Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Orchard Park Health Care & Rehab Center during CMS and state inspections, most recent first.
Failure to protect a resident from resident-to-resident abuse: a resident with PTSD and a long history of physical and sexual abuse reported another resident repeatedly entered their room at night, then later exposed himself, blocked the resident from leaving, and used meth in front of them. The record lacked an investigation, trauma assessment, psychosocial monitoring, and documented behavior-based monitoring for the other resident, and staff interviews confirmed the concerns were not fully addressed in the chart.
Survey Results Binder Not Readily Available: The facility failed to post the location of survey results and did not place the survey binder in an identifiable location. Residents stated they were unaware they could review prior survey results and did not know where the binder was located. The receptionist was not familiar with the binder or its location, and the ADM stated the binder should have contained the past 3 years of surveys and complaint investigations, but the signage directing residents and visitors to review it was not readily available.
Failure to Review Residents’ AD Decisions: The facility did not ensure that 3 residents were informed of and had their AD decisions reviewed. Each resident was able to make needs known and was their own responsible party, but the EHR did not show review of AD decisions on admission or at care conferences. The Social Services Director and Administrator both acknowledged the missing reviews.
The facility failed to properly identify, report, and investigate abuse allegations involving two residents. One resident reported a staff member yelled at them and was rough with their roommate, but the incident was not documented or reported, and an LPN admitted not reporting it because they did not believe the resident. Another resident reported inappropriate touching by a peer, but the investigation lacked witness or resident statements, and ordered 1:1 supervision was not consistently provided despite repeated behaviors documented by staff and observations showing the resident unsupervised.
A facility failed to provide written transfer/discharge notices, bed-hold notices, and Ombudsman notifications for four residents transferred or discharged to the hospital. Records showed no completed transfer/discharge forms or bed-hold offers for residents with conditions including COPD, HF, pneumonia, and respiratory failure, and one resident reported not receiving a bed-hold notice or returning to the same room after hospitalization.
The facility failed to complete required MDS assessments within the required timeframe for 11 of 11 sampled residents. EHR review showed quarterly, annual, and discharge MDSs were completed well after the ARD, and the RN/MDS Coordinator stated remote corporate staff controlled the MDS schedule. The Administrator stated MDS were expected to be completed timely and accurately.
Delayed and incomplete care plans and care conferences: A hospice resident’s care plan was not started promptly after hospice admission, and multiple residents had overdue or incomplete IDT care conferences. Documentation showed missing attendees, incorrect information, and forms that were not fully completed or signed, while staff stated conferences should occur on admission and quarterly and include the resident and IDT members such as nursing and therapy.
Insufficient staffing prevented the facility from providing ordered one-to-one supervision for two residents after resident-to-resident incidents. Observations showed the residents without staff supervision, and interviews with the Staffing Coordinator and DON confirmed the facility could not consistently implement the care-planned supervision because of staffing shortages and competing supervision needs.
Delayed Medication Regimen Review Follow-Up: The facility did not ensure timely follow-up on MRR recommendations for multiple residents. One resident with encephalopathy, MI, and respiratory failure had a pharmacy recommendation to review a psychotropic for possible dose reduction or discontinuation that was still not addressed when reviewed later. Two other residents with depression, anxiety, heart failure, and liver failure had missing or unlocated monthly MRR documentation, and the DON stated the records could not be found after a pharmacy change.
Infection Control Surveillance Data Not Tracked or Trending: The facility failed to maintain an infection prevention and control program by not accurately analyzing infection surveillance data, identifying trends, or documenting interventions for multiple months. Infection logs, infection maps, and monthly summary reports showed inconsistent counts for UTIs and other in-house acquired infections, and the IP and DON acknowledged the inaccurate surveillance and the expectation for accurate tracking, trending, and interventions.
Failure to Educate and Document COVID-19 Vaccination Status: The facility did not document that a resident with a stroke diagnosis who could not make needs known, or the resident's representative, was educated on the risks and benefits of the COVID-19 vaccine or offered/administered the vaccine. Staff interviews also showed that employees were only asked for vaccine status on hire and were not educated on the vaccine, offered it, or directed where to obtain it, despite expectations from the HR Director, DNS, and Administrator.
Failure to issue NOMNC forms for two residents before Medicare skilled coverage ended. The BOM stated they were responsible for the notices and none could be found for the residents, and the Admin stated Medicare-insured residents were supposed to receive advance NOMNC notice.
A resident’s cell phone went missing and was not found or replaced, despite staff awareness and documentation that the resident’s personal effects included a phone with charger. The grievance record addressed missing clothing items but did not address the phone, and both the LPN/Resident Care Manager and Administrator stated the issue did not meet expectations.
A resident with dementia, UTI, diabetes, and acute pyelonephritis was prescribed and given Seroquel for agitation even though the record did not document behaviors or agitation. The EHR and MDS showed no indication for antipsychotic use, and staff stated the order did not meet expectations.
Delayed Admission MDS Completion: A resident admitted with kidney failure and a bladder infection had an admission MDS still in process nearly a month after admission, with multiple sections unanswered. The MDS/RN and DON both stated the admission MDS should have been completed within the required 14-day timeframe.
A resident with metabolic encephalopathy and dysphagia was admitted to hospice for a terminal CVA, but the facility did not complete a significant change condition MDS within 14 days of the hospice admission. The MDS/RN acknowledged the assessment was not done timely, and the DON stated the resident should have had a significant change MDS when hospice services began.
Two residents had inaccurate MDS coding. One resident with cancer, anemia, and diabetes reported needing glasses and being unable to read TV, but the admission MDS coded adequate vision and no corrective lenses. Another resident with respiratory failure, weakness, and dysphagia was documented as a current smoker with nicotine dependence, yet the admission MDS coded no tobacco use. The LPN/MDS and DON acknowledged the coding errors.
PASRR assessments were not accurately completed for 3 residents reviewed for PASRR and unnecessary meds. One resident with paranoid personality disorder, delusional disorder, dementia, and HF had a Level I PASRR indicating a Level II referral was required, but no referral was made. Another resident with PTSD, COPD, and CKD had an exempt hospital discharge PASRR, but when the discharge did not occur there was no documentation of a Level II referral. A third resident with depression, anxiety, and HF had a hospital PASRR that did not reflect the mental health diagnoses, and the SSD stated it should have been corrected with a Level II referral.
A resident admitted with traumatic subdural hemorrhage, T5-6 vertebral fractures, and respiratory failure did not have a baseline care plan with instructions for positioning, bed mobility, or transfers within 48 hours of admission. The EHR and bedside Kardex lacked guidance for nursing staff, and observations showed the resident slouching in bed and later with feet touching the lower bed frame. An LPN and the DON both stated the care plan did not meet expectations.
Care plans were not accurate for two residents. One resident had a provider-ordered fluid restriction for ESRD, but the care plan did not include it. Another resident was documented as having minimal hearing difficulty on the MDS, but the care plan did not address the communication deficit related to being hard of hearing. Staff, including the DON, acknowledged the care plans did not meet expectations.
Failure to monitor and offload existing pressure injuries: A resident with encephalopathy, MI, and respiratory failure had stage 2 pressure ulcers to the tail bone and heel documented on admission, but no further wound monitoring was found. The care plan lacked repositioning and offloading interventions, and repeated observations showed the resident lying on their back with heels pressed on the bed and no pillows or other offloading devices in place. The resident said staff were not turning them or placing pillows under their feet, and the DON confirmed weekly assessments and pressure-reduction interventions were expected but did not occur.
A resident’s fall was not investigated or documented even after the resident reported rolling out of bed and later showed a forehead bruise, and smoking assessments and interventions for the same resident were delayed despite nicotine dependence and current smoking status. In a separate issue, another resident identified as an elopement risk was observed without the required Wander Guard on multiple occasions, while staff were unaware the device was missing and the TAR did not support shift documentation of the device.
Fluid restriction orders were not implemented or documented correctly for two residents. One resident with DM and ESRD had conflicting MAR and nursing documentation for a 1500 mL fluid restriction, with no clear total amount and inconsistent amounts from dietary vs nursing. Another resident with DM, dysphagia, and HTN had hospital discharge orders for a 1.6 L/day fluid restriction, but the EHR care plan and diet orders did not include it, and staff said it should have been implemented or clarified on admit.
Two residents with feeding tubes had enteral nutrition documented inconsistently with provider orders. For one resident, staff recorded pump on/off times but not the total amount infused; for another resident, nurses only initialed shifts without documenting actual start/stop times or fluid amounts. An LPN, resident care manager, and DON acknowledged the documentation did not meet expectations.
The facility failed to have an active agreement with the dialysis center for two residents who were dependent on dialysis. One resident had diabetes, a leg amputation, and ESRD, and the other had diabetes and renal dialysis dependence. The Administrator stated the facility did not have a contract with the dialysis center and was waiting to receive one.
A resident with tremors and heart failure was found to have unmet psychosocial needs after staff told them they could not spend long periods talking with reception staff and should limit social interaction to care-related matters or activities staff. The resident reported feeling depressed, confused, and isolated to their room for several days and filed a grievance stating they had been isolated and did not understand why. Social services and admissions later clarified the resident could talk to anyone in the building, but the record showed no documented psychosocial assessment at the time of the incident.
Failure to document NPI before PRN oxycodone was given to a resident with bipolar disorder and dementia. The resident had an order for PRN oxycodone and a separate order for NPI, but MAR review showed the medication was administered nine times and the progress notes did not show NPI was used first. The UM and DON stated NPI should be attempted before PRN pain meds are given.
A resident with no natural teeth, dysphagia, and chewing/swallowing difficulty did not receive prompt dental services, and the oral health care plan did not match the resident’s current status. Staff said the dental referral was sent late, the dentist was in the facility but the resident was not seen, and the DON stated the need for dentures should have been addressed sooner.
Failure to honor a documented food allergy: A resident with an onion allergy was repeatedly served food containing onions despite the allergy being listed in the chart, diet order, and nutrition assessment. The resident developed tongue and throat swelling with difficulty speaking, received epinephrine with improvement, and was evaluated by telehealth and EMS; the DON said new staff missed the allergy.
A resident developed a diffuse peri-area rash after a prolonged wait for a bedpan and an episode of urinary and fecal incontinence. The provider ordered zinc oxide for the rash, but no doses were documented as given, the skin change was not reflected in the care plan, and nursing staff reported they were not aware of the rash or treatment order.
A resident was discharged with medications belonging to two other residents, including furosemide and Xarelto, along with the resident’s own discharge meds. The resident said they took the pills until realizing they were not theirs and later told staff they had received someone else’s medications. The DON and administrator stated they expected med safety procedures to be followed, but the resident’s report showed the discharge med mix-up had occurred.
Two residents experienced unwitnessed falls that were documented in nursing notes and reviewed by the IDT, but the facility failed to enter these incidents into the incident reporting log and did not report them to the State Survey Agency within the required timeframe. One resident, alert and oriented after recent hip/femur surgery, fell while attempting to transfer to a chair and had subsequent hip imaging, while another bedridden resident with dementia and multiple comorbidities was found on the floor next to the bed and could not explain the fall. In both cases, staff later acknowledged the falls were recorded in the internal system but not added to the State reporting log, resulting in noncompliance with required reporting standards.
A resident with a history of stroke, contractures, and limited mobility was discharged from skilled PT with goals and recommendations to continue splinting, ROM techniques, and use of a splint and brace. The care plan later identified limited physical mobility related to contractures and included a referral to a Restorative Nurse Assistant, but staff could not locate the written restorative program or any documentation that restorative services, including right knee splinting three times per week, were provided during the period after therapy discharge. This failure to implement and document the restorative nursing program for ROM and mobility resulted in a cited deficiency.
Facility staff did not incorporate a wound care specialist’s ten documented recommendations for PI prevention and treatment into the comprehensive care plan or CNA Kardex for a resident admitted with diabetes, malnutrition, muscle weakness, existing PIs, and total dependence for turning and repositioning. Despite facility policy requiring development and revision of interdisciplinary care plans for skin integrity, the specialist’s directives—such as q2h turning, maintaining clean and dry skin, avoiding massage of bony prominences, using positioning devices, minimizing HOB elevation, keeping sheets wrinkle-free, eliminating fragranced products, and implementing aggressive offloading—were never translated into provider orders or care plan entries. The DON later verified that none of these interventions appeared in the resident’s care plan or Kardex and acknowledged that CNAs rely on the Kardex and verbal report to obtain resident care instructions.
A resident with bilateral heel wounds and dependence for repositioning did not receive adequate PI prevention and treatment. The care plan lacked a turning schedule and pressure-relief mattress, and the Kardex used by CNAs did not reflect needed interventions. A contracted wound care provider documented a worsening Stage 4 right heel PI with increasing necrotic tissue, maceration, and a large increase in wound size, and issued multiple recommendations, including aggressive offloading, but none were entered as orders or care-planned. Additional PIs, including an unstageable left 4th toe PI, a deep tissue PI on the left lateral ankle, and an unstageable sacral PI, were later identified at the hospital but were not documented or treated by facility staff prior to transfer. Facility provider notes recorded escalating foot and heel pain without documented wound examination, and no further antibiotics were ordered despite later hospital findings of calcaneal osteomyelitis and a non-salvageable right lower extremity.
Fire watch was not performed as directed after the fire alarm panel malfunctioned and part of the system was taken offline. Staff gave conflicting accounts about who was assigned, and one LPN was also administering meds while assigned fire watch. Observation and resident interviews showed staff were not consistently entering rooms or making the required rounds, and the log sheet contained an incorrect entry.
Multiple residents experienced harm due to the facility's failure to provide adequate supervision and follow care plans, including incidents of elopement, falls, and injuries. Residents at risk for wandering were not properly monitored or equipped with required safety devices, and staff did not consistently follow protocols for assistance during transfers and repositioning. Care plans were not timely updated after incidents, and required safety interventions were not always implemented.
The facility did not thoroughly or promptly investigate falls and injuries for multiple residents, including those with dementia and mobility issues. Several incidents, such as repeated falls, a head injury during repositioning, and a hip dislocation during transfer, were either not documented, not investigated, or not followed by timely care plan updates. Staff confirmed that required investigations and care plan revisions were not completed as expected.
Several residents were not accurately assessed for dental conditions, respiratory care, and restraint use. Two residents with missing or broken teeth had their dental issues omitted from the MDS, while a resident on oxygen therapy for COPD was not coded for oxygen use in the MDS despite having a provider order and being observed on oxygen. Another resident was incorrectly documented as using a trunk restraint. Staff interviews confirmed these assessment errors.
Two residents received oxygen therapy at flow rates higher than ordered by their providers, as observed and confirmed by staff interviews. Documentation did not reflect the actual oxygen settings, and there was no evidence of provider notification or order clarification. The deficiency involved failure to follow physician orders and monitor oxygen settings as required.
Surveyors found that a resident's IV nutrition, infuvite vials, and infusion kit were stored in a food refrigerator instead of the medication refrigerator, and multiple expired medical supplies—including viral transport kits, peroxide test strips, cleansing towelettes, and a wound vac therapy system—were kept in the medication room. Both an LPN and the DON confirmed these practices did not meet facility expectations.
Several residents reported that their food preferences, including specific meal choices and requests for double portions, were not consistently honored. Despite filing grievances, residents continued to experience issues with not receiving their preferred foods or portions, and staff interviews revealed gaps in communication and follow-through regarding dietary changes.
The facility did not report a Covid-19 outbreak involving two residents to the local health department as required, and failed to maintain complete infection surveillance for two of three months reviewed. Additionally, a resident with an open wound and chronic kidney disease did not receive timely urine testing for infection, and their infection was not tracked on the facility's infection control line list.
Two CNAs did not receive required training in abuse prevention, dementia care, or annual competency assessments. Training records showed one CNA had no documented training, while another had only a single in-service session. The Administrator confirmed the lack of completed education and competencies for these staff members.
A resident with cerebral palsy and other medical conditions was unable to set their own shower schedule, and showers were not provided as planned despite being scheduled. Staff assigned showers based on room location, and documentation confirmed missed showers. Staff interviews indicated that resident preferences were not honored as expected.
A resident with dementia and psychotic disturbance was prescribed antipsychotic medication, but staff failed to complete or document a baseline abnormal involuntary movement (AIM) assessment as required. Despite the medication administration record indicating the need to monitor for extrapyramidal symptoms, no AIM assessment was found in the electronic health record. Both an LPN and the DON confirmed the assessment should have been completed and acknowledged the deficiency.
Two residents with mental health diagnoses did not receive required PASARR Level II referrals. One resident with dementia and depression, unable to communicate needs and receiving multiple antidepressants, had indications for serious mental illness but no Level II referral was completed. Another resident with anxiety, depression, and PTSD was admitted under a hospital exempt discharge but remained in the facility beyond 30 days without a corrected PASARR or Level II referral, contrary to facility policy.
Surveyors found that the facility did not develop or implement individualized care plans for three residents, including one receiving oxygen therapy for COPD and two with significant oral or dental issues. Staff confirmed that care plans lacked necessary details about oxygen use and dental status, despite provider orders and resident reports.
Three residents did not receive care in accordance with professional standards: a resident did not have protective boots applied as ordered and refusals were not documented; another received midodrine outside of provider-specified blood pressure parameters; and a third, dependent on a central line for nutrition, had no provider orders or care for the line. Staff interviews confirmed these lapses in following provider orders and documentation.
A resident with encephalopathy, diabetes, and dementia was admitted without an activities assessment or an activity-focused care plan. The resident was repeatedly observed sitting in a wheelchair near the nurse's station, and staff interviews revealed that no recreation assessment or activity care plan was completed due to the resident's isolation status at admission, with uncertainty about the current isolation status. The Administrator confirmed that activity care plans should be completed within 72 hours and that isolated residents should receive one-on-one or in-room activities.
Failure to Protect Resident from Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse and failed to provide adequate supervision and effective interventions when Resident 7 reported fear and unsafe interactions with another resident. Resident 7 was admitted with COPD and PTSD and had a documented history of childhood through adulthood abuse, including physical and sexual abuse, domestic violence, and trafficking. A trauma questionnaire showed Resident 7 had previously tried to avoid reminders of past events and reported that nothing made them feel worse at that time. In one incident, Resident 7 told staff they were afraid to go to sleep because another resident came to their room at night and shook them awake. The resident admitted going to the room and waking Resident 7, and staff educated that resident about safety and respect. The progress note did not appear in the incident log or grievance log, and the record did not show an investigation, monitoring for negative psychological social outcomes, a trauma assessment, or care plan interventions to promote a sense of security. Staff interviews confirmed the social service department was unaware of the situation and that a trauma assessment should have been completed. In a second incident, Resident 7 reported that the same resident blew methamphetamine smoke in their face in the smoking shed, blocked them from leaving with a wheelchair, and exposed and masturbated in front of them. Resident 7 stated the event triggered past childhood trauma and made them feel trapped. The facility investigation documented a separation plan and one-to-one supervision for Resident 7, while the other resident was placed on alert status with increased monitoring and behavior risk. However, the record did not show implementation of behavior-based monitoring for the other resident, and observations later showed Resident 7 without staff supervision.
Survey Results Binder Not Readily Available
Penalty
Summary
The facility failed to post the location of the survey results and failed to place the survey binder in an identifiable location. During an interview with Resident Council on 05/21/2026 at 1:32 PM, residents stated they were unaware they could review previous survey results and did not know where the survey binder was located. Observations on 05/18/2026 at 9:00 AM, 05/19/2026 at 2:00 PM, 05/22/2026 at 10:30 AM, and 05/26/2026 at 9:00 AM showed a sign at the reception desk stating that reports of surveys, certifications, and complaint investigations for the preceding three years were available for any individual to review upon request. During interviews on 05/26/2026, the receptionist stated they were not familiar with the survey binder and did not know where it was located, and the Administrator stated the survey binder should have included the past three years' surveys and complaint investigations and that the signage referring residents and visitors to the Administrator to review the binder did not meet expectations because it was not readily available.
Failure to Review Residents’ Advance Directive Decisions
Penalty
Summary
The facility failed to ensure that residents were informed of their right to establish an advance directive for 3 of 3 sampled residents reviewed for advance directives. Resident 6 was admitted with diagnoses including COPD and diabetes, was able to make needs known, and was their own responsible party, but the electronic health record did not show that the facility reviewed the resident’s advance directive decisions. Resident 11 was admitted with diagnoses including metabolic encephalopathy and diabetes, was able to make needs known, and was their own responsible party, but the record also did not show review of advance directive decisions. Resident 141 was admitted with diagnoses including acute kidney failure and diabetes, was able to make needs known, and was their own responsible party, but the record did not show review of advance directive decisions. During interviews, the Social Services Director stated that residents’ advance directive decisions should be reviewed on admission, at quarterly care conferences, and at the resident’s request. The Social Services Director later stated that Resident 6’s most recent care conference on 02/24/2026 did not include review of the advance directive decision, Resident 11’s initial care conference on 04/07/2026 did not include review, and Resident 141’s most recent care conference on 11/17/2025 did not include review. The Administrator also stated that social services would review advance directive decisions with residents on admission and at quarterly care conferences, and acknowledged that the lack of review for Residents 6, 11, and 141 did not meet expectations.
Failure to Report and Supervise Resident Abuse Allegations
Penalty
Summary
The facility failed to implement policies and procedures for identifying, reporting, and investigating resident-to-resident abuse for 2 residents. Resident 114, who was admitted with kidney failure and a bladder infection and was able to make needs known, reported that about two weeks earlier a staff member yelled at them and was rough with their roommate. The resident said they told another staff member but did not hear anything further. The EHR and May 2026 incident log contained no documentation of the incident. During interview, the administrator stated they were not aware of the allegation and would start an investigation. The facility investigation later showed an LPN was aware of the allegation but did not report it because they did not believe the resident, stating the resident makes things up. Resident 150, who was readmitted with depression, anxiety, and heart failure and was able to make needs known, reported that Resident 102 touched them inappropriately on three occasions and entered their room at 3 AM to touch their shoulders from behind. Resident 150 stated staff were aware and that they did not feel as safe as they used to, and they reported keeping a fork on their bedside table to use if needed. Resident 102 had an order to monitor and document inappropriate sexual behaviors, and the facility investigation showed no witness statements or statement from Resident 102. The intervention plan required one-to-one supervision, but observations showed Resident 102 in the hall or room without staff supervision, the TAR documented repeated inappropriate sexual behaviors in April and May 2026, and the staffing schedule showed no one-to-one supervision assigned on multiple days. The DON stated the facility had not been able to implement the planned one-to-one supervision due to lack of staffing.
Missing transfer notices, bed-hold notices, and Ombudsman notifications
Penalty
Summary
The facility failed to notify residents and their representatives in writing of the reason for transfer or discharge to the hospital and failed to provide written bed-hold notice at the time of transfer for 4 of 5 sampled residents reviewed for discharge and hospitalization. The affected residents were Resident 7, Resident 157, Resident 155, and Resident 8. Resident 7 was admitted with chronic obstructive pulmonary disease, heart failure, and muscle weakness, was able to make needs known, and was hospitalized on 02/07/2026 with readmission to the facility afterward; the record did not show that a bed hold was offered, that the required transfer/discharge form was completed and provided, or that the Ombudsman was notified. Resident 157 was admitted with respiratory failure, heart failure, and pneumonia, was able to make needs known, and had a resident-initiated against-medical-advice discharge; the record did not show the required transfer/discharge form was completed and provided or that the Ombudsman was notified. Resident 155 was transferred to the hospital, but the record showed the resident was not offered a bed hold, there was no notice for the transfer to the hospital, and the Office of the State Long-Term Care Ombudsman was not notified. Resident 8 reported being hospitalized for about five days and stated they did not return to the same room and were not given a bed hold or transfer notice; the record also did not show a bed hold or transfer form and did not show Ombudsman notification. Staff stated that bed hold and transfer forms were used for hospital transfers, and the DON stated that lack of bed hold, transfer-to-hospital form, and Ombudsman notifications did not meet expectations.
Late Completion of MDS Assessments
Penalty
Summary
The facility failed to ensure resident quarterly, admission, and discharge MDS assessments were completed within 14 days of the ARD for 11 of 11 sampled residents reviewed for resident assessments. Review of the RAI showed quarterly assessments and discharge assessments must be completed no later than the ARD plus 14 calendar days. EHR review showed multiple assessments were completed well beyond that timeframe, including an annual MDS for Resident 46 completed 39 days after the ARD, quarterly MDSs for Residents 55, 70, 99, 5, 118, 121, 128, 142, and 153 completed 34 to 40 days after the ARD, and a discharge MDS for Resident 73 completed 37 days after the ARD. During interview, the RN/MDS Coordinator stated remote corporate staff were doing the MDS and had control over the schedule. The Administrator stated the expectation was for MDS to be completed timely and accurately. The report identified the deficiency under WAC 388-97-1000(4)(a)(5)(d).
Delayed and Incomplete Care Plans and Care Conferences
Penalty
Summary
The facility failed to ensure care plans were timely revised and/or care conferences were held timely for 6 of 23 sampled residents. The deficiency involved residents with diagnoses including metabolic encephalopathy, dysphagia, diabetes, asthma, muscle weakness, COPD, heart failure, tremors, acute kidney failure, and hospice enrollment. Survey review and staff interviews showed that care planning and interdisciplinary care conference processes were not completed within expected timeframes and, in some cases, were incomplete or missing required participants. For Resident 123, the record showed the resident was admitted to hospice on 12/26/2025, but the hospice care plan was not initiated until 01/02/2026. Staff stated the hospice care plan should have been started once hospice admission was confirmed and that it should have been created sooner, within 48 hours of hospice admission. For Resident 12, the record showed care conference documentation that was incomplete and not signed, with one form focused on discharge planning and another form not identifying who attended. Staff stated the initial care conference should occur within 48 hours of admission and should include the resident and the interdisciplinary team, including nursing and other disciplines as needed. For Resident 11, care conference forms showed incorrect admission information, no nursing or therapy involvement, and incomplete review of form sections. For Resident 7, the last care conference was documented on 01/13/2026, and staff stated the resident should have had a conference in April 2026. For Resident 128, the last care conference was documented on 10/15/2025, and staff stated care conferences were behind and should have been offered quarterly. For Resident 141, the last care conference was documented on 11/17/2025, and staff stated care conferences should be offered on admission, quarterly, and at resident request. The report cited WAC 388-97-1020(2)(c)(d), (e)(f)(4)(b)(d)-(f), (5)(b).
Insufficient staffing to provide ordered one-to-one supervision
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents who were care planned for one-to-one supervision after resident-to-resident allegations. A review of the investigation dated 04/27/2026 showed that Resident 102 was to receive one-to-one supervision related to the incident, but observations on 05/19/2026, 05/22/2026, 05/26/2026, and 06/01/2026 showed the resident either in the East Hall or in the room without staff supervision. A separate investigation dated 05/22/2026 showed that Resident 7 was to receive one-to-one supervision related to the incident, but observations on 05/26/2026 and 06/01/2026 showed the resident without staff supervision. During interviews, Resident 7 stated on 06/01/2026 that they were not receiving one-to-one supervision as discussed, and another resident in the same room stated they had not seen staff providing one-to-one supervision to Resident 7. The Staffing Coordinator stated there were three residents who required one-to-one supervision and that, due to a recent fire and the need for smoking aid, the facility did not have sufficient staff to provide one-to-one supervision each day. The Staffing Coordinator also stated that if a resident who required one-to-one appeared stable, staff would rotate between smoking supervision and one of the residents care planned for supervision. Review of the staff schedule for 05/26/2026 through 05/31/2026 showed no scheduled one-to-one supervision for Residents 102 and 7, and the DON stated the facility had not been able to implement the care planned one-to-one supervision due to lack of staffing.
Delayed Medication Regimen Review Follow-Up
Penalty
Summary
The facility failed to ensure that Medication Regimen Review (MRR) recommendations were implemented in a timely manner for 3 of 5 sampled residents reviewed for unnecessary medications. For Resident 1, the EHR showed diagnoses of encephalopathy, myocardial infarction, and respiratory failure, and the resident was able to make needs known. The pharmacy completed an MRR on 04/23/2026 and recommended reviewing the use of a psychotropic medication for possible discontinuation or dose decrease, but the recommendation had not been addressed by the provider when reviewed on 05/20/2026. Staff B, the DNS, stated the MRR should have been reviewed and addressed timely but was not. For Resident 150, the EHR showed a readmission with diagnoses including depression, anxiety, and heart failure, and the resident was able to make needs known. Consultation reports for March and April 2026 did not list Resident 150 as having new medication recommendations from the consulting pharmacist, and Staff B stated on 05/26/2026 that they had knowledge of the resident's MRRs for those months but were unable to locate any documentation. For Resident 122, the EHR showed diagnoses of liver failure and depression, and the resident was able to make needs known. The EHR showed an MRR completed on 05/20/2026, but no other monthly reviews were found in the EHR. Staff B stated on 05/20/2026 that the facility had recently changed pharmacies and was unable to locate the March and April 2026 MRRs, and that this did not meet expectations.
Infection Control Surveillance Data Not Tracked or Trending
Penalty
Summary
The facility failed to maintain an infection prevention and control program by not completing analysis of infection control data, identifying trends, or completing follow-up activities in response to those trends for February, March, and April 2026. Review of the facility’s Infection Prevention and Control Program showed it followed accepted infection prevention and control standards set by the CDC, but the surveillance records and monthly summary reports did not consistently match and did not include trend identification or interventions. For February 2026, the infection surveillance log showed 15 total infections, including two UTIs, while the infection control map showed seven UTIs and the monthly summary report listed 18 healthcare acquired infections with seven UTIs, without trends or interventions. For March 2026, the surveillance log showed 19 in-house acquired infections with four UTIs, while the monthly summary report listed 14 in-house acquired infections and did not identify trends or interventions. For April 2026, the surveillance log showed no identification of infectious organisms and 29 in-house acquired infections, the infection control map showed 13 total infections, and the monthly summary report listed 14 healthcare acquired infections without trends or interventions. The LPN/Infection Preventionist stated they had recently started as the IP and were aware of the inaccurate infection surveillance, and the DON stated it was the expectation that infection surveillance be accurate and that the monthly summary include tracking, trending, and interventions implemented.
Failure to Educate and Document COVID-19 Vaccination Status
Penalty
Summary
The facility failed to implement policies and procedures to ensure each resident and staff member was offered and received education about the COVID-19 vaccine, and that vaccination status was properly documented. Review of the electronic health record for Resident 75 showed the resident was admitted with a diagnosis of stroke and was not able to make needs known. The record contained no documentation that Resident 75 or the resident's representative was educated on the risks and benefits of the COVID-19 vaccine, or that the vaccine was offered or administered. During interviews, the LPN/Infection Preventionist stated the facility should have offered and educated the resident or representative on the COVID-19 vaccine but found no records showing this was done for Resident 75. The DNS stated it was the expectation that Resident 75 or the representative received education on the risks and benefits and was offered the vaccine. For staff vaccination practices, the Human Resources Director stated staff COVID-19 vaccine status was requested on hire, but staff were not educated on the risks and benefits, offered the vaccine, or directed where to obtain it. The Administrator stated it was the expectation that residents receive education and be offered the vaccine, and that staff be provided education and offered or directed where to obtain the vaccine on hire, with this documented and tracked.
Failure to Issue Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to issue Notification of Medicare Non-Coverage (NOMNC) forms at least two calendar days before Medicare skilled coverage ended for 2 of 3 sampled residents reviewed for beneficiary notices. Resident 27 was admitted to the facility and later discharged on 04/27/2026 to an adult family home, and the record showed no NOMNC form was provided before discharge. Resident 161 was admitted to the facility and later discharged on 12/02/2025 to home, and the record also showed no NOMNC form was provided before discharge. During interview, the Business Office Manager stated they were responsible for issuing the notices and that none could be found for Residents 27 and 161, and the Administrator stated Medicare-insured residents were supposed to receive NOMNC notice in advance and that the lack of notices for these residents did not meet expectations.
Missing Resident Cell Phone Not Addressed
Penalty
Summary
The facility failed to provide a safe environment to ensure reasonable care and protection of a resident’s personal property from loss or theft for 1 of 3 sampled residents reviewed for environment. Resident 2 was admitted with diagnoses including diabetes and high blood pressure and was able to make needs known. During an interview, Resident 2 stated their cell phone had gone missing, staff were aware, and it had not been found or replaced. The resident’s Inventory of Personal Effects, dated 04/17/2026, listed a cell phone with charger and black bag among the resident’s personal items. The facility’s grievance/concern log showed a grievance on 04/27/2026 that the resident’s family reported missing items, with the issue marked resolved on 05/08/2026. The Complaint/Grievance Report dated 05/08/2026 documented that the family reported missing clothing items and a phone on 04/26/2026; the clothing items were found and the issue was resolved, but the report did not address the missing phone. Staff interviews confirmed the phone was still missing: the LPN/Resident Care Manager stated the grievance report should have addressed the missing phone and did not meet expectations, and the Administrator stated they were not aware the resident was still without a cell phone and believed it had been found with the clothing items.
Unnecessary Antipsychotic Use Without Documented Indication
Penalty
Summary
The facility failed to ensure one resident was free from unnecessary psychotropic medication use when Resident 65 was prescribed and administered Seroquel for agitation without documented behaviors or agitation in the record. Resident 65 was admitted with diagnoses including UTI, diabetes, dementia, and acute pyelonephritis, and was not able to communicate needs. Observation showed the resident sitting in a wheelchair by the nurse’s station with head down and eyes closed on multiple occasions. Review of the EHR showed progress notes from 04/30/2026 through 05/15/2026 did not document behaviors or agitation, and the admission MDS dated 03/26/2026 did not show behaviors or indications for antipsychotic use. During interview, the LPN/Resident Care Manager stated the facility’s process was to first rule out infection, environmental factors, and pain, then refer to mental health, and stated the Seroquel order did not meet expectations. The DON also stated the resident should have indications for antipsychotic use and that this did not meet expectation.
Delayed Admission MDS Completion
Penalty
Summary
The facility failed to timely complete the admission minimum data set (MDS) assessment within 14 days of admission for Resident 114. The resident was admitted with diagnoses of kidney failure and bladder infection and was able to make needs known. Review of the electronic health record on 05/19/2026 showed the admission comprehensive MDS was still in process 29 days after admission, with multiple sections unanswered. During interviews, the MDS/RN stated the admission MDS should have been completed within 14 days but was not, and the DNS stated it was their expectation that the MDS be completed per schedule and that Resident 114 should have had the admission MDS completed within 14 days of admission.
Failure to Complete Significant Change Assessment After Hospice Admission
Penalty
Summary
The facility failed to complete a significant change in condition assessment for Resident 123, who was admitted with diagnoses including metabolic encephalopathy and dysphagia and was able to make needs known and sometimes understand others. The resident was admitted to hospice on 12/26/2025 for a terminal diagnosis of cerebrovascular accident, and the record showed the resident received hospice services. However, a significant change condition MDS assessment was not completed within 14 days of the hospice admission. During interviews, the MDS/RN stated the assessment was not done timely after hospice admission, and the DON stated the resident should have had a significant change condition MDS when admitted to hospice and that this did not meet expectations.
Inaccurate MDS Coding for Vision and Tobacco Use
Penalty
Summary
The facility failed to ensure minimum data set (MDS) assessments were completed accurately for 2 of 23 sampled residents, Residents 8 and 85, during review of resident assessments. Resident 8 was admitted with diagnoses including breast and bone cancer, anemia, and diabetes, and was able to communicate needs. During an interview, Resident 8 stated they needed new glasses, were nearsighted, and were unable to read what was on TV, and also stated they had a pair of glasses at home. However, the admission MDS coded the resident as having adequate vision and not using corrective lenses. Staff later stated the vision assessment had been done by remote staff and they were unsure if it was accurate, and the DON stated the coding did not meet expectations. Resident 85 was admitted with diagnoses including respiratory failure, generalized muscle weakness, and dysphagia, and was able to make needs known. During an interview, Resident 85 stated they smoked supervised in the courtyard and staff kept their smoking materials. The diagnosis list showed nicotine dependence, and a provider progress note documented the resident as a current smoker of a half pack per day with no tobacco cessation counseling documented. Despite this, the admission MDS coded the resident as not using tobacco. The MDS/RN stated the admission MDS should have been coded yes for tobacco use and needed to be modified, and the DON stated the MDS was not accurately coded for tobacco use and needed to be modified.
PASRR assessments not accurately completed for 3 residents
Penalty
Summary
PASRR assessments were not accurately completed for 3 of 8 sampled residents reviewed for PASRR and unnecessary medications. Resident 13 was admitted with diagnoses including paranoid personality disorder, delusional disorder, dementia, and heart failure, and was able to make needs known. The EHR showed a Level I PASRR completed on 11/29/2022 indicating a Level II evaluation referral was required because of serious functional limitations during the past 6 months related to mental illness, but the facility did not refer the resident to the appropriate state-designated authority for a Level II PASARR evaluation and determination. Resident 14 was admitted with diagnoses including PTSD, COPD, and chronic kidney failure, and was able to make needs known. The EHR showed a Level I PASRR completed on 03/17/2026 stating the attending physician certified the individual was likely to require fewer than 30 days of NF services under an exempted hospital discharge, with no Level II indicated at that time unless the scheduled discharge did not occur; however, there was no documentation that the facility referred the resident for a Level II PASARR evaluation and determination when the discharge did not occur. Resident 150 was re-admitted with diagnoses including depression, anxiety, and heart failure, and was able to make needs known. The hospital-completed Level I PASRR showed no serious mental illness indicators checked and stated no Level II was indicated, but the SSD stated the PASRR should have been corrected to reflect the resident’s depression and anxiety and that a referral for a Level II evaluation should have been completed.
Baseline Care Plan Not Completed for Bed Mobility and Transfers
Penalty
Summary
The facility failed to formulate a baseline care plan within 48 hours of admission for Resident 159, who was admitted with traumatic subdural hemorrhage, fractures of the T5-6 vertebrae, and respiratory failure and was not able to communicate needs. Review of the electronic health record showed the resident’s care plan dated 05/10/2026 contained no instructions or directions for positioning in bed, bed mobility, or transfers, and the Visual/bedside Kardex also had no instructions for nursing assistants on bed mobility and transfers. Observations showed the resident in bed with the head of the bed elevated and the body slouching down on 05/18/2026, and again in bed with the head of the bed elevated and the feet touching the lower bed frame on 05/20/2026. During interview, the LPN/Resident Care Manager stated the baseline care plan should have included directions and instructions on bed mobility and transferring, and the DON stated the care plan did not meet expectations.
Care plans did not reflect fluid restriction and hearing needs
Penalty
Summary
The facility failed to ensure care plans were accurate and reflected resident care needs for 2 of 23 sampled residents. Resident 103 was admitted with diagnoses including diabetes, leg amputation, and end stage renal disease, and was able to communicate needs. The EHR showed a provider order dated 05/05/2026 for a fluid restriction of 1500 mL per day, with 900 mL allotted for dietary and 600 mL for nursing, but the care plan dated 04/30/2026 did not include the fluid restriction. During interviews, a CNA stated the care plan and Kardex contained instructions for nursing assistants if someone was on fluid restriction, an LPN stated the fluid restriction was documented in the care plan for nursing assistants to know and follow, and the DNS stated Resident 103's care plan did not meet expectations. Resident 2 was admitted with diagnoses including diabetes, dysphagia, and high blood pressure, and was able to make needs known. The modification of the admission MDS showed minimal difficulty hearing with no hearing aid. The current care plan initiated on 04/17/2026 did not include a communication deficit related to being hard of hearing. An LPN/MDS staff member stated they were unable to locate a care plan related to the resident's difficulty hearing and that there should have been one, and the DNS stated Resident 2 should have had a communication deficit related to hard of hearing care plan initiated and implemented and that this did not meet expectations.
Failure to Monitor and Offload Existing Pressure Injuries
Penalty
Summary
The facility failed to provide care and services to monitor actual pressure injuries and to prevent new pressure injuries for one resident who was reviewed for pressure injuries. The resident was admitted with diagnoses including encephalopathy, myocardial infarction, and respiratory failure, and was able to make needs known. During an interview, the resident stated that their sitting bones were sore. The resident was later sent to the hospital and returned to the facility. The admission nursing assessment documented a 6 cm by 10 cm stage 2 pressure ulcer to the tail bone and a 3 cm by 2 cm stage 2 pressure ulcer to the left heel, but no further monitoring of the pressure injuries was found in the EHR. A body check assessment did not list the pressure injuries, although it noted pressure ulcer prevention measures including pillow, offloading, and turning and positioning. The active plan of care showed the resident had declined a low air loss mattress, but no other interventions such as offloading and repositioning were listed. Multiple observations showed the resident lying on their back in bed with no offloading devices and heels pressed on the bed. The resident stated staff never put pillows under their feet or turned them on their side. Staff interviews confirmed that residents with pressure injuries should have positioning devices, frequent repositioning, weekly monitoring, and care plan interventions, but these were not in place for this resident.
Falls, Smoking Oversight, and Elopement Device Failures
Penalty
Summary
The facility failed to investigate and document a resident’s fall and related injury. Resident 85 was admitted with respiratory failure, generalized muscle weakness, and dysphagia, and could make needs known. The resident stated they rolled out of bed during the night and were helped back into bed by two people, but the incident log and the EHR contained no fall documentation. Later observations showed a yellow, green, and purple/pink bruise/bump on the left forehead, and staff members acknowledged they were only learning about the fall after the fact. The RN/SDC stated that if a resident was found on the floor, the resident should be assessed, notifications made, incident reporting initiated, and the event documented, but those steps had not been completed when the fall was discovered. The facility also failed to have smoking assessments and interventions in place for Resident 85 in a timely manner. The resident had a diagnosis of nicotine dependence and was documented as a current smoker, with supervised smoking in the courtyard and staff keeping the smoking materials. The provider progress note identified the resident as a current smoker, but no tobacco cessation counseling was documented. A smoking evaluation requiring supervised smoking and the related care plan were not initiated until after the nicotine dependence and smoking status had already been identified. Staff later stated the smoking evaluation and care plan should have been completed when the nicotine dependence was first known. The facility further failed to protect Resident 14 from elopement by ensuring the Wander Guard device was in place. Resident 14 had diagnoses including PTSD, COPD, and chronic kidney failure, and the EHR showed the resident was at risk for elopement and required a Wander Guard on the left arm. However, observations showed the resident outside smoking without the device on the arm on multiple occasions. The resident stated they had removed and discarded the device after admission and would do the same if another were applied. Staff were unaware the device was no longer in place, the TAR had no area to document the device, and the unit manager later stated the order had been entered incorrectly and did not appear on the TAR.
Fluid restriction orders were not implemented or documented for two residents
Penalty
Summary
Fluid restrictions were not implemented or documented correctly for 2 of 4 residents reviewed for nutrition. Resident 103 was admitted with diabetes, leg amputation, and end stage renal disease and was able to communicate needs. The EHR showed a provider order for a 1500 mL fluid restriction, with 900 mL from dietary and 600 mL from nursing per day, but the May 2026 MAR showed a different order for water restriction of 1500 mL for nursing only, broken into 600 mL in the morning, 600 mL in the evening, and 300 mL at night. Nursing documentation did not show a total amount and contained conflicting amounts for what was provided by dietary versus nursing. Staff stated the documentation should have been clearer and should have included a total amount, and the DON stated the documentation did not meet expectations. Resident 2 was admitted with diabetes, dysphagia, and hypertension and was able to make needs known. The EHR showed a diet order for a liberal renal diet with easy-to-chew texture and thin liquids, but no fluid restriction order. The nutritional care plan included offering and encouraging fluids of choice and did not include fluid restriction, even though hospital discharge orders listed a 1.6 liter per day fluid restriction. The RD noted the hospital had the resident in fluid restriction and planned to follow up with the provider, and a cardiology note later referenced fluid restriction per nephrology guidance. Staff stated the hospital discharge fluid restriction should have been implemented or clarified on admission and that it should have been addressed earlier.
Tube Feeding Administration and Documentation Deficiencies
Penalty
Summary
Enteral nutrition was not administered and documented in accordance with provider orders for two residents who had feeding tubes. Resident 9 was admitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, dysphagia, and aphasia, and was assessed to require nutrition through a feeding tube. The care plan identified the resident as at nutritional risk. A provider order dated 03/05/2026 directed Jevity 1.5 to be given continuously via pump at 97 milliliters per hour for 15 hours each day, from 8:00 PM to 11:00 AM. Review of the May 2026 MAR showed staff documented only the times the pump was turned on and off, but did not document the total amount of enteral feeding infused. Staff M stated nursing staff were not documenting the total received on the MAR or in a progress note, and Staff B stated the MAR should have included supplemental documentation for the amount of nutrition received daily. Resident 4 was admitted with diagnoses including diabetes, dysphagia, and artificial tube feeding, and could communicate needs. The resident stated the tube feeding was turned off at 7:00 AM and restarted at 9:00 AM, while the MAR order directed Osmolyte at 70 milliliters per hour for 22 hours, off at 5:00 AM and restarted at 7:00 AM. The MAR showed nurses initialed day and night shifts without documenting the actual times or fluid amount given. Staff O stated the tube feeding should have been documented with specific start and stop times and the amount given, and Staff B stated the documentation did not meet expectations.
Missing Dialysis Center Contract for Two Residents
Penalty
Summary
The facility failed to have an active agreement and contract with the dialysis center for two residents who required dialysis services. Resident 103 was admitted with diagnoses including diabetes, leg amputation, and end stage renal disease, and was dependent on dialysis. Resident 2 was admitted with diagnoses including diabetes and was also dependent on renal dialysis. Both residents were able to communicate their needs. Review of facility contracts showed no active agreement with the dialysis center where these two residents were receiving dialysis, and the Administrator stated the facility did not have an agreement or contract with the dialysis center and was waiting to receive one.
Failure to Address Resident Psychