and greasy hair, but the findings did not include supporting documentation of the alleged refusal or discussion with the resident, and the grievance was not signed by the resident. Resident 124’s grievance about being showered near a resident of the opposite sex and experiencing a two-hour call light delay was considered resolved as isolated, but the findings did not address the call light circumstances in detail, did not include interviews with other residents, and did not include call light audits or documentation of staff education related to shower room practices. Resident 47’s grievance about unclear communication and a nurse threatening them was resolved with a statement that medications would be given as ordered, but no further interviews or documentation were completed to rule out abuse or neglect. Resident 95’s grievance about communication problems and call light delays was received 12 days after it was dated, lacked documentation of the nature and timing of the concerns, and had limited audit and education documentation. Resident 57’s grievance about a staff member having an attitude and not responding appropriately when the resident reported bowel movement needs and difficulty keeping food down was not escalated to an investigation, and the findings did not address the potential verbal/mental abuse or neglect concerns. Resident 30’s grievances about delayed call light response, a full urinal, and wet clothing were handled with limited documentation and education, but the findings did not identify or rule out neglect. Resident 79’s grievance about staff saying they did not have time or help to provide care lacked details about the care not provided and did not include interviews with other residents to determine whether the issue affected others.
Psychotropic Medications Given Without Required Behavior Monitoring
Penalty
Summary
The facility failed to ensure that 5 of 7 sampled residents were free from unnecessary psychotropic medications because behavioral symptoms, non-pharmacological interventions, and medication effectiveness were not monitored or documented as required. The report states that the facility policy required behavior monitoring to identify problem behaviors and specific interventions before psychoactive medications were initiated, and that if behaviors changed, an evaluation, alert charting, notification, behavioral monitoring, and non-pharmacological interventions were to be documented. Resident 4 had diagnoses including anxiety and depression, intact cognition, minimal depression, and verbal behaviors toward others. The resident was prescribed buspirone, duloxetine, and hydroxyzine, and these medications were administered daily. The record contained no physician orders to monitor behavioral symptoms and no orders for non-pharmacological interventions or documentation of whether they were effective. Resident 6 had diagnoses including anxiety, depression, PTSD, and disorganized schizophrenia, and was prescribed buspirone, duloxetine, quetiapine, and trazodone, all given daily. The record likewise lacked orders to monitor behaviors, lacked orders for non-pharmacological interventions, and lacked documentation of whether interventions were effective. Resident 104 had diagnoses including dementia, anxiety, and depression, with impaired cognition, minimal depression, and delusions noted on the MDS. The resident was prescribed quetiapine twice daily, but there were no physician orders to monitor behavioral symptoms and no orders for non-pharmacological interventions or documentation of effectiveness. Resident 13 had diagnoses including Alzheimer’s disease, anxiety, depression, and delirium, with severely impaired cognition and a care plan listing target behaviors such as anxiousness, crying, wandering, insomnia, panic, withdrawal, and self-isolating. The resident received escitalopram and quetiapine daily and lorazepam twice in March 2026, but there were no orders to monitor behavioral symptoms and no orders for non-pharmacological interventions. Resident 18 had diagnoses including frequent falls, Parkinson’s disease, and anxiety, and had an order for alprazolam every 12 hours as needed. The resident received 6 PRN doses in March and 8 PRN doses in April, but the MARs did not document any non-pharmacological interventions attempted before administration, did not identify target behaviors that justified the medication, and only noted that the medication was effective afterward. Interviews with nursing and leadership staff confirmed that licensed nurses were not completing daily behavior monitoring for residents receiving routine or PRN psychotropic medications, that NAC documentation was being used instead, and that staff could not provide documentation showing licensed nurses monitored behaviors or documented non-pharmacological interventions for these residents.
PASRR referrals and follow-up were not completed or documented for residents with mental health needs
Penalty
Summary
The facility failed to ensure Level 1 PASRRs were referred and followed up on for multiple residents with mental health or cognitive diagnoses. Review of records showed that Residents 11, 13, 73, 82, and 104 all had PASRR-related issues involving required Level 2 referrals, follow-up, or revision of the screening when the resident’s condition was not accurately reflected. Staff K, the Regional Social Services Director, stated that positive Level 1 PASRRs were expected to have a Level 2 evaluation or Notice of Determination on file, and that for 30-day exemptions a request for Level 2 should be sent around day 24 to 25. Resident 82 was admitted with anxiety disorder, schizophrenia, and unspecified psychosis. The Level 1 PASRR dated 02/22/2026 identified serious mental illness indicators and stated that a Level 2 evaluation was not needed at that time because of an exempted hospital discharge, but that if the resident remained in the nursing home longer than 30 days, a Level 2 evaluation had to be completed. On 04/07/2026, the record lacked documentation of a Level 2 request or communication with the PASRR coordinator, and Staff K later provided an email dated 04/07/2026 but could not provide documentation of any earlier submission for the Level 2 request before the deadline. Residents 11 and 73 each had Level 1 PASRRs dated 11/24/2025 that required Level 2 referrals, and progress notes documented that the Level 1 PASRRs were sent to the Level 2 evaluator on 11/26/2025. However, Staff K stated there was no monthly follow-up for Resident 11, and for Resident 73 Staff K was unsure whether documentation existed showing contact or monthly follow-up with the Level 2 evaluator between 11/26/2025 and 04/07/2026. Resident 13 had PASRRs showing Level 2 referral was required for serious mental illness, but the electronic chart did not contain Level 2 evaluation documents, and the record did not show ongoing follow-up documentation after the referral was sent. Resident 104 had a Level 1 PASRR that indicated a Level 2 was needed, but the resident’s later records documented unspecified psychosis, repeated auditory and visual hallucinations, frequent 911 calls, and wander/elopement risk; Staff G could not locate a PASRR revision, and the Level 1 PASRR was not revised to reflect the resident’s psychosis and need for a Level 2 evaluation.
Care Plans Not Updated for Changes in Condition
Penalty
Summary
The facility failed to revise care plans as needed for residents with changes in condition, including residents reviewed for accidents, skin issues, and activities of daily living. The report states that 5 of 9 sampled residents had care plans that were not updated to reflect current needs, including 2 of 6 residents reviewed for accidents, 2 of 3 residents reviewed for skin issues, and 1 of 6 residents reviewed for ADLs. Resident 56 was admitted with diagnoses including convulsions, Parkinson's disease, polyneuropathy, and anxiety, and the admission MDS documented severe cognitive impairment. The resident had seizure activity on 02/18/2026 and was transported to the emergency room. The record showed seizure precautions were ordered every shift, the resident was assessed as a high fall risk, and the resident experienced falls on 03/01/2026, 03/09/2026, 04/09/2026, and 04/10/2026. The care plan dated 02/12/2026 addressed fall risk and included interventions such as keeping the call light within reach and maintaining a safe environment, but it did not include seizure precautions. Staff interviews confirmed seizure precautions were on the physician orders but not on the care plan. Resident 84 was admitted with diabetes, peripheral vascular disease, and venous insufficiency, and the quarterly MDS documented an infected diabetic foot ulcer with dressing orders. Wound documentation showed a diabetic ulcer to the right heel, and the resident was observed with the right heel on the bed with an ice pack on the foot. The care plan identified risk for pressure ulcer related to limited mobility and noted the resident developed a right heel diabetic ulcer, but it lacked individualized goals and interventions for prevention and treatment of the wound. Resident 41 developed MASD after the admission MDS showed no MASD, and the quarterly MDS later documented MASD, but the care plan was not revised when the skin issue developed. Resident 46's quarterly MDS documented independence with toileting, dressing, bed mobility, transfers, ambulation, and continence, while the ADL care plan still listed supervision, assistance, and dependence for several ADLs; staff observed the resident ambulating and obtaining weight independently, and staff interviews indicated the care plan did not reflect the resident's current ADL needs.
Expired and Unlabeled Medications in Carts
Penalty
Summary
Drugs and biologicals were not consistently labeled, dated, or stored free of expired items. In Medication Cart B on the second floor, an insulin pen was found with an expired date of 04/03/2026, and Staff P removed and disposed of it after the observation. In Medication Cart C on the first floor, two opened insulin vials were observed without a date showing when they were first used. Staff Q stated that insulin vials should be dated when opened and that they are only good for 28 days after opening. In the Treatment Cart on the first floor, 11 packets of lubricating jelly and 2 boxes of Saline Fleets Enema were found expired. Staff Q stated that all nurses are responsible for checking medication and treatment carts for expired items, and the DNS stated they were not aware of the expired medications and unlabeled insulin vials in the carts.
