Average — CMS composite of the measures below.
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Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Olympia Transitional Care And Rehabilitation during CMS and state inspections, most recent first.
A cognitively intact resident was moved to a different room without documented agreement or notification of the change. Records showed the resident preferred the original room and declined a room change for bathroom access, while the SS Director and DON stated they had no documentation that the resident agreed to or was notified of the move.
The facility failed to send accurate transfer and discharge notifications to the Ombudsman and did not include the required transfer/discharge notice for several residents. Monthly lists were inconsistent about whether residents were expected to return and where they were discharged, including residents who returned after hospitalization, a resident who left AMA, and a resident who did not return after hospitalization. Staff confirmed only the monthly list was sent, and one resident also lacked an eInteract transfer form and documentation of report to the hospital.
Nursing staff did not consistently follow provider orders or document care accurately for several residents. A resident’s diabetic nail care was missed, another resident’s nail care was charted as completed when it was not, PRN med orders for pain and SOB were unclear, an insulin-related blood sugar check was left blank, an LPN left meds at a resident’s bedside without confirming administration, and another resident received O2 above the ordered flow rate.
Pharmacy review recommendations were not addressed or implemented for three residents. An LPN and the DON/DNS discussed that one resident’s crushed PreserVision via feeding tube should have been reviewed with the provider, while two other residents’ orders for topical diclofenac and PRN oxycodone were not updated to include required directions and pain scale details after the pharmacist’s recommendations.
Medication parameters and PRN pain documentation were not followed for multiple residents. A resident with HTN received antihypertensives outside BP hold limits, another resident lacked BP documentation tied to a BID metoprolol order and received a dose when SBP was below the hold parameter, and two residents received oxycodone outside ordered pain thresholds. For one resident, PRN opioid orders were unclear and nonpharmacological interventions were documented only by code numbers and initials without times or effectiveness, so it could not be determined whether the PRN meds were warranted.
A facility failed to obtain informed consent before giving psychotropic meds and using devices that could restrict movement for three residents. One resident received lorazepam without documentation of prior resident or representative consent, another had a perimeter mattress, bed bars, and a wheelchair seatbelt in use without device evaluation or consent, and a third received hydroxyzine before the POA signed consent; the DON confirmed the missing documentation.
Two residents had psychotropic medication-related deficiencies involving missing documentation and monitoring. One resident with depression and moderate cognitive impairment had a PRN lorazepam order left active beyond 14 days without a documented clinical rationale, no care plan focus on the target behaviors, and no documented NPIs before eight PRN doses were given. Another resident with severe cognitive impairment and dementia-related behavioral disturbance had a Depakote behavior-monitor order listing target behaviors and NPIs, but the TAR did not provide a place to document the behaviors or interventions.
Care plans for several residents were incomplete or inaccurate. A resident with a central line and IV vancomycin had no CP for the line or IV therapy, another resident's preference to be up and dressed by noon was not reflected, a hospice resident on lorazepam had no CP for the anxiolytic therapy or target behaviors, and a resident with MRSA had a CP that did not identify the infection source or location. The DON confirmed the CPs needed revision.
Failure to follow bowel protocol and provider orders: Two residents had documented periods without bowel movements, but MARs showed no ordered PRN Miralax or Dulcolax was given. One resident was moderately cognitively impaired and had no documented BM for 4 days with no bowel protocol meds or progress note, while another had two extended no-BM periods and received no PRN bowel meds. The DON confirmed the omissions.
A resident admitted with a right heel surgical wound and a left heel DTI did not receive consistent heel offloading or wound care. The care plan called for floating both heels, but observations showed the resident repeatedly in bed with heels resting directly on the mattress, without heel boots, wedges, or pillows in place. The left heel DTI enlarged and deteriorated, and a daily betadine gauze and foam dressing order was not transcribed to the TAR.
A resident with DM and prior amputations did not receive ordered weekly diabetic nail care. Nurses documented the care was not done because the toenails were too long, thick, and brittle to safely trim, but there was no documentation explaining the missed care or notifying the provider. The resident’s remaining toenails were observed to be thick, yellow, brittle, and overgrown, and the resident was not seen by podiatry despite staff stating a referral was needed.
A resident with severe cognitive impairment and a fortified diet order had a water mug repeatedly left on a nightstand out of reach, often blocked by a wheelchair, while meal trays did not include ordered whole milk. The POA reported concern about inadequate fluid intake, and staff confirmed that water cups should be within reach and that fortified-diet residents should receive whole milk with meals.
Antibiotic stewardship was not effectively implemented for three residents. One resident remained on long-term Cephalexin for chronic cystitis without an end date, while two other residents had antibiotic orders and surveillance log entries that did not match McGeer criteria or were not fully documented, including missing end dates, incomplete infection indications, and antibiotics not reflected on the surveillance logs. The IP stated some residents did not meet criteria and that provider discussions and reassessments were not documented.
A resident with dementia, behavioral disturbances, and documented wandering and elopement risk, residing in a secure dementia unit with a wander guard in place, was able to leave the building through a window whose alarm did not sound when opened. The window screen from the resident’s room was later found on the ground outside, and the resident returned by ringing the front entrance doorbell. Facility leadership reported that window alarms were visually checked and that batteries were changed on a periodic basis, but they could not provide documentation of regular functional testing of the window alarms in the secure dementia unit.
A resident with Parkinson’s disease, hyperparathyroidism, and cognitive impairment had an elevated calcium level and provider orders for PTH, vitamin D, and ionized calcium testing. On two separate occasions, ordered PTH and ionized calcium labs were not performed because no specimens were received by the lab, despite facility policy requiring completion and follow-up of ordered tests and tracking of pending or missing results. Later, after additional lab orders including a CMP, the lab reported a critical calcium value, and the resident was transferred to the hospital, where a markedly elevated calcium level and related diagnoses were documented. The Administrator acknowledged that the ordered labs were not obtained and that nursing was responsible for ensuring collection, submission, and receipt of lab results.
The facility did not consistently assess and document non-pressure skin injuries for a resident on antiplatelet therapy, failed to provide bowel care according to physician orders and protocol for three residents, and did not report dental pain for a resident with cognitive impairment. These actions resulted in missed monitoring, delayed interventions, and unaddressed pain.
The facility failed to maintain an effective infection prevention and control program, with incomplete infection surveillance data, lack of action on infection trends, and repeated lapses in staff hand hygiene and use of personal protective equipment during resident care. Laundry processes were also inadequate, leading to cross-contamination, and two residents did not receive COVID vaccinations despite documented consent.
The facility did not ensure complete and accurate documentation or evaluation of antibiotic use for three residents, including missing infection details, lack of timely culture results, and failure to notify providers when prescribed antibiotics were not indicated or when organisms were resistant. The Infection Preventionist confirmed these lapses, which included incomplete logs and missing provider notifications.
A resident's trust account balance was not transferred to the state Office of Financial Recovery within the required timeframe following the resident's discharge due to death. The trust account still held funds several months after discharge, as confirmed by the business office manager.
The facility did not ensure care plans were reviewed and updated to reflect the actual care needs of four residents, including one with a NPO order who was inappropriately directed to receive oral intake, another whose dental and oral care needs were not addressed, a resident with constipation lacking a care plan, and a resident on a diuretic whose care plan failed to document this medication.
The facility did not meet professional standards in several areas, including failure to document and address a resident's skin impairment, inaccurate documentation and provision of oral care for a resident who was NPO, incomplete documentation of treatments for two residents, and failure to administer an influenza vaccine to a resident despite consent and vaccine availability. Staff interviews and record reviews confirmed that required care and documentation were not consistently provided or accurately recorded.
A resident with moderate cognitive impairment, dependent on staff for ADLs, did not receive adequate bathing or oral care. The resident's bathing preferences were not documented, and only one shower was provided over 18 days, with unclear documentation of sponge baths. Oral care was provided only once, despite orders for twice-daily care, and necessary supplies were unavailable. Staff interviews and observations confirmed these deficiencies.
A resident with severe cognitive impairment had a critical lab result that was not reported to the provider for over two days due to a name mismatch in the EHR, resulting in the result being placed in an unmatched category and not seen by staff. The facility's process relied on both lab calls and daily EHR checks, but lacked an alert system for new results, leading to the delay.
A resident with a surgical incision required daily wound care per physician's orders, which was not completed as documented. A nurse admitted to misunderstanding the treatment order, leading to missed dressing changes. The oversight was confirmed by the DON, and the resident was at risk for prolonged wound healing and infection.
The facility failed to provide timely lab services for two residents, risking delayed treatment. One resident had missing lab results due to equipment issues and lack of follow-up, while another had lab results not documented or forwarded as required. The DON acknowledged these lapses, contributing to the deficiency.
A resident with chronic health conditions and severe pain, dependent on staff for bed mobility, fell and broke their leg when a CNA attempted to reposition them alone, contrary to the care plan requiring two-person assistance. Concerns about the bed size and safety were previously raised but not addressed, leading to the incident.
The facility failed to provide timely toileting and bathing assistance for several residents, leading to prolonged discomfort and potential health risks. A resident with PTSD waited over three hours for incontinence care, while another fell attempting to self-transfer due to long wait times. Additionally, residents dependent on staff for bathing were observed with poor hygiene, indicating missed and undocumented showers.
Resident room change occurred without documented resident choice
Penalty
Summary
The facility failed to honor a cognitively intact resident’s choice for a room change. Resident 80 was admitted to the facility and, on the Quarterly MDS dated 02/24/2026, was documented as cognitively intact. On 04/22/2026, the resident stated that staff wanted them to move into a different room and that they were not given a choice, adding that they liked the old room better. Record review showed the resident’s room location changed from room [ROOM NUMBER]-2 on 08/28/2025 to room 314-2 on 11/03/2025. A nursing progress note dated 09/29/2025 documented that the resident liked their room and would prefer not to move, and that staff educated the resident about risks related to sharing a bathroom with three other residents; the resident responded, “I don’t care,” and clarified, “I didn’t fall, I sat on the ground.” A follow-up note dated 12/12/2025 stated the resident preferred the current room and declined a room change for bathroom access. When interviewed, the Social Services Director and the DON stated they did not have documentation that the resident agreed to the room change or was notified of it, and the DON stated that if the resident did not want to move, they could have stayed on the 400 hall.
Inaccurate Ombudsman Transfer and Discharge Notifications
Penalty
Summary
The facility failed to ensure that transfer and discharge notifications sent to the Office of the State Long-Term Care Ombudsman were accurate and included the required copy of the notice provided to residents or their representatives. Monthly ombudsman notifications reviewed for three months showed that the resident return columns and discharge location columns did not match, with many residents marked as expected to return when the discharge location was not a hospitalization, and many marked as not expected to return when the discharge location was acute care or psychiatric care. The notifications also did not include any additional documentation showing that the required transfer or discharge notice had been sent with the list. Resident 9 was hospitalized and returned to the facility, but the ombudsman notification listed the resident as not expected to return and did not show where the resident went afterward. Resident 8 and Resident 4 were both hospitalized and returned to the facility, but each was listed on the ombudsman notification as not expected to return and discharged to acute care, and neither resident’s transfer notice was sent with the notification. Resident 4 also did not have an eInteract transfer form completed for the hospitalization, and staff confirmed there was no progress note documenting that report had been called to the hospital. Resident 84 was hospitalized and did not return to the facility, but the transfer notice was not sent with the ombudsman notification. Resident 86 was discharged against medical advice and left the facility, but the ombudsman notification listed the resident as expected to return and discharged to home, and the transfer notice was not sent with the notification. Staff responsible for social services confirmed that only the monthly list was sent to the ombudsman, and the DON acknowledged the form was confusing and reversed from what it should have been.
Failure to Follow Orders and Document Care
Penalty
Summary
The facility failed to ensure nursing services met professional standards of practice by not consistently following physician orders, documenting care accurately, or ensuring medications were actually taken by residents. The report identified deficiencies involving diabetic nail care, clarification of medication orders, blood sugar monitoring tied to insulin administration, medication administration at the bedside, and oxygen delivery above the ordered flow rate for multiple sampled residents. Resident 4 had an order for weekly diabetic nail care, and the care plan also directed weekly licensed nurse nail care. On multiple dates in April 2026, the resident’s toenails were observed thick, yellow, untrimmed, and curved around the toes, while the MAR showed missed or blank entries for the ordered nail care. The EHR contained no documentation explaining why the care was not provided, and the DNS acknowledged there was no documentation that the physician had been notified that nursing could not carry out the order. Resident 2 also had an order for weekly diabetic nail care, but the resident’s fingernails were observed to be longer than a centimeter on several occasions. Although the MAR showed nurses signed that the care had been completed, the DNS stated the nurses had erroneously signed for a task they did not complete. Resident 7 had PRN morphine and lorazepam orders for pain, anxiety, or shortness of breath, but the orders did not specify which medication should be given first for SOB or which pain medication should be used for different pain ranges, and the DNS stated the orders needed clarification. Resident 3 had an insulin lispro sliding-scale order before meals and at bedtime, but the April 2026 MAR had a blank entry for an evening blood sugar check, and staff stated the blood sugar should have been checked as ordered. During a medication pass for Resident 54, an LPN poured Tylenol and pregabalin into a cup, left the medications at the bedside, and walked out before confirming administration; the DNS stated medications could not be left at the bedside unless a self-medication assessment had been completed. Resident 65 had an order for oxygen at 2 LPM, but was observed receiving oxygen at 3 to 4 LPM on multiple occasions, and staff acknowledged the higher flow had been used without the order being adjusted.
Pharmacy Recommendations Not Addressed in Medication Orders
Penalty
Summary
The facility failed to ensure a licensed pharmacist’s monthly drug regimen review recommendations were addressed or implemented for 3 of 5 sampled residents reviewed for unnecessary medications. For Resident 3, the pharmacy consultation dated 03/02/2026 documented that PreserVision capsules should not be crushed when administered via feeding tube and recommended discussing alternative therapy with the provider; however, on 04/23/2026 the LPN/Supervisor stated this may have been an oversight and that the issue should have been discussed with the doctor, and on 04/24/2026 the DNS stated the recommendation was not addressed and that pharmacy recommendations were expected to be addressed. For Resident 6, the pharmacist recommended on 03/03/2026 that the topical diclofenac order be updated to include the quantity in grams and the location of application for joint pain, but review on 04/22/2026 showed the order had not been updated since it was ordered on 11/07/2025 and still lacked grams and location. For Resident 14, the pharmacist recommended on 03/03/2026 that the PRN oxycodone order be updated to include a pain scale of moderate to severe pain of 5-10/10, but review on 04/21/2026 showed the order had not been updated since it was ordered on 11/05/2025 and still did not include a pain scale. During interview, the DNS stated the provider was expected to accept or decline and sign pharmacy recommendations, or nursing should address them if applicable, and acknowledged the recommendations for Residents 6 and 14 were not reflected in the orders.
Medication Parameters and PRN Pain Documentation Not Followed
Penalty
Summary
The facility failed to follow medication hold parameters and to document nonpharmacological interventions for residents receiving unnecessary medications. Resident 85 had diagnoses including hypertension and was moderately cognitively impaired. The resident had orders for amlodipine, chlorthalidone, and lisinopril with instructions to hold each medication if systolic blood pressure was less than 110. Review of the January 2026 MAR showed amlodipine was administered 8 times, chlorthalidone 8 times, and lisinopril 4 times when the recorded blood pressure was below the ordered hold parameter. The DNS reviewed the MAR and acknowledged the medications should have been held and that no progress notes were found regarding the administrations. Resident 6 had hypertension and was cognitively intact. The resident had an order for metoprolol tartrate twice daily with instructions to hold for systolic blood pressure less than 110. Review of the MAR and vital signs record showed blood pressure was not documented on multiple days, and when it was obtained there was only one blood pressure recorded on days the medication was ordered twice daily. The DNS confirmed blood pressures should have been documented with the metoprolol order and stated the resident did not have blood pressures associated with any of the orders. The DNS also confirmed metoprolol was given on one date when the recorded blood pressure was 109/76, outside the ordered parameters. Resident 6 also had two active oxycodone orders with different pain thresholds, and doses were given outside the ordered parameters when pain scores were 3, 4, and 4 for the lower-dose order and 4 and 3 for the higher-dose order. Resident 7 had PRN morphine and oxycodone orders, but the orders did not specify which medication should be used for pain levels outside the 5-6 range. The April 2026 MAR showed oxycodone was administered for pain scores of 7/10 and 0/10, outside the provider order. In addition, the order required nonpharmacological interventions before PRN pain medication, but the MAR only recorded intervention numbers and initials twice daily without times or whether the interventions were effective or ineffective, so it could not be determined whether the PRN pain medications were warranted or unnecessary.
Failure to Obtain Consent Before Psychotropic Medication and Device Use
Penalty
Summary
The facility failed to obtain consent from residents and/or their representatives before implementing medical devices that could restrict movement and before administering psychotropic medication for three residents reviewed for the right to be informed about treatment decisions. Resident 7, who was moderately cognitively impaired and had diagnoses including depression, received lorazepam on 04/02/2026 after an order dated 04/01/2026, but the record contained no documentation that the resident or representative had been informed of the risks and benefits or had consented before the medication was given. Resident 4, who had moderate cognitive impairment and a recent fall history, was observed with a perimeter mattress, bilateral grab/mobility bars on the bed, and a tilt-in-space wheelchair with a fastened seatbelt, but the record only showed a restraint safety device evaluation and consent for a left side mobility bar; no device evaluation or consent was found for the perimeter mattress, wheelchair, or seatbelt. Resident 14, who was severely cognitively impaired, received hydroxyzine on 04/20/2026 for agitation/anxiety, but the consent signed by the power of attorney was not completed until the following day, and the Director of Nursing Services could not find documentation that consent had been obtained before the first dose was administered.
Unnecessary Psychotropic Medication Use and Missing Behavior Monitoring
Penalty
Summary
The facility failed to ensure two residents reviewed for unnecessary psychotropic medications were free of chemical restraints. For one resident with moderate cognitive impairment and diagnoses of depression, the record showed an order for lorazepam 0.5 mg every two hours as needed for anxiety or shortness of breath that had remained in place for 23 days without a stop date. The electronic health record contained no provider documentation explaining why the PRN lorazepam order was extended beyond 14 days, and the Director of Nursing confirmed there was no such resident-specific clinical rationale documented. The same resident’s care plan did not address the PRN lorazepam use, the goal of treatment, or the specific behaviors the medication was intended to target. The April 2026 MAR identified non-pharmacological interventions for other medications, but none were identified for PRN lorazepam, and the MAR showed the medication was administered eight times without attempts at non-pharmacological interventions first. For another resident with severe cognitive impairment and diagnoses including depression, anxiety disorder, unspecified dementia with behavioral disturbance, and vascular dementia with psychotic disturbance, the record showed a Depakote order for behavior disturbance with target behaviors listed as labile mood, unprompted outbursts, and agitation, along with nonpharmacological interventions to assist the resident back to the room, allow expression of feelings, and assist with problem solving. However, the TAR had no area for staff to document the target behaviors or the nonpharmacological interventions, and the DON confirmed the documentation area was not present.
Care plans were incomplete and did not reflect residents' current needs
Penalty
Summary
The facility failed to ensure comprehensive care plans were reviewed, revised, and accurately reflected the care needs of 4 of 19 residents reviewed. Resident 4 was re-admitted with a central line in the right upper chest and orders for IV vancomycin for bacteremia, and the 5-day MDS showed IV medications were being given through the central line. The comprehensive care plan initiated on 09/25/2025 did not address the central line or IV antibiotic therapy. Resident 4 was also observed using a tilt-in-space wheelchair, a seatbelt, and a perimeter alternating low air loss mattress, but these interventions were not care planned. In addition, an ADL care plan documented that Resident 4 may use a left-sided mobility bar, while observation showed mobility bars on both the right and left sides of the bed. Resident 2 stated a preference to be up and dressed by noon, but the ADL care plan initiated on 10/24/2024 documented only that the resident preferred to get up after breakfast and did not include the noon preference. Resident 7 had moderate cognitive impairment, a wound infection, received opioid and antianxiety medication, and was on hospice services; the comprehensive care plan did not address lorazepam use, the target behaviors it was intended to treat, or the goals of the anxiolytic therapy. Resident 40 had a MRSA care plan that directed staff to follow enhanced barrier precautions, but it did not identify the source or location of the infection. Staff B, DNS, confirmed the care plans for these residents were incomplete, inaccurate, or needed revision.
Failure to Follow Bowel Protocol and Provider Orders
Penalty
Summary
The facility failed to provide bowel care according to provider orders and its bowel protocol for 2 of 7 residents reviewed for bowel management. The bowel protocol required Miralax 17 gm in 8 oz fluid as needed if there was no bowel movement after 3 days, followed by Dulcolax 10 mg suppository if Miralax was ineffective and/or there was still no bowel movement after 4 days, with provider notification if both were ineffective. The policy also required documentation of all efforts and interventions. Resident 3, who was moderately cognitively impaired and required assistance with activities of daily living, had no documented bowel movement for 4 days, but the April 2026 MAR showed no bowel protocol medications were given and there was no progress note documenting Miralax administration. Staff stated there was no documented bowel movement and Miralax should have been offered, with the DON stating there was no documentation that Miralax was given and that the first step of the bowel protocol should have been provided. Resident 7 had orders for Miralax every 72 hours as needed and Dulcolax suppository if no bowel movement after 4 days, but the March and April 2026 bowel records showed two periods without bowel movements lasting 4 days and 8 days, and the MARs showed no as-needed bowel medications were administered. The DON stated the facility did not administer the ordered Miralax or Dulcolax.
Failure to Offload Heels and Provide Consistent Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure appropriate pressure ulcer care and consistent offloading for a resident admitted with a right heel surgical wound and a left heel deep tissue injury. On admission, the resident was cognitively intact and had a right heel wound after incision and drainage for osteomyelitis and abscess formation, along with a small non-blanchable purple/reddish area on the left heel that was assessed as a deep tissue injury. The care plan directed staff to float the heels, use a wedge cushion to float both heels, and monitor the wound for changes, while wound orders included treatment for the right heel surgical wound, treatment for the left heel DTI, and an alternating low air loss mattress for offloading and pressure redistribution. The left heel wound remained nearly unchanged for several weeks, then worsened significantly. Weekly skin notes showed the left heel DTI measured 0.5 cm by 0.7 cm and later 0.5 cm by 0.5 cm, but by 04/16/2026 it had increased to 5.5 cm by 6 cm while still intact. A later wound note documented the left heel at 6 cm by 4 cm by 0.3 cm depth and stated the wound was deteriorating with increased size and area of involvement. The record also showed the 04/17/2026 order to apply betadine gauze and a foam dressing daily to the left heel was not transcribed to the TAR, and the TAR entry for monitoring skin issues did not specify which dressing belonged to which wound. Observations showed the resident repeatedly lying in bed with both heels resting directly on the mattress surface, without socks or footwear, and without heel lift boots, wedges, or pillows in place to float the heels. On one observation, the resident had a wound vac to the right heel and the left heel was open to air; on later observations, the right heel was dressed but still resting on the mattress and the left heel had no dressing in place. Staff confirmed there was no wedge or pillows in the room to float the heels, and the DON stated that if the heels were care planned to be offloaded with a foam wedge, staff were expected to do that. The resident later had a clear fluid-filled blister on the left heel where the prior deep purple non-blanchable area had been located.
Failure to Provide Ordered Diabetic Nail Care
Penalty
Summary
The facility failed to ensure diabetic nail care was provided for Resident 4, who had a right above-knee amputation and an amputation of the fifth digit on the right foot related to diabetes. A provider order dated 04/13/2026 directed licensed nurses to provide diabetic nail care every seven days and as needed, and the resident’s diabetes care plan also called for weekly nail care by the licensed nurse. Observations on 04/21/2026 and 04/23/2026 showed the remaining toes on the left foot had thick, yellow, brittle, untrimmed toenails that curved around the ends of the toes to the plantar aspect. The April 2026 MAR showed diabetic nail care was not provided on 04/02/2026, 04/14/2026, and 04/21/2026, and the scheduled care on 04/09/2026 was left blank. The EHR contained no documentation explaining why the ordered care was not provided or that the provider had been notified. Staff later confirmed nurses documented they did not perform the care because the toenails were too long, thick, and brittle to safely cut, and stated the resident needed referral to podiatry. Records showed the podiatrist last visited the facility on 03/05/2026 and Resident 4 was not seen, and the DON acknowledged that, given the resident’s diabetes, history of amputations, and the missed or uncompleted nail care, she would have expected to be notified and a podiatry referral or appointment to already have been made, but it did not occur.
Fluids Not Kept Within Reach and Ordered Fortified-Diet Milk Not Provided
Penalty
Summary
Provide enough food and fluids to maintain a resident's health was not met for Resident 60, who was admitted with unspecified dementia and was documented on the Significant Change MDS as severely cognitively impaired and dependent on staff for care. Resident 60 had a fortified diet order with regular texture and thin liquids, and the care plan noted a recent need for IV hydration and encouragement to drink fluids due to risk for potential fluid deficit. During observations on multiple days, Resident 60's clear water mug was repeatedly found sitting on the corner of the nightstand and not within reach. The resident's wheelchair was parked between the bed and the nightstand, creating an obstacle between the resident and the water mug. On one observation, the mug was only one-fourth full; on later observations it was full, but still remained in the same out-of-reach location. Resident 60's POA stated concern that the resident had not been receiving enough fluids to stay hydrated and pointed out that the water cup had been left out of reach for three days. Meal tray observations also showed that ordered fortified-diet beverages were not present. On one lunch tray, no whole milk was observed, and on another lunch tray the drink provided was coffee with no whole milk observed. Staff interviews confirmed that water cups should be placed within reach of the resident and that residents on fortified diets should receive whole milk with meals. Staff also acknowledged that the water mug on the nightstand was not within reach and was not an acceptable placement.
Antibiotic Stewardship Program Not Effectively Implemented
Penalty
Summary
The facility failed to implement an effective Antibiotic Stewardship Program to promote appropriate antibiotic use and reduce unnecessary antibiotic exposure for three residents reviewed for antibiotic stewardship. The facility policy required the team to assess residents for infection using McGeer’s criteria and to ensure antibiotic orders included the indication, dose, and duration. The facility’s own McGeer guidance for UTI stated that only symptomatic UTIs should be surveilled and that asymptomatic bacteriuria was not recommended for surveillance because it represented baseline status for many residents. Resident 9 had been receiving Cephalexin since 01/21/2026 for chronic cystitis. The March 2026 Infection Prevention and Control Surveillance Log listed level of consciousness as the sign and symptom, but did not explain what the LOC finding meant, and the current antibiotic order did not include an end date. The Infection Preventionist stated that Resident 9 met criteria when the antibiotic started in January 2026 but no longer met criteria, and acknowledged that she had not discussed the long-term antibiotic use with the provider and that the antibiotic should have had an end date. Resident 96 had urinary symptoms listed on the February and March 2026 surveillance logs as agitation, confusion, restlessness, and aggression, with Nitrofurantoin in February and Bactrim in March. The Infection Preventionist stated that Resident 96 did not meet criteria for the prescribed antibiotics and that she could not find documentation showing she had discussed the lack of criteria with the provider. Resident 3, who had an indwelling urinary catheter, had multiple antibiotic orders and surveillance log entries that did not align: the February 2026 log listed pain, burning, and LOC with amoxicillin and Cefdinir, but Cefdinir continued without an end date; Nitrofurantoin ordered on 02/13/2026 was not on the February log; Gentamicin Sulfate ordered on 03/25/2026 for UTI had no end date and was not on the March log; and Ceftriaxone ordered on 03/10/2026 for infection did not specify the type of infection. The Infection Preventionist stated Resident 3 had been on antibiotics for too long, that Cefdinir should have had an end date, that reassessment had not occurred until the day before the interview, and that she missed the Nitrofurantoin order altogether.
Failure to Monitor and Maintain Functioning Window Alarms in Secure Dementia Unit
Penalty
Summary
The facility failed to ensure that window alarms in a secure dementia unit were adequately monitored and functioning to prevent elopement. A resident with dementia, behavioral disturbances, wandering behaviors, and impaired safety awareness was assessed as cognitively impaired and at high risk for elopement, with a documented history of attempts to leave a previous facility unattended. The resident’s care plan identified elopement risk and wandering, and a wander guard was implemented as an intervention. The resident had a physician’s order to reside in the secured dementia unit. Despite these identified risks and interventions, the resident was able to exit the facility through a window in the secure dementia unit. A progress note documented that the window screen from the resident’s room was found on the ground outside and that the resident had likely exited through the window, walked around the exterior of the building, and then rang the front entrance doorbell to return. The facility’s investigation determined that the resident left the facility unattended through an alarmed window that did not sound when opened, and that the window alarm had malfunctioned. The Administrator and Plant Operations Manager reported that window alarms were visually checked and reportedly tested or had batteries changed approximately quarterly, but they were unable to provide documentation of functional checks for the window alarms in the secure dementia unit.
Failure to Complete Ordered Laboratory Tests for Resident With Hyperparathyroidism
Penalty
Summary
The facility failed to ensure ordered laboratory tests were completed and followed up for a resident with hyperparathyroidism and elevated calcium levels. Facility policy required that laboratory services ordered by a provider be obtained, that results and pending or missing labs be included in shift report, and that pending or missing labs be followed up in daily clinical meetings. The resident, admitted with Parkinson’s disease and hyperparathyroidism and documented cognitive impairment, had a calcium level of 12.2 (normal 8.6–10.2). A provider ordered PTH, vitamin D, and ionized calcium testing, but laboratory results for that date showed PTH and ionized calcium were not performed because no specimen was received. A subsequent provider note documented that PTH and ionized calcium had not been performed and were reordered. A later physician order again directed that PTH and ionized calcium be obtained, but laboratory results again showed these tests were not performed due to no specimen being received. Another order was written for a CBC and CMP, and on that date the lab called the facility with a critical calcium value, after which the resident was transferred to the hospital. Hospital records documented a calcium level of 17 and admission for acute pulmonary embolism, aspiration pneumonia, and hypercalcemia. During interview, the Administrator acknowledged that the resident had provider orders for PTH and ionized calcium on two separate dates, that the lab indicated specimens were not obtained on those dates, and that nursing was responsible for ensuring labs were collected, sent, and results received as ordered.
Failure to Monitor Skin, Provide Bowel Care, and Report Dental Pain
Penalty
Summary
The facility failed to ensure routine assessment and monitoring of non-pressure skin injuries for a resident with moderate cognitive impairment who was on high-risk antiplatelet therapy. Upon admission, staff documented the presence of bruising on multiple body areas but did not provide specific descriptions, measurements, or detailed locations of the bruises. Subsequent weekly skin evaluations noted the presence of a surgical incision and multiple bruises, but again lacked comprehensive documentation regarding the size, color, and evolution of the bruises. A large bruise extending from the abdomen to the back was observed but not properly documented or monitored, and the care plan instructions for daily skin inspection and monitoring for antiplatelet complications were not followed as there was no direction on the MAR or TAR for staff to monitor the bruising. The facility also failed to provide bowel care in accordance with physician orders and facility protocol for three residents. For one resident, there were multiple periods where the resident went several days without a bowel movement and did not receive the prescribed PRN bowel medications, such as Miralax or Dulcolax suppository, as required by the protocol. Another resident experienced similar lapses, with extended periods without a bowel movement and no administration of bowel medications after the required timeframe. A third resident, who was on hospice care, also went several days without a bowel movement, and the prescribed bowel care was not administered or documented, with confusion over medication discontinuation and lack of notification to the power of attorney. Additionally, the facility failed to report dental pain for a resident with severe cognitive impairment and obvious dental issues. The resident was observed to have a missing front tooth and reported pain in that area on multiple occasions. Oral hygiene records showed frequent refusals of care, and a CNA reported that the resident refused oral care due to pain but did not notify a nurse as required. The DON confirmed that such refusals due to pain should have been reported to nursing staff for further action, but this did not occur.
Infection Control Program Deficiencies and Lapses in Standard Precautions
Penalty
Summary
The facility failed to fully implement an effective Infection Prevention and Control Program, as evidenced by incomplete and inaccurate infection surveillance data, lack of ongoing monitoring and analysis, and failure to document or act on identified infection trends. Specifically, infection control line listings for January and February did not match the Infection Control Reports, with missing or incomplete documentation of signs, symptoms, diagnostic testing, and microorganism identification. For example, several urinary tract infections and skin infections were either not listed or lacked supporting clinical data, and no action or staff education was documented in response to a trend of yeast infections among female residents. Staff did not consistently follow standard precautions, enhanced barrier precautions (EBP), or perform proper hand hygiene during resident care. Observations revealed that staff entered rooms and provided care to residents on EBP without donning appropriate personal protective equipment or performing hand hygiene before and after glove use. In one instance, a CNA provided oral care to a resident with a gastrostomy without wearing a gown or gloves and failed to perform hand hygiene. In another, a CNA caring for a resident with a suprapubic catheter repeatedly changed gloves without hand hygiene and misunderstood the requirements of EBP. Additionally, a nurse providing wound care to a resident with multiple wounds changed gloves multiple times without hand hygiene, and no hand sanitizer was available at the bedside. Laundry services were also found to be deficient, with soiled linen being improperly handled and cross-contaminated with clean laundry due to the absence of a separating door and lack of hand hygiene by staff. Environmental surfaces in the laundry area were covered in lint and not properly maintained. Furthermore, the facility failed to administer COVID vaccinations to two residents despite having obtained consent, with no documentation or explanation for the missed vaccinations. These failures were confirmed through staff interviews and direct observation.
Failure to Implement Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, as evidenced by incomplete and inaccurate documentation and evaluation of antibiotic use for three residents. For one resident started on Augmentin for a suspected respiratory infection, the infection control log lacked documentation of the infection type, signs and symptoms, diagnostic results, and whether McGeer's Criteria were met. There was no record of the chest x-ray being obtained or results being communicated to the provider, and the required reassessment and documentation were not completed. The Infection Preventionist confirmed these omissions and that the criteria for antibiotic treatment were not met. Another resident was started on doxycycline for a wound infection, but the documentation did not include the presenting signs and symptoms, the specific microorganisms identified, or their sensitivity to the antibiotic. The most recent wound culture was outdated and showed resistance to doxycycline, yet there was no evidence the provider was notified. A third resident was started on Macrobid for a urinary tract infection, but the organism identified was resistant to the prescribed antibiotic, and again, there was no documentation that the provider was informed. These failures were confirmed by the Infection Preventionist during interviews and record reviews.
Delayed Transfer of Resident Trust Funds After Discharge
Penalty
Summary
The facility failed to transfer the trust account balance of a resident who was on Medicaid and discharged due to death on 12/23/2024. Review of the resident's trust account ledger showed a remaining balance of $106.46 on the date of discharge. As of 04/01/2025, staff confirmed that the trust balance had not yet been conveyed to the state Office of Financial Recovery (OFR) as required. This inaction resulted in a delay in the reconciliation of the resident's trust funds, contrary to regulatory requirements.
Failure to Maintain Accurate and Updated Care Plans for Multiple Residents
Penalty
Summary
The facility failed to ensure that care plans were reviewed, revised, and accurately reflected the care needs of four residents. For one resident with a NPO order due to dysphagia, multiple care plans inappropriately directed staff to offer or encourage oral food and fluid intake, which conflicted with the resident's dietary restrictions. Another resident with significant dental issues and recommendations for twice-daily oral care did not have these needs or recommendations incorporated into their care plans, despite documented dental consults identifying decayed teeth and specific oral hygiene instructions. A third resident, assessed as constipated on the MDS and reporting ongoing constipation, did not have a care plan developed or implemented to address this issue. Additionally, a fourth resident prescribed a diuretic and identified as severely cognitively impaired had a care plan that incorrectly stated the resident was not on a diuretic and lacked any section addressing diuretic use, despite medication records confirming daily administration. These deficiencies were confirmed by staff interviews and record reviews, indicating that the care plans did not accurately reflect the residents' current needs and conditions.
Failure to Meet Professional Standards in Documentation and Care Delivery
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice in several areas, as evidenced by inaccurate or missing documentation and failure to follow physician orders. For one resident with severe cognitive impairment, staff did not accurately document a visible skin impairment on the left ankle, despite observations of redness and scabbing under a wander guard. Skin assessments in the electronic health record repeatedly stated no new skin issues, and staff confirmed the impairment was not documented as required. Another resident, who was dependent on staff for oral care and had orders for twice-daily oral care due to being NPO, reported not receiving oral care as ordered. Staff interviews revealed that oral care was not provided on multiple occasions, and a nurse signed the Medication Administration Record (MAR) for oral care that was not actually completed. The Director of Nursing confirmed that documentation was inaccurate, as the nurse had signed for care not provided. Additionally, two residents had incomplete documentation on their MAR and Treatment Administration Record (TAR) for various treatments, including wound care, catheter care, and application of skin products. Staff could not confirm whether these treatments were completed, and there was no documentation of completion or resident refusal. In another case, a resident who had consented to an influenza vaccination did not receive it, despite the vaccine being available, and the MAR was signed off as "Other/See nurse Notes" with a note stating the vaccine was out of supply, which was later contradicted by the infection preventionist.
Failure to Provide Adequate Bathing and Oral Care for Dependent Resident
Penalty
Summary
The facility failed to provide adequate bathing and oral care for a dependent resident who was admitted with moderate cognitive impairment and required staff assistance for activities of daily living. Upon review, it was found that the resident's bathing preferences were not documented upon admission, and the resident received only one shower in an 18-day period, with staff documenting sponge baths on other days. However, the facility did not have a clear policy defining a sponge bath, and the resident reported that the care provided did not meet their expectations for cleanliness. The resident also reported a strong foul odor and unclean appearance, which was confirmed by observation. Additionally, the resident received oral care only once during the same period, despite physician orders for twice-daily oral care due to NPO status from dysphagia. Staff interviews revealed that oral care supplies were unavailable, and neither CNAs nor RNs consistently provided or documented oral care as required. The resident's room lacked any oral care items, and staff acknowledged that oral care was not consistently provided. These failures were confirmed through record review, staff interviews, and direct observation.
Delayed Notification of Critical Lab Result Due to EHR Matching Error
Penalty
Summary
The facility failed to ensure the timely reporting of a critical laboratory result to the provider for one resident. According to the facility's policy, critical laboratory values are to be reported to the attending physician or provider immediately. In this case, a resident who was severely cognitively impaired had a critical lab value collected and resulted, but the provider was not notified until over two and a half days later. The delay was due to a misspelling of the resident's name, which caused the result to be placed in an unmatched category in the electronic health record (EHR) system, preventing it from being seen promptly by staff. Staff interviews confirmed that the process for handling critical lab results relies on both direct calls from the laboratory and diligent daily checks of the EHR results tab by nursing staff. However, there was no notification system in place to alert staff to new results, and if a call from the laboratory was missed, results could go unnoticed. The Director of Nursing Services acknowledged that the delay in notifying the provider did not meet expectations and was directly related to the unmatched lab result in the EHR.
Failure to Follow Physician's Orders for Wound Care
Penalty
Summary
The facility failed to complete wound care per physician's orders for a resident, identified as Resident 2, who was admitted with diagnoses including diabetes, orthopedic aftercare following surgical amputation, and peripheral vascular disease. The resident had a 21.5-centimeter surgical incision with staples and required specific wound care as per a physician's order dated 08/12/2024. The order specified that the surgical incision on the left knee should be cleaned with wound cleanser, skin prep applied, and covered with a dry dressing daily, along with an ace wrap as needed. However, the electronic treatment administration record (ETAR) indicated that the treatment was not signed as completed on 08/12/2024 and was incorrectly documented as completed on 08/13/2024 and 08/14/2024. A registered nurse, identified as Staff C, admitted to not performing the dressing changes on 08/13/2024 and 08/14/2024, mistakenly believing the order was for monitoring the dressing rather than changing it. This oversight was acknowledged by the Director of Nursing Services, Staff B, who confirmed that the surgical dressing was not changed daily as ordered on the specified dates. The resident was no longer at the facility at the time of the acknowledgment. The failure to adhere to the physician's orders placed the resident at risk for prolonged wound healing and infection, as noted in a provider's note dated 08/14/2024, which described the management of the wound as unacceptable.
Failure to Provide Timely Laboratory Services
Penalty
Summary
The facility failed to provide timely laboratory services for two residents, leading to a risk of delayed identification and treatment of health conditions. Resident 3, who was admitted with diagnoses including aftercare following hip joint prosthesis and osteomyelitis, had weekly lab tests ordered, including CBC, CMP, ESR, and CRP. However, there were missing lab results for specific dates, and the facility did not have the appropriate equipment to draw blood on one occasion. Additionally, there was no documentation of attempts to complete the missing labs or notify the provider about the issues encountered. Resident 4, admitted with orthopedic aftercare and arthritis due to bacteria in the right hip, also had lab tests ordered, but there was no documentation of the results in the medical record. The Director of Nursing Services acknowledged that the lab results were not forwarded to the Infectious Disease office as ordered, and the results were not available for nurses to review. This lack of documentation and follow-up on lab results contributed to the deficiency identified by the surveyors.
Failure to Follow Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to ensure that residents were free from avoidable accidents, specifically for one resident who required assistance with Activities of Daily Living (ADLs) and bed mobility. The resident, who had no cognitive issues but suffered from chronic health conditions and severe pain, was dependent on staff for toileting hygiene and bed mobility. The care plan specified that two staff members were needed for bed mobility, but this was not followed. On one occasion, a CNA attempted to reposition the resident alone, resulting in the resident rolling off the bed and sustaining a broken leg. The incident occurred despite previous concerns raised about the resident's bed size and the difficulty staff had in positioning the resident safely. The facility's policy required adherence to individualized care plans, which included using two people for bed mobility. However, the CNA did not follow this directive, leading to the resident's fall and subsequent injury. The resident expressed that the bed was too narrow and lacked siderails, contributing to the fall. The Director of Nursing confirmed that the care plan was not followed during the incident.
Deficiencies in Toileting and Bathing Assistance
Penalty
Summary
The facility failed to provide timely toileting assistance for several residents, leading to prolonged periods of discomfort and potential health risks. Resident 1, who was dependent on staff for toileting due to a broken leg and PTSD, reported waiting over three hours for incontinence care after requesting assistance. This delay resulted in Resident 1 sitting in a soiled brief through breakfast. Similarly, Resident 8, who had memory problems and required assistance for toileting, experienced long wait times for help, leading to a fall while attempting to self-transfer to the commode. Resident 9, who was on diuretics and required substantial assistance for transfers, also reported extended wait times for toileting assistance, sometimes over an hour. The facility also failed to provide adequate bathing services for some residents. Resident 3, who had severe cognitive problems and was dependent on staff for bathing, was observed with dark matter under their nails and a strong urine odor, indicating a lack of proper hygiene care. The facility's records showed inconsistencies in documenting showers and nail care for Resident 3, with no evidence of regular bathing as per the care plan. Resident 4, who had severe cognitive problems and was dependent on staff for bathing, was frequently observed with greasy, uncombed hair and a musty odor, suggesting infrequent bathing. The facility's records showed missed and undocumented showers, with no evidence of attempts to address refusals or preferences for bathing. Additionally, Resident 11 experienced similar issues with bathing services, with records showing missed and undocumented showers. The facility's failure to adhere to care plans and provide timely assistance for activities of daily living, such as toileting and bathing, resulted in inadequate care for the residents, compromising their dignity and quality of life.
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What surveyors actually found near you
We read the 570 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Olympia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Woodard Creek Health & Rehabilitation | 0.1 mi | ★★★★★ | 45 | 1 |
| Panorama City Conv & Rehab Ctr | 1.6 mi | ★★★★★ | 6 | 0 |
| Regency Olympia Rehabilitation And Nursing Center | 2.5 mi | ★★★★★ | 15 | 0 |
| Crystal Cove Post Acute | 2.7 mi | — | 43 | 0 |
| Lacey Post Acute & Rehabilitation | 3.7 mi | ★★★★★ | 11 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.