Unpalatable and poorly presented meals
Penalty
Summary
The facility failed to provide a nourishing, palatable, well-balanced diet that met residents’ daily nutritional and special dietary needs and preferences for 4 of 14 residents reviewed. Resident 121 stated the facility food did not look or taste good, and at the time of observation the lunch tray was uncovered on the overbed table and pushed to the side, with three pieces of uneaten fish and a scoop of brown rice and carrots. Resident 119 stated their fish was cold and dried out and that their coffee was warm for the first time ever. Resident 35 stated the food was terrible and they would not feed it to their dog, and Resident 19 stated the facility food tasted terrible, was not appealing, and looked like canned food. An observation of two test trays showed the gluten meal and regular meal temperatures at 142.3 degrees and 148.5 degrees for the main dish casserole, with mixed vegetables at 117.8 degrees and 127.8 degrees. The gluten-free meal had no roll while the regular meal had a roll, and there were no condiments other than salt and pepper. There were no drinks on the trays because drinks were resident specific and poured by staff before trays were provided. The casserole was molded into the scoop used to serve it, creating an institutional presentation rather than a homelike one. The vegetables were overcooked, very soft, and lacked color, and the meat in the casserole was described as poor quality, almost too lean, and thinned. The dish lacked spices or flavor and tasted like nothing, and the dessert was a brownie with a dab of whipped topping.
Improper Storage and Monitoring of Nourishment Refrigerators
Penalty
Summary
The facility failed to ensure food was stored under sanitary conditions in 2 of 4 snack/nourishment refrigerators. In the second-floor nourishment refrigerator, surveyors observed 12 small bottles of drinkable yogurt with an expiration date of 03/31/2026, dairy creamer with an expiration date of 2/2026, a plastic bag containing an undated to-go box, and opened, undated salad dressing in the door, and no temperature logs were observed during the observation. In the first-floor nutrition refrigerator, the temperature log was present but the temperature and signature boxes were blank for 04/08/2026 and 04/09/2026, and expired resident yogurt dated 12/2025 was found in the refrigerator. Staff stated they were unaware of who was supposed to monitor the refrigerator temperature and food items, and the Senior Regional Registered Dietitian stated the expired yogurt was discarded and documented on the temperature log for the current date.
Resident Council Concerns Not Documented or Addressed in Meeting Minutes
Penalty
Summary
The facility failed to document and address issues raised by the Resident Council for seven consecutive months of meeting minutes reviewed. The facility policy stated resident council concerns were to be discussed, resolved through the grievance policy, and responded to by the next meeting. However, the minutes for September, October, November, and December 2025 showed no issues or concerns with administration, nursing, maintenance, social services, or activities, and no old business was discussed. The January 2026 minutes included an unidentified grievance, a maintenance concern about heat in an unknown location, and a dietary concern about weekend meals, while the February 2026 minutes noted concerns discussed with the DON and a concern about call lights being answered in a timely manner. The March 2026 minutes again stated there were no issues or concerns and no old business. The grievance log showed resident council concerns, including rude staff and a dirty ice scoop, were escalated to a grievance report and investigation on 03/18/2026. During a resident council interview, residents stated grievances from meetings were not followed up on, the minutes were not accurate, complaints had gone unresolved for months, and residents were scared to write grievances. Staff E, the Activity Director, acknowledged that concerns were escalated to grievance forms but also acknowledged writing that no concerns were voiced on the resident council minutes. The DON stated that documenting no issues or concerns on the resident council meeting forms was not accurate and needed to change.
Failure to assess and monitor wedges used as restraints
Penalty
Summary
The facility failed to comprehensively assess and monitor the need for physical restraints for two residents who had green wedges placed under their fitted sheets along the edges of their beds. Resident 41 was admitted with diagnoses including intracerebral hemorrhage, generalized anxiety disorder, and aphasia, and had severe cognitive impairment, was not understood, and required two-person assistance with bed mobility and transfers. Resident 55 was admitted with profound developmental delay, autism, depression, anxiety disorder, and a history of falling with a recent neck fracture, and had impaired cognition and needed one-person assistance with bed mobility and transfers. Both residents were documented in MDS assessments as not currently using physical restraints. Observations showed Resident 41 repeatedly in bed with two or three green triangular wedges tucked under the fitted sheet, lining the edge of the bed and not removable by the resident. The resident was seen attempting to climb over the wedges, crying and trying to get over them, and later found sitting on the floor on the fall mat. Staff stated the wedges were in place so the resident stayed in bed and did not fall, while the ADON stated the wedges should be used for positioning only and was not aware they were being used to line the bed. The resident’s spouse stated they did not sign consent for the wedges to be used to keep the resident in bed. The clinical record showed no evidence of a comprehensive and accurate assessment, physician order, consent, care plan, or ongoing evaluation supporting restraint use. Resident 55 was observed restless in bed with a neck collar, positioned in the middle of the bed with two green wedges under the fitted sheet and a mat on the floor, and the wedges were not removable by the resident. Repeated observations showed the wedges lining the edge of the bed over several days. Review of the clinical record showed no evidence of a comprehensive and accurate assessment, physician order, consent, care plan, or ongoing evaluation for restraint use. Staff interviews indicated the wedges were supposed to be for positioning only and that using them to line the bed would be a restraint, and the DON stated the issue would be fixed immediately because the wedges should be used for positioning only.
Failure to Provide Grooming Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide assistance with grooming, including shaving and nail care, for residents who were dependent on staff for ADLs. Resident 89 was admitted with diagnoses including traumatic brain bleed, multiple sclerosis, and COPD. Their admission MDS documented dependence for personal hygiene, and the care plan documented dependence on staff for grooming. Observations on 04/07/2026 and 04/09/2026 showed prominent chin hairs and unkempt hair, and on 04/13/2026 Resident 89 was observed in bed with unbrushed wet hair, nails not trimmed, and chin hairs not shaved, despite documentation that they had a bed bath that day. Staff stated shaving and nail care were typically done on shower days, and the DON stated the expectation was that ADLs, including hair, shaving, and nail care, were completed every day. Resident 121 was admitted with diagnoses including type 2 diabetes, bladder infection, and heart failure. Their care area assessment documented that they required assistance with all ADLs, and the care plan documented dependence on staff for grooming with a preference for showers twice weekly. The record showed bed baths on multiple dates, but there was no documentation explaining why bed baths were provided instead of the resident’s preferred showers. The resident stated they had not had a shower since admission, only bed baths, and that the bed baths were not adequate. They were observed with facial hair approximately a quarter to a half inch long, became tearful when discussing the lack of help, and stated they needed assistance and were not getting it. The resident also stated they needed a hair removal product rather than a razor because razors caused bumps on their face. Resident 104 was admitted with diagnoses including dementia, anxiety, and depression. The quarterly MDS showed cognitive impairment and no refusal of care. A provider note documented very dry and scaly skin on the lower limbs and feet related to deficient hygiene care. Observations showed white chin hairs, long and jagged fingernails, and later continued need for shaving and nail care, including unsafe nails remaining on the right hand after partial trimming. Provider notes documented thickened, discolored, brittle toenails consistent with onychomycosis and ongoing dry, scaly skin requiring regular showering. Behavior monitor documentation included refusal of care in February and neglecting self-care in March, and the DON stated NACs were responsible to shave men and women and that the facility did not have an ADL policy.
Failure to assess abuse allegations and carry out ordered care
Penalty
Summary
The facility failed to assess and document possible injury and psychological distress after abuse allegations involving two residents. Resident 72 reported that an LPN left pills for them to take when they wanted to, then told them they had to take a narcotic because it had already been removed from the narcotic card. Resident 72 also reported that a female aide suggested they urinate or defecate in a diaper because the bathroom was occupied, and the resident said they reported this concern to the ADNS. The record reviewed for the days after these allegations contained no mention of the allegations, no assessment for injury, and no monitoring for psychological distress. Resident 106, who had diagnoses including cerebral palsy, seizure disorder, bipolar disorder, and pain, was reported by another resident during a Resident Council meeting to have been left soiled in a wheelchair with a dinner tray in front of them for about three hours. The report was said to have been made to staff, but when the allegation was brought to the DON, the record reviewed for the following days showed no skin injury assessment, no mention of the allegation, and no monitoring for psychological distress. The DON stated they were responsible for setting up alert charting after the allegations and was not aware that no alert documentation had been completed for either resident. The facility also failed to ensure Resident 28 received care and treatment for a suprapubic catheter and failed to obtain the ordered behavioral health consult for Resident 104. Resident 28, who had hereditary spastic paraplegia and neurogenic bladder, stated their suprapubic catheter had not been changed since admission. Hospital discharge orders indicated follow-up with urology for a routine catheter change, but the chart contained no documentation of the catheter type, no order for catheter change, and no record of the scheduled urology appointment. Resident 104, who had dementia, anxiety, depression, impaired cognition, minimal depression, and delusions, had a provider order to arrange a behavioral health consult after increased paranoid behavior and delusions were documented, but the clinical record contained no evidence that the consult occurred and no care conference documentation showing discussion of the consult.
Failure to Assess and Support ROM for Resident With Stroke-Related Right-Side Impairment
Penalty
Summary
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason, was not comprehensively addressed for one resident with a history of stroke affecting the dominant right side. The resident was observed with the right hand balled into a fist except for two fingers, and no splints, hand rolls, or other devices were present. The care plan, last revised on 02/11/2026, documented the resident was not on any restorative programs. Record review and staff interviews showed the resident had previously received restorative services, but those services had ended when therapy resumed after hospitalization. The Director of Rehabilitation stated the resident was screened quarterly by staff knowledge of baseline rather than a formal tool, and the resident was currently receiving PT only. The PT stated the resident had limited ROM on the right side due to stroke, had spasticity, and had no known splinting device or interventions for the right hand. OT staff manually opened the right hand and observed thickened yellow matter on the palm, stated an OT evaluation would need to be completed, and noted the hand could develop a contracture if not addressed and left for several months. The resident's OT records showed prior right wrist ROM changes and a prior goal for tolerance of a resting hand roll splint, while the DON stated the facility expectation was that residents were evaluated by PT and OT as changes or decline were identified.
Unsafe fall prevention and smoking material storage
Penalty
Summary
The facility failed to ensure residents were free from accidents for two residents reviewed for falls and four residents reviewed for smoking safety. The report states that smoking materials were not consistently secured and that fall prevention interventions were not fully implemented or updated after falls, leaving residents exposed to unsafe conditions documented by surveyors through observation, interview, and record review. Resident 56 was admitted with diagnoses including convulsions/seizure activity, Parkinson’s disease, polyneuropathy, depression, and anxiety, and the admission MDS documented severe cognitive impairment. The resident’s records showed a high fall risk, seizure disorder, and multiple falls after admission, including non-injury and injury falls. Although seizure precautions were ordered, the care plan did not include seizure precautions. Staff and collateral contacts stated the resident was known to be a high fall risk, that the family declined one proposed bed placement, and that fall mats were not provided until after the third fall. Staff also stated they were unaware of what seizure precautions were and that typical fall prevention measures included fall mats and bed positioning. Resident 18 was admitted with diagnoses including frequent falls, Parkinson’s disease, and anxiety, and was assessed as a high fall risk. The care plan included basic fall interventions such as call light use, proper footwear, and keeping the room free of clutter. After the resident was documented as not initiating use of the call light and needing staff to anticipate needs, the resident sustained a fall with a head laceration requiring emergency room transfer and staples. A second fall occurred shortly afterward, but the record did not include nursing documentation of the details, and staff statements were incomplete. The care plan was not updated after the first fall, and additional interventions such as a low bed, fall mat, frequent safety checks, toileting program, and keeping the resident in public areas were added only after the second fall. Observations later showed the fall mat was not consistently positioned and was sometimes absent when the resident was observed leaning toward the floor. For smoking safety, the facility policy stated smoking materials, including cigarettes and lighters, were to be locked up. Surveyors observed one resident with cigarettes in a dresser drawer and later with cigarettes and a butane lighter on a table in the dining room, while another resident stated smoking materials were kept in the room because staff took too long to retrieve them and that they had no key to the lock box. Additional residents reported having lock boxes without keys or keeping smoking materials in their rooms. Staff acknowledged they were unaware that smoking materials were not consistently secured and confirmed that the location of smoking materials should be included on the care plan. The report also states this smoking safety issue was a repeat deficiency from prior surveys.
Failure to Provide and Document Ordered Fluids and Fluid Restriction
Penalty
Summary
The facility failed to provide adequate fluids to maintain hydration for Resident 56 and Resident 89, and failed to ensure a fluid restriction was implemented and documented for Resident 121. The report states that the facility also failed to implement, monitor, and accurately document fluids consumed to ensure fluid restrictions were followed per provider orders. The cited policy, Hydration Program, required staff to offer fluids unless contraindicated by a physician order for fluid restrictions and noted that water pitchers were to be available at bedside for residents not on fluid restrictions. Resident 89 had diagnoses including a brain bleed, multiple sclerosis, COPD, and neuromuscular dysfunction of the bladder, with severe cognitive impairment and an indwelling catheter. The resident’s care plan identified altered nutrition/hydration status, maximum assistance needed for eating and drinking, and monitoring for signs and symptoms of dehydration. The nutrition evaluation estimated fluid needs of 1982-2180 mLs per day. Observations showed an IV pole in the room with half a bag of 0.9% sodium chloride and tubing connected on multiple dates in April. The order summary showed IV hydration was ordered for only four days, while other orders included thin liquids, one-on-one assistance with meals, a house supplement with meals, catheter output every shift, a diuretic for left hand swelling, and Lactulose three times daily. Resident 56 had diagnoses including Parkinson’s disease, convulsions, and hypertension, and severe cognitive impairment. After an unwitnessed fall, the resident’s blood pressure was documented as low at 82/58, and IV hydration with 0.9% Sodium Chloride was ordered; after about one hour of IV fluids, the blood pressure returned to 122/62. A family member stated the resident’s lunch tray was often left untouched because staff did not assist with feeding, and that water bottles brought from home were empty about half the time. Resident 121 had diagnoses including type 2 diabetes, bladder infection, and heart failure. The hospital discharge summary documented a carbohydrate-controlled diet with a 1500 mL fluid restriction and daily weights, but the restriction was not entered in the orders, the care area assessment did not document it as a consideration, the MAR/TAR had no documentation related to the restriction, and no weekly weight was documented. Nursing assistant documentation showed the resident consumed more than 1500 mLs on five of eleven days, and kitchen meal slips did not include the fluid restriction.
Respiratory Care Orders and Care Plan Missing for Resident on Oxygen
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met for Resident 89, who was admitted with acute and chronic respiratory failure with hypoxia and COPD. The resident’s admission MDS documented oxygen use. The physician orders included checking oxygen levels every shift and administering supplemental oxygen if oxygen was less than 90%, and also included Albuterol nebulization every six hours as needed for wheezing or shortness of breath. The facility policy stated that oxygen administration should be per physician’s order and that orders should specify the method of administration, liter flow, and parameters for duration and/or frequency. Resident 89’s care plan, dated 12/30/2025, had no documentation related to oxygen needs, respiratory medications, or respiratory diagnoses. During observations, Resident 89 was seen wearing oxygen via nasal cannula at 2 lpm, then 2.5 lpm, then 3 lpm. Staff interviews indicated that Resident 89 always wore oxygen and that oxygen levels were checked every shift, while the Assistant DON stated the oxygen order only directed oxygen use when the resident’s oxygen level was less than 90% and that the oxygen order should include the flow rate and oxygen should be on the care plan. The DON stated expectations were for oxygen physician orders to include the flow rate and for oxygen to be included in the care plan.
Incomplete and Inaccurate Resident Charting
Penalty
Summary
The facility failed to ensure resident records were complete and accurate for 2 of 5 residents reviewed. Resident 28 was admitted with diagnoses including hereditary spastic paraplegia and neuromuscular dysfunction of the bladder. Hospital discharge orders dated 03/14/2026 and timestamped 03/16/2026 documented a suprapubic catheter change, but the resident’s care plan dated 04/08/2026 documented only an indwelling catheter without specifying the catheter type or any catheter-specific care instructions. Review of the MAR/TAR showed missing documentation for catheter output on multiple shifts, including evening shift 03/17/2026, day and overnight shifts 03/22/2026, day shift 03/27/2026, evening shift 04/02/2026, day and evening shifts 04/05/2026, and day and overnight shifts 04/06/2026. Resident 121 was admitted with diagnoses including type 2 diabetes, bladder infection, and heart failure. Review of the MAR/TAR from 04/01/2026 through 04/09/2026 showed missing documentation for medicated vaginal cream on 04/02/2026, drain output on 04/04/2026 evening shift and 04/06/2026 overnight shift, and ear drops on 04/06/2026 evening shift. In interview on 04/13/2026 at 9:43 AM, Staff D, LPN/Resident Care Manager, stated it was the facility’s expectation that nurses and nursing assistants complete charting, that a daily report was printed and missing documentation was reviewed, and that staff responsible were contacted to complete charting, though it was more difficult to hold agency staff accountable.
Infection Control Practices Not Followed During Wound Care and Medication Administration
Penalty
Summary
The facility failed to ensure infection control practices were followed for a resident with Enhanced Barrier Precautions related to an implanted medical device and wounds. Resident 28 was admitted with multiple decubitus ulcers on the buttocks and bilateral legs, osteomyelitis, hereditary spastic paraplegia, and a suprapubic catheter. During wound care observation, the RN/ADNS provided wound care without wearing a gown despite EBP signage outside the room directing staff to use a gown and gloves for high-contact resident care. The RN/ADNS also donned and doffed gloves during the wound care without performing hand hygiene in between. The facility also failed to follow hand hygiene and glove-use practices during medication administration. An LPN put on gloves without performing hand hygiene, cut a pill in half, entered a resident’s room with the same gloves, and administered the medication. After removing the gloves, the LPN touched the medication cart computer mouse without observed hand hygiene. The LPN stated hand hygiene should have been done before putting gloves on and after taking them off, and the DON and infection disease nurse stated staff were expected to perform hand hygiene before donning gloves and after doffing gloves.
Failure to Post Complete Daily Nurse Staffing Information
Penalty
Summary
The facility failed to consistently post the required daily nurse staffing information in a location readily accessible to residents, family members, and visitors, and failed to include the required information for all days reviewed. During observation on 04/13/2026 at 9:55 AM, the daily nurse staffing information was found posted on a wall near the reception desk, with the current information for 04/13/2026 displayed and the prior posting dated 04/10/2026. However, the postings for the weekend dates of 04/11/2026 and 04/12/2026 were missing. In an interview on 04/10/2026 at 9:50 AM, the staffing coordinator stated they were responsible for posting and updating the daily nurse staffing information. In a subsequent interview on 04/13/2026 at 10:00 AM, the same staffing coordinator reported that no one completes the daily nurse staffing information on weekends when they are not present, resulting in the absence of required staffing and census information for those days. This failure placed residents, family members, and visitors at risk of not being fully informed of current staffing levels and resident census information.
Failure to Protect Resident From Sexual Abuse and to Immediately Report Allegation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from sexual abuse and to immediately recognize and report an allegation of sexual abuse by a staff member. The facility’s abuse policy defined sexual abuse as non-consensual contact of any type with a resident, including unwanted intimate touching, and required all employees as mandated reporters to report allegations immediately, defined as as soon as possible but not later than two hours after an allegation is made. Despite this, a resident with diagnoses including bipolar disorder, agoraphobia, and anxiety disorder, and a care plan focus on impaired psychosocial well-being and feeling safe in the facility, reported sexually inappropriate touching and comments by a contracted NAC during peri-care. According to the facility’s investigation, the resident stated that the NAC entered their room to change their brief, stroked the inside of their thigh, commented that the resident was “hot,” made the peri area “very wet” with wipes, and responded to the resident’s objection by saying “that’s how it’s supposed to be.” The NAC also allegedly asked if the resident was single or married. The resident consistently repeated the same account of events, including specific details such as clothing color, and stated they would not feel comfortable if the NAC continued to work at the facility. The resident had previously informed another caregiver about feeling uncomfortable with the NAC’s care and comments, and that caregiver switched room assignments so the NAC would no longer care for the resident that day, but did not report the allegation or the reason for the room change to nursing staff. Staff interviews and documentation show that the allegation was not reported in accordance with the facility’s policy. One caregiver acknowledged being told by the resident that the NAC made them feel very uncomfortable, said they were skinny and beautiful, and provided peri-care differently—taking longer and being gentle—but only told the nurse they were switching rooms, without disclosing the resident’s statements. The LPN/Resident Care Manager documented the allegation the following day and reported being informed of the incident at the end of that day, and the DON stated they were notified later that same day by phone. During this time, the NAC reported having worked a double shift and providing care to the resident more than once, and stated they performed care alone and were unaware the resident required cares in pairs. The delay in recognizing and reporting the allegation meant the alleged perpetrator continued working with residents and retained access to the resident after the alleged sexual abuse.
Failure to Timely Report Sexual Abuse Allegation to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely reporting of a sexual abuse allegation to the State Agency in accordance with its abuse reporting policy and state and federal law. The facility’s policy, updated October 2022, required that all suspected or alleged abuse be reported immediately, and no later than two hours, when events involve allegations of abuse or result in serious bodily injury. Resident 1, admitted with bipolar disorder, agoraphobia, and anxiety disorder, had an admission MDS showing intact cognition, no refusal of care, no behaviors, and dependence on staff for toileting and personal care. The facility’s investigation documented that an alleged sexual allegation involving Resident 1 as the victim and a NAC (Staff H) as the alleged perpetrator occurred on 02/22/2026, but the allegation was not reported in the state Secure Reporting and Tracking System (STARS) until 02/23/2026 at 7:22 PM. Multiple staff members were informed of the allegation on the day it occurred but did not report it. Staff D, NAC, stated that during the 6:00 AM–2:00 PM shift on 02/22/2026, Resident 1 reported that Staff H made sexual comments and touched them inappropriately during care; Staff D only switched rooms with Staff H and did not report the allegation. During the 2:00 PM–10:00 PM shift on 02/22/2026, Staff E, NAC, was informed in shift report that Resident 1 had reported sexually inappropriate comments by Staff H and feeling uncomfortable, and Staff F, NAC, stated Resident 1 told them that Staff H had sexually assaulted them and made inappropriate comments during care; neither Staff E nor Staff F reported the allegation. The DON later stated the sexual allegation should have been reported immediately once the first staff member was informed, and the Administrator was unaware that multiple staff had knowledge of the allegation on 02/22/2026 and had failed to report it.
Failure to Conduct Thorough Abuse and Misappropriation Investigations
Penalty
Summary
The deficiency involves the facility’s failure to conduct thorough investigations into allegations of abuse and misappropriation, contrary to its own abuse investigation policy. The policy, updated in October 2022, requires the administrator/abuse coordinator to oversee investigations and ensure identification and interviews of the alleged victim, alleged perpetrator, witnesses, and others with knowledge of the allegation. Surveyors found that these requirements were not followed in two separate incidents involving alleged sexual abuse of one resident and missing narcotic medication for another resident. In the first case, a resident with bipolar disorder, agoraphobia, and anxiety disorder, who had intact cognition and was dependent on staff for toileting and personal grooming, reported that a staff member made inappropriate comments and touched them inappropriately while providing peri-care. The facility’s investigation identified a NAC as the alleged perpetrator and documented that the incident occurred on a specific date. The investigation included statements from two NACs and two nurses who worked the evening shift, as well as a statement from the Resident Care Manager. However, both NAC statements indicated the alleged incident occurred during the day shift, and no staff from that day shift were interviewed. A NAC identified in a witness statement as the first person to whom the resident reported the allegation was not interviewed, and no statement from this NAC was obtained. The DNS, who was responsible for completing the investigation, acknowledged not interviewing any day-shift staff and stated they had not conducted further interviews beyond the statements already gathered. In the second case, the facility failed to thoroughly investigate missing narcotic medication for another resident. An investigation report documented that during narcotic count it was determined that the resident’s narcotic medication was missing and that the facility could not establish the location of the medication or whether it was lost or mistakenly destroyed. The incident report included a police report for theft and an email from the DNS describing the medication as misplaced, which was inconsistent with the investigation documentation. The incident report contained no witness statements and no statements from nurses who had recently worked the medication carts. The ADON described an established medication destruction process and required documentation, but the DNS stated they had not reviewed any destruction forms faxed to the pharmacy and had not gathered witness statements or interviewed other nurses who had worked the medication cart prior to discovering the medication missing. A night-shift RN reported notifying the DNS about the missing narcotics and being instructed to copy the narcotic book page and place it in the DNS’s box, but did not see or meet the DNS before leaving the facility, further underscoring the lack of follow-through in the investigation.
Failure to Follow Physician Orders for Antiseizure Medication Administration
Penalty
Summary
The facility failed to ensure physician orders for medications were followed for a resident with a seizure disorder and a lumbar vertebral fracture. The resident’s care plan dated 01/14/2026 documented a seizure disorder with a goal for the resident to remain injury free from seizure activity. During an interview on 03/02/2026 at 9:30 AM, the resident reported that their antiseizure medications were late several times and that some nurses understood the importance of these medications while others did not. The resident stated they had spoken with an LPN (Staff M) about these concerns. In a separate interview on 03/02/2026 at 10:31 AM, Staff M stated they had met with the resident and discussed concerns about antiseizure medications being given at the same time rather than spaced apart as prescribed, and identified that an agency RN (Staff N) had administered the antiseizure medications at the same time. A grievance dated 01/29/2026, signed by the resident, documented that on 01/27/2026 the nurse was an hour late giving evening medications, administered evening and bedtime antiseizure medications together at 10 PM, and did not provide the resident’s pain medication. Review of the Medication Administration Audit Report from 01/31/2026 through 02/05/2026 showed that Staff N administered the resident’s Divalproex Sodium DR tablet, scheduled for 9:00 AM on 02/01/2026, at 12:29 PM, nearly three and a half hours late.
Failure to Initiate CPR and Maintain Accurate POLST/Code Status Information
Penalty
Summary
The deficiency involves the facility’s failure to ensure immediate initiation of CPR for two residents who were found unresponsive, not breathing, and without a pulse, despite having physician orders to attempt resuscitation or, in one case, an unknown code status that required CPR by policy. The facility’s CPR policy required licensed nurses to maintain current CPR certification and to initiate CPR for residents who requested it via advance directives or POLST, as well as for residents without a documented directive, while another staff member verified code status using a centrally located POLST binder. Surveyors found that the POLST binders on both floors were disorganized: some residents’ POLST forms were filed under the wrong room, one resident’s form was on the wrong floor, and several residents had duplicate POLSTs with conflicting CPR choices. Staff interviews showed confusion about where to find code status information, with at least one NAC believing it was in the electronic service plan rather than the POLST binder. For Resident 1, who had diagnoses including endocarditis and sepsis, a signed POLST documented a choice for full resuscitation/CPR if they had no pulse and were not breathing. On the morning in question, the resident experienced breathing difficulty; a NAC reported the resident calling for help, appearing short of breath, and being coached through breathing exercises while on oxygen, then assisted back to bed and reported to a nurse. Later, a therapist found the resident unresponsive in bed, not waking or responding even to a sternal rub, and notified nursing staff. Multiple licensed nurses and a nurse practitioner entered the room, assessed the resident, and confirmed absence of pulse and respirations. Although someone in the room stated the resident was a full code, no one initiated CPR while staff discussed or attempted to verify code status. EMS records showed that 911 was called and EMS arrived at the bedside 14 minutes after the call, at which time EMS personnel, not facility staff, initiated CPR. The facility’s own investigation and staff interviews confirmed that no licensed staff started CPR on Resident 1 despite the full-code POLST. For Resident 2, who had diagnoses including a bladder tumor, kidney disease, and vasovagal response, the facility’s incident report documented an unwitnessed fall and an unanticipated death at the same time. The report and associated statements lacked a clear timeline, did not specify who performed CPR, how long it was performed, or which staff were involved. EMS documentation indicated that EMS was notified early in the morning and arrived to find the resident unresponsive, with CPR having been initiated but then stopped, and it was unclear why CPR was not in progress upon EMS arrival. One LPN stated they helped another nurse move the resident back to bed and applied oxygen after finding a pulse, then went to the nurse’s station to look for the resident’s code status but could not locate it, and did not perform any CPR. Two NACs described being directed to start CPR: one placed a rescue board and counted respirations while the other performed 30–50 chest compressions, then stopped when nurses arrived and did not provide further direction. Neither NAC had current CPR certification on file, and one NAC stated they were the only person who provided compressions and stopped due to fatigue, with no nurse taking over. Another RN reported only assisting with locating code status and bringing the crash cart, without going to the resident’s room or assessing them. Facility leadership confirmed that CPR was required when code status was unknown, but staff did not consistently initiate or continue CPR in accordance with that expectation. The surveyors determined that these failures—delayed or absent initiation of CPR for residents found pulseless and not breathing, disorganized and inaccurate POLST binders, staff confusion about where to find code status, and reliance on uncertified NACs to perform CPR without nurse oversight—constituted noncompliance with the requirement to provide basic life support, including CPR, prior to EMS arrival, subject to physician orders and advance directives. The deficiency was cited at F678 and determined to be Immediate Jeopardy, beginning when the facility failed to perform CPR immediately for a resident with a physician order to initiate CPR.
Removal Plan
- Educating staff in emergency response
- Reviewing the facility CPR policy with staff
- Reviewing all residents' POLST forms for accuracy
- Ensuring CPR training is completed
- Implementing a plan of correction to sustain ongoing compliance
Failure to Thoroughly Investigate Unexpected Death and Potential Abuse/Neglect
Penalty
Summary
The facility failed to thoroughly investigate a potential abuse/neglect allegation related to an unexpected death for one resident. Facility policy required thorough investigations of potential, suspected, and alleged abuse or neglect, including identifying and interviewing individuals with knowledge of the event and maintaining complete documentation. Resident 2 was admitted with diagnoses including a bladder tumor, kidney disease, and vasovagal response and was receiving skilled services with a plan to return home. An incident report documented that the resident experienced a fall without fracture and an unanticipated death at the same time, 5:30 AM. The incident report included a nursing description, three staff witness statement forms, a visitor’s written statement, and a fall investigation checklist. However, the incident report documented that the fall and unanticipated death were not witnessed, which contradicted statements within the investigation. The investigation also contained a statement attributed to staff, without an associated signed statement, indicating that police and 911 were called after the resident was found on the floor, moved to bed, given oxygen, and then stopped breathing, at which point the crash cart was obtained to start CPR. The incident report did not include a timeline of events, did not identify who performed CPR, did not state how long CPR was performed, and did not list the names of staff involved. The DON stated that for an unexpected death they would expect an investigation to include staff witness statements, past medical history, and a thorough review of diagnoses, and acknowledged that the state hotline was not notified because the death was not considered suspicious. The DON further stated they were unaware that police had been notified and that the police report was not reviewed as part of the investigation. When asked how abuse or neglect was ruled out, the DON stated the resident was very ill and therefore the death was not unexpected, and also indicated that staff were interviewed but that this information existed only as scribbled notes and in their memory, not in the investigation record.
Failure to Prevent Falls and Medication Errors Related to Antihypertensives
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free from avoidable accident hazards and to provide adequate supervision and monitoring for a resident with a known fall risk and complex medication regimen. The resident was admitted with hypertension, chronic kidney disease, heart failure, and vision deficit, and was assessed as high risk for falls. The Care Area Assessment (CAA) identified medications as a fall risk factor and directed staff to proceed to a fall-related care plan. The care plan included a problem related to mood and behavior medications with side effects such as dizziness, drowsiness, unsteadiness, blurred vision, and orthostatic hypotension, and a separate fall risk problem related to deconditioning. Interventions focused on environmental and behavioral strategies such as call light within reach, proper footwear, keeping the room free of clutter, and having the resident sit at the edge of the bed before standing. The care plan did not include a focus area or specific interventions related to the resident’s cardiac blood pressure medications, despite the identified medication-related fall risk. Beginning in early December, the resident experienced multiple falls. On one date, the resident fell, hit their head, underwent a neurological assessment, CT scan, and lab work, and one blood pressure medication was discontinued, but there were no new fall interventions or care plan updates. A subsequent fall occurred several days later with no new orders or care plan changes. Additional falls in early January included an event where the provider documented orthostatic hypotension with a significant drop in blood pressure upon standing and positive signs of dehydration, for which the resident received IV fluids. The resident also slid from a wheelchair and had another fall the following day, again without new orders, interventions, or care plan revisions. A pharmacist review later noted frequent falls and frequent medication order changes due to dizziness, weakness, and falls, yet the care plan was not updated to address actual falls or medication side effect monitoring. On a mid-January date, the resident fell in their room, struck their face, and complained of back pain, later being diagnosed in the emergency department with a right forehead hematoma and an acute L2 vertebral compression fracture. The ED report documented that the resident stated they fell because of their blood pressure. Review of the Medication Administration Record (MAR) showed the resident had three blood pressure medications with parameters to hold doses if the diastolic blood pressure was below 60, but the medications were administered when the blood pressure was 112/58 on the day of the fall, and on multiple other occasions when the diastolic reading was below the ordered parameter. These administrations were later acknowledged by facility staff as medication errors that should not have occurred. The facility’s incident investigation for the mid-January fall documented no apparent injuries at the time of the incident and no injuries post-incident, left pain and level-of-consciousness sections blank, and left the predisposing factors section blank. Although the investigation stated that neurological checks were done, there was no documentation of these checks in the report or medical record, and medication risk factors previously identified in the CAA were not reviewed as part of the post-fall investigation. Interviews further described the resident’s decline and ongoing symptoms. The resident representative reported problems and overdosing with blood pressure medications since admission, frequent falls, dehydration requiring fluids, and that the resident had become weaker and in pain, impacting their ability to participate in therapy. Nursing staff explained that the electronic medication system required entry of vital signs but did not prevent administration outside ordered parameters, and that it was the nurse’s responsibility to hold medications when indicated; they confirmed that the administrations outside parameters were errors and that the provider should have been notified. Staff also reported the resident had been sleeping more, staying in bed, and not eating breakfast. The resident described ongoing dizziness, new problems with blood pressure and blood pressure medications, a fall associated with feeling dizzy at the sink, and persistent back pain after being told they had broken their back. The resident also reported using the call light as instructed but stated it usually took at least half an hour for staff to respond. The DON acknowledged that administering blood pressure medications outside ordered parameters constituted medication errors and that these errors and medication as a contributing factor were not identified during the fall investigation.
Failure to Follow Antihypertensive Parameters Leading to Fall and Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when nurses did not follow physician-ordered blood pressure parameters for multiple antihypertensive medications. The resident had hypertension, chronic kidney disease, congestive heart failure, and a history of falls, and was ordered furosemide, hydralazine, and lisinopril at 11:00 AM with specific instructions to hold each medication if systolic blood pressure or diastolic blood pressure fell below defined thresholds. Review of the Medication Administration Record showed that on several dates, including when the resident’s diastolic blood pressure was below 60 or systolic blood pressure was below 110 as specified in the orders, staff still administered one or more of these medications instead of holding them and notifying the provider. Staff interviews confirmed that the electronic system did not prevent administration outside parameters and that it was the nurse’s responsibility to review the full order and hold medications when vital signs were outside the ordered range. On one of the days when medications were administered despite a diastolic blood pressure below the ordered parameter, the resident experienced dizziness while standing at the sink, attempted to turn and sit on the bed, and fell, striking the face and later being found to have a right forehead hematoma and an acute L2 compression fracture. The resident reported ongoing back pain and described having a lot of problems with blood pressure and blood pressure medications. The resident’s representative reported concerns about overdosing with blood pressure medications since admission, stating the resident had falls, dehydration requiring fluids, and increased weakness due to mismanagement. The Director of Nursing acknowledged that administering blood pressure medications outside the ordered parameters constituted medication errors and that these errors were not identified during the investigation of the resident’s fall, and medication was not identified as a contributing factor at that time.
Failure to Accurately Identify and Use Resident’s Legal Representative
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate designation of a legal representative for a resident with developmental delay, as required by its advance directives policy. The policy states that during admission the facility must identify the resident’s primary decision maker or legal representative and invoke this person when the resident is unable to make relevant health care decisions. The resident was re-admitted with a diagnosis of developmental delay and was documented in the medical record as their own responsible party, with an outside agency case manager listed as the first emergency contact and identified as family. No Durable Power of Attorney (DPOA) documentation was located in the record. The resident’s care plan noted impaired cognition related to developmental delay, directing staff to use yes/no questions and one-step instructions, and a provider note described the resident as an intermittently poor historian who communicated more by body language, with family assisting. Despite this, the facility’s records showed the resident signed their own POLST and other consents. Social services documented contacting the outside agency case manager to schedule a care conference, and an admission note recorded that this case manager approved a room move. In interviews, the case manager stated the resident had a DPOA and that the facility sought questions and updates from the case manager even though they were not the DPOA and had no right to make decisions. The LPN/Resident Care Manager reported concern at admission and again when reviewing the POLST, noting that the case manager told them the resident could sign for themself and that admissions and the business office should verify any DPOA. The Interim DON stated they were unaware of any DPOA and believed social services should confirm DPOA status. The identified DPOA reported having served in that role for a couple of months, never receiving calls from the facility, and learning of the resident’s catheter incident and hospital transfer only through the case manager, rather than directly from the facility.
Failure to Maintain Accessible and Accurate POLST/Code Status Information During CPR Event
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Physician Orders for Life-Sustaining Treatment (POLST) and advance directives were readily accessible and accurately reflected in the electronic medical record (EMR) for use during emergencies. Facility policy required that POLST or advance directive forms be placed in a central, accessible binder on each unit and used to direct care during a code event, with a staff member assigned to obtain the resident’s code status from the binder. The policy also stated that residents have the right to formulate an advance directive and that, during admission, it is determined whether an advance directive is in place and a POLST is offered or assistance provided in completing one. Despite these policies, the facility did not maintain an effective system to ensure that POLSTs were consistently available in binders or accurately documented in the EMR. Resident 2, who had been admitted from the hospital, had a hospital discharge summary indicating a Do Not Resuscitate (DNR) status and referencing an advance care planning note. On the night of the incident, staff were summoned when Resident 2 was found on the floor, initially warm with a palpable radial pulse, short of breath, and later becoming unresponsive with no pulse. Staff attempted to locate the resident’s code status by checking the POLST binder and the EMR but were unable to find a POLST or any clear code status documentation. The Medication Administration Record directed staff to see a disaster recovery binder for advanced directives and code status, but no POLST for Resident 2 was present in the unit’s POLST book, and there was no documentation in the clinical record that code status had been discussed or that a POLST was in the chart. During the emergency, 911 was called, and the operator instructed staff to initiate CPR because no POLST could be located. CPR was started by staff and continued until paramedics arrived. While this was occurring, another nurse located information in the hospital discharge paperwork indicating that Resident 2 was DNR and wished for no CPR, at which point CPR was stopped. A collateral contact, the spouse of Resident 2’s roommate, reported that staff had verbally indicated the resident was DNR and that medics repeatedly asked for the POLST, which was reportedly only available online in the hospital file; medics later confirmed the hospital had a DNR on file and then stopped life-saving measures. Review of the second-floor POLST book showed that 23 of 52 residents on the unit had no POLSTs available, and multiple staff interviews confirmed that POLST binders were incomplete, not up to date due to room moves and workload, and that code status was not displayed in the EMR per company policy. Staff also reported that some POLSTs and advance directives were awaiting scanning, were stored in financial folders, or were otherwise not readily accessible to nursing staff, contributing to the inability to promptly verify Resident 2’s code status during the event. Additional interviews revealed systemic issues in the facility’s process for handling POLSTs and advance directives. Staff described that upon admission, nurses were expected to obtain POLSTs, review them with residents, and then send them for provider signature, after which copies were to be placed in binders and scanned into the EMR. However, staff acknowledged that there were missing POLSTs, a backlog of forms to be scanned, and inconsistent auditing of POLST binders, with some binders not audited for weeks. It was also noted that only certain floors were audited regularly and that some advance directives might be placed in financial folders that nurses would have difficulty accessing. At the time of surveyor observation, POLST binders were located at the reception desk, out of reach of nurses, while they were being audited, further limiting immediate access. These actions and inactions resulted in the facility’s failure to have an accurate, accessible system for code status information, directly affecting the care provided to Resident 2 during a cardiopulmonary emergency. The report states that this failure to access and follow POLST instructions for CPR or ensure the POLST was readily available for Resident 2 placed residents at risk for receiving unwanted CPR against their known wishes, avoidable trauma, and other negative health outcomes.
Failure to Maintain Complete and Accurate Medical Records for Adverse Event and Hospital Visit
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete, accurate, and accessible medical records for two residents. For Resident 2, an incident report documented that the resident experienced a syncopal episode on the toilet around 2:00 AM, after which a nurse checked vital signs, kept the resident up in a chair for 30 minutes, and then returned the resident to bed. The clinical record, including progress notes, did not contain any documentation of the syncopal episode, the assessment, the vital signs, or whether the provider was contacted. In an interview, the LPN responsible for the resident that night stated that a NAC reported the resident had passed out during a bowel movement on the toilet, that the resident’s color was not good, and that the resident was up and down in their wheelchair. The LPN stated they had the NAC take vital signs, which were at baseline, and that no further assessment was done beyond asking the resident questions and taking vitals. The LPN acknowledged they did not document the episode or notify the provider and stated they should have charted it but did not before the resident died at 5:30 AM. For Resident 3, the deficiency centers on missing hospital documentation following a hospital visit for reinsertion of a urinary catheter. Review of the clinical record showed there were no hospital records from that visit at the time of the initial review. When the HIM was asked to obtain the hospital records, the dictation from the hospital visit was later obtained and added to the record. In interviews, the HIM stated that nurses were usually responsible for obtaining hospital records after hospital visits, and the Interim DON stated that hospital visits and adverse events such as syncope should be documented in the clinical record and accessible. The survey findings concluded that the facility failed to ensure a system was in place to keep residents’ records complete, accurate, accessible, and systematically organized, as required by WAC 388-97-1720.
Failure to Employ Qualified Social Worker for Facility Size
Penalty
Summary
The facility failed to employ a qualified full-time social worker as required for a facility licensed for more than 120 beds. At the time of review, the facility had 122 available beds, but the acting social services director did not possess a bachelor's degree or the necessary qualifications for the position. The previous social service director left employment on 11/3/2025, and the current acting director assumed the role the same day without meeting the qualification requirements. Two new social service staff were hired on 12/15/2025, but there was no indication that a qualified social worker was in place during the period reviewed. These findings were confirmed through interviews and review of facility records.
Failure to Document and Address Resident Grievances
Penalty
Summary
The facility failed to establish and maintain a system to ensure that resident grievances were properly initiated, logged, addressed, and resolved in a timely manner. One resident repeatedly verbalized multiple concerns and grievances regarding their care, including issues with pest control, the cleaning of linen and clothing after pests were found, and dissatisfaction with meal service, specifically being served cold meals. Despite these repeated complaints, there was no documentation of the grievances in the facility's grievance logs for the relevant months, nor any record of the concerns or meetings in the resident's electronic medical record. Interviews with staff confirmed that the resident had voiced numerous complaints, including missing or damaged clothing and ongoing dissatisfaction following a pest control incident. Staff members, including the social worker, resident care manager, and administrator, were unable to locate any grievance logs or documentation related to the resident's concerns. This lack of documentation and follow-up prevented the facility from identifying care trends and determining the effectiveness of any actions taken to resolve the grievances, resulting in the resident repeatedly reporting the same issues without resolution.
Failure to Conduct Thorough Abuse and Neglect Investigations
Penalty
Summary
The facility failed to conduct thorough investigations into multiple allegations of abuse and neglect involving five residents. In the case of two cognitively impaired residents, one alleged inappropriate touching by their roommate. The investigation did not identify which staff member initially received the report, and the original reporter was not asked to provide a written statement. The investigation relied solely on statements from the two residents, both of whom had significant cognitive impairment, and did not include interviews with other staff or witnesses who may have had relevant information. For another resident receiving hospice care, a fall resulted in a head injury. The resident's roommate later alleged that a nursing assistant had been rough and verbally harsh, contributing to the fall. The investigation included general questions to other residents about their care but did not specifically address the allegation. No interviews were conducted with other staff who may have had knowledge of the incident, and the statement from the accused nursing assistant was not signed or dated. Additional allegations of rough treatment and verbal aggression by the same nursing assistant were made by two other residents. These investigations also lacked specific interviews with the accused staff member regarding the allegations, did not include targeted questions to other residents, and failed to gather statements from other staff who might have relevant information. The facility's approach was to ask general, open-ended questions rather than specific ones related to the incidents, and the investigations were incomplete as a result.
Failure to Follow Physician Orders for Labs, Weights, and Respiratory Care
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards and person-centered care plans for two residents. One resident, re-admitted with a sacral pressure wound infection and a history of pressure ulcers, had physician orders for weekly laboratory tests, including ESR, while on IV antibiotics. The medical record showed that after an initial high ESR result, a subsequent test was not completed due to a laboratory issue, and there was no documentation of follow-up for the missing result. The weekly ESR order was later discontinued by the provider without explanation or documentation regarding the missing test or the rationale for discontinuation. Another resident, admitted with diagnoses including liver failure, heart failure, and pulmonary hypertension, had physician orders for daily weights and CPAP therapy at night. The resident reported not receiving weekly weights or CPAP since admission, despite documentation in the MAR indicating CPAP was provided. Observations confirmed the absence of a CPAP device in the resident's room, and the last recorded weight was over a month prior. Staff interviews revealed a lack of awareness of the resident's heart failure diagnosis and uncertainty regarding the process for obtaining a CPAP device, despite existing orders.
Failure to Follow Wound Care Orders and Infection Control Procedures for Pressure Ulcer
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards for a resident with a history of multiple pressure ulcers, including a sacral wound infection. Upon re-admission, the resident had specific wound care orders, including cleansing with wound cleanser, applying medicated foam and Dakin's solution-moistened gauze as packing into the wound and undermining/tunneling, and securing with bordered gauze. Observations revealed that these orders were not consistently followed, as wound packing was omitted during dressing changes, despite the orders specifying its use. The resident was also observed lying on their back, contrary to discharge instructions to offload pressure from the wound, and reported difficulty maintaining side positioning due to discomfort and lymphedema in the left leg. During wound care observation, a registered nurse was seen donning gloves from their uniform pocket without performing hand hygiene between glove changes, and using supplies from their uniform, which is considered unclean. The nurse did not apply packing to the wound bed as ordered, and there was confusion regarding the current wound care orders. The resident expressed awareness of the need for packing and frequent dressing changes due to stool contamination, but the nurse denied that packing was part of the current orders. The wound dressing was also observed to be soiled with stool, and the dressing technique covered the resident's anus, potentially increasing the risk of further contamination. Interviews with nursing staff and management confirmed that the wound care orders included packing with Dakin's solution and that this should be done with every dressing change. Staff acknowledged the challenges posed by the resident's anatomy and frequent incontinence, which contributed to wound contamination. Infection control breaches were noted during wound care, including improper glove use and lack of hand hygiene, and staff did not demonstrate awareness of these issues during the surveyor's observation.
Inadequate Investigations and Unlogged COVID-19 Outbreak
Penalty
Summary
The facility failed to conduct thorough investigations for three residents and did not log a COVID-19 outbreak, placing residents at risk for repeat incidents and injury. Resident 1, who had severe cognitive impairment and was dependent on staff for transfers, suffered a fracture to the left foot after a transfer incident. The investigation into this incident was inadequate, lacking statements from all involved staff and a root cause analysis, and did not rule out abuse or neglect. The care plan did not accurately reflect the resident's required level of care. Resident 2, with severe cognitive impairment and a history of falls, experienced an unwitnessed fall while returning to their room with a cup of coffee. The investigation was incomplete, missing witness statements and a thorough neurological assessment, and failed to rule out abuse or neglect. The care plan intervention to assist with transfers and ambulation overnight was not followed, contributing to the incident. Resident 3, who had moderate cognitive impairment and was at risk for falls, was found on the floor after an unwitnessed fall. The investigation lacked a neurological assessment and did not provide evidence to support the root cause analysis. Additionally, the facility did not log a COVID-19 outbreak in February 2025, despite being aware of the first positive case and notifying the local health department and state reporting agency. The facility's failure to conduct thorough investigations and log the outbreak demonstrates a lack of adherence to policies and protocols.
Failure to Complete PASRR Evaluations Timely
Penalty
Summary
The facility failed to ensure the completion of the Pre-Admission Screening and Resident Review (PASRR) forms according to federal guidelines for three residents. Resident 5, who was admitted with major depression disorder and anxiety, had a Level I PASRR indicating a need for a Level II evaluation, with a 30-day exemption. However, no Level II evaluation was documented after the exemption period expired. Similarly, Resident 6, admitted with a traumatic brain injury, also required a Level II evaluation after a 30-day exemption, but no documentation was found. Resident 4, admitted with anxiety and depression, had a Level I PASRR completed five days post-admission, indicating a delay in the required screening process. Interviews with facility staff revealed lapses in the PASRR process. Staff L, the Social Services Director, acknowledged the oversight in tracking exemptions and the delay in completing the Level I PASRR for Resident 4. Staff B, the Director of Nursing, was unaware of the residents' need for Level II evaluations and the expiration of their exemptions. These deficiencies in the PASRR process placed residents at risk of not receiving timely mental health services, as required by federal regulations.
Failure to Implement Fall Prevention Care Plan
Penalty
Summary
The facility failed to ensure that fall prevention care plans were implemented for a resident, leading to an avoidable accident. Resident 2, who was admitted with diagnoses including vascular dementia, COPD, and heart failure, had a care plan indicating a high risk for falls due to deconditioning and balance problems. The care plan required staff assistance with transfers and ambulation overnight. However, on the night of the incident, Resident 2 was found on the floor after attempting to return to their room with a cup of coffee, without staff assistance as outlined in the care plan. Interviews with facility staff revealed that Resident 2 was not supposed to transfer themselves, and there was no documentation to show that the care plan was followed. Staff E, an LPN/RCM, confirmed the lack of documentation, and Staff B, the Director of Nursing Services, acknowledged that the care plan should have been followed, confirming the absence of evidence in the investigation to support that the care plan was adhered to. This oversight placed all residents at risk for unmet care needs and a diminished quality of life.
Failure to Ensure Safe Smoking Practices for Residents
Penalty
Summary
The facility failed to ensure that residents who engaged in smoking were assessed for adequate supervision to prevent injury from burns and to provide a safe environment, necessary devices, and supplies to safely smoke. This deficiency was observed in two residents who were reviewed for smoking. The facility's policy stated that it was a non-smoking facility, yet residents were found smoking on the property without proper supervision or safety measures in place. This failure potentially placed all residents at risk for injury related to unsafe smoking practices and constituted an Immediate Jeopardy. Resident 66, who had a history of nicotine dependence and was on nicotine replacement therapy, was observed smoking on the sidewalk outside the facility. Despite the facility's non-smoking policy, Resident 66's room and hallway smelled heavily of cigarette smoke, and the resident admitted to smoking off the property and keeping cigarette butts in their pockets due to the lack of disposal receptacles. The facility had not conducted a smoking safety evaluation or developed a care plan addressing the resident's nicotine dependence, despite the resident's high risk to smoke due to recent stressors and impaired mobility. Similarly, Resident 78, who also had a history of nicotine dependence, was observed smoking unsupervised on the sidewalk outside the facility. The resident reported going outside to smoke multiple times a day and keeping cigarette butts in their pocket until they could dispose of them inside the facility. Like Resident 66, there was no smoking safety evaluation or care plan in place for Resident 78, despite their known smoking habits and nicotine replacement therapy. The facility's lack of assessment and planning for these residents' smoking habits contributed to the unsafe environment and potential risk of injury.
Removal Plan
- Initiated safe smoking evaluations for residents.
- Conducted skin assessments for burns.
- Performed room inspections to ensure cigarette butts were properly disposed of.
- Provided a safe smoking location with a safe disposal receptacle.
- Educated Residents 66 and 78 on the safe smoking location and safe disposal of cigarette butts in the smoking receptacle.
- Instructed residents to turn in their smoking paraphernalia when they return to the building.
- Educated staff to ensure awareness of the new smoking safety plan.
- Directed staff to ask residents to show that they do not have any cigarette butts on their persons when they returned from smoking.
Failure to Complete Annual CNA Performance Reviews
Penalty
Summary
The facility failed to ensure that annual performance reviews were completed for six Certified Nursing Assistants (CNAs) who had been employed for more than one year. This deficiency was identified through interviews and record reviews conducted on January 22, 2025. The CNAs affected were Staff F, G, H, I, J, and K, with hire dates ranging from 2006 to 2023. During an interview, the Director of Nursing Services, Staff B, acknowledged that the facility was behind on completing these evaluations. This oversight had the potential to negatively impact the competency of the CNAs and the quality of care provided to residents.
High Medication Error Rate Due to Late Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by a 91% error rate observed during a medication pass. Staff P, an LPN, was responsible for administering medications to several residents, including Resident 46, Resident 12, Resident 6, and Resident 25. During these observations, Staff P administered medications significantly later than the prescribed times, with all medications being given more than one hour past their scheduled administration. This delay in medication administration was acknowledged by Staff P, who stated that medications are considered late if administered more than one hour after they are due. The report details specific instances of late medication administration for each resident. For Resident 46, medications ordered for 7:00 AM, 8:00 AM, and 9:00 AM were administered at 12:07 PM. Similarly, Resident 12's medications, due at 7:30 AM and 8:00 AM, were given at 12:16 PM. Resident 6's medications, scheduled for 8:00 AM and 10:00 AM, were administered at 12:49 PM, and Resident 25's medications, due at 8:00 AM, were given at 12:55 PM. Interviews with Staff P, the Resident Care Manager, and the Director of Nursing Service revealed that staff were expected to seek assistance if running late with medication passes, and that late administration should be communicated to the provider and the resident or their POA. The failure to adhere to these protocols contributed to the high medication error rate observed.
Failure to Provide Transfer/Discharge Notice
Penalty
Summary
The facility failed to provide the required notice of transfer or discharge to a resident at the time of their transfer to the hospital. Resident 50, who was admitted with diagnoses including congestive heart failure affecting fluid balance, experienced a change in condition and was transferred to the emergency department. Upon review of the clinical record, it was found that there was no documentation indicating that the required transfer or discharge notice had been provided to the resident. During an interview, the Director of Nursing Services acknowledged that while a transfer form was completed and sent to the hospital, it was not provided to the resident themselves, and they were unable to produce the notice or documentation of review for Resident 50.
Failure to Provide Bed Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to provide written bed hold notices at the time of transfer to the hospital for two residents, which is a requirement under the regulations. Resident 50, who was admitted with congestive heart failure, experienced a change in condition and was transferred to the emergency department. Upon review of Resident 50's clinical record, there was no documentation of a bed hold notice being provided at the time of transfer. The Director of Nursing Services (DNS) confirmed that the process involves reviewing the bed hold notice with the resident or following up with the family, but they were unable to produce any documentation of this process being followed for Resident 50. Similarly, Resident 72, who was admitted with diabetes and a left lower extremity infection, was transferred to the hospital for an infection. The clinical record review showed no documentation of a bed hold notice being offered or provided. Staff interviews revealed that the facility did not obtain a bed hold for Resident 72, and the Licensed Practical Nurse (LPN) stated that they are supposed to offer and document the bed hold offer when residents are sent to the hospital. This lack of documentation and failure to provide the required notices placed the residents at risk of not being informed about their right to hold their bed during hospitalization.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for three residents who were dependent on staff for care. Resident 58, who required one-person assistance for bathing, was not provided with showers according to their care plan, which specified showers on Sundays and Wednesdays. Documentation showed that Resident 58 received significantly fewer showers than scheduled, with no records of attempts to provide bathing after refusals. Similarly, Resident 68, who also required one-person assistance for bathing, did not receive showers as per their care plan, with documentation indicating only one shower in January. Staff interviews revealed that there were no specific shower aides, and missed showers were not consistently reassigned or documented. Resident 20, who had advanced dementia and diabetes, required extensive assistance with ADLs, including nail care. Observations revealed that Resident 20's toenails were thick, overgrown, and growing in various directions, indicating a lack of proper nail care. The Treatment Administration Record (TAR) showed weekly diabetic nail care was supposed to be completed by Licensed Nurses, but there was no documentation of care or refusals. Interviews with staff indicated that Resident 20 was supposed to be seen by a podiatrist, but there was no documentation of a recent visit, and the facility had not facilitated an appointment with an outside provider. The facility's failure to provide necessary ADL assistance, including bathing and nail care, placed the residents at risk for unmet care needs and poor hygiene. The lack of documentation and follow-up on missed care further contributed to the deficiency. Staff interviews highlighted gaps in the facility's processes for ensuring that residents received the care outlined in their individualized care plans.
Failure to Administer Medications and Conduct Lab Tests as Ordered
Penalty
Summary
The facility failed to provide care and treatment in accordance with professional standards for two residents, leading to unmet care needs and potential medical complications. Resident 58, who was admitted with high blood pressure, dementia, and constipation, did not receive bowel medications as ordered by the physician despite having multiple periods without a bowel movement. Additionally, Resident 58's blood pressure medication, Hydralazine, was not administered as ordered when the resident's systolic blood pressure exceeded 160. These lapses in care indicate a failure to adhere to the prescribed treatment plan. Resident 68, admitted with high blood pressure and anemia, did not have a Complete Blood Count (CBC) lab draw performed as ordered by an Advanced Registered Nurse Practitioner. The Director of Nursing was unaware of the missed lab and found no documentation indicating that the ARNP was notified. The facility's protocol for bowel management and medication administration was not followed, as evidenced by the lack of documentation and action regarding the residents' care needs. This deficiency was noted as a repeat issue from a previous Statement of Deficiency.
Failure in Dialysis Communication and Documentation
Penalty
Summary
The facility failed to ensure proper communication and collaboration with the hemodialysis center for a resident requiring dialysis services. The facility's policy required the completion of a Dialysis Transfer Form to document pre- and post-dialysis weights, lab results, medications, and follow-up care. However, the facility did not consistently complete these forms or ensure they were returned from the dialysis center, leading to missing documentation for specific dates. Resident 335, who was admitted to the facility and received dialysis three times a week, had missing Dialysis Transfer Forms for certain dates. Interviews with staff revealed a lack of awareness and understanding of the process for handling incomplete forms. The facility's records showed missing entries for post-dialysis weights and vital signs, and there was no documentation of follow-up communication with the dialysis center when forms were incomplete. The Director of Nursing Services acknowledged the expectation for nurses to assess residents post-dialysis, obtain vital signs, and ensure the completion of the Dialysis Transfer Form. However, there was no evidence of documented follow-up with the dialysis center when forms were incomplete. This lack of documentation and communication placed the resident at risk for unidentified medical complications.
Inappropriate Use of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that three residents were free from unnecessary psychotropic medications, as required by regulations. The facility did not provide appropriate indications for the use of these medications, nor did it obtain proper consent that included a discussion of the risks and benefits. This oversight placed the residents at risk for medication-related complications and unnecessary use of psychotropic drugs. Resident 68 was admitted with diagnoses including bipolar disorder and hyperactivity disorder. Despite having no documented signs of psychosis, the resident was prescribed Olanzapine, an antipsychotic, with a conflicting diagnosis of schizophrenia. The resident's clinical record did not support this diagnosis, indicating a lack of proper justification for the medication. Resident 72, who was cognitively intact and showed no signs of psychosis, was prescribed Ativan for agitation and aggression, which are inappropriate indications. Additionally, Risperidone was prescribed without a documented diagnosis or indication. Resident 26, diagnosed with Alzheimer's and anxiety, was prescribed Sertraline for generalized anxiety disorder, but there was no documentation supporting the use of an antidepressant for this condition. The facility's failure to document and justify the use of these medications was a repeat deficiency.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 112 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bellingham
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alderwood Park Health And Rehab Of Cascadia | 2.2 mi | ★★★★★ | 14 | 0 |
| Avalon Healthcare Bellingham | 3.1 mi | ★★★★★ | 15 | 0 |
| Shuksan Rehabilitation And Health Care | 4.5 mi | ★★★★★ | 5 | 0 |
| Mt Baker Care Center | 6.9 mi | ★★★★★ | 2 | 0 |
| Highland Health And Rehabilitation Of Cascadia | 7.3 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for North Cascades Health And Rehabilitation.
100% money-back within 48 hours.
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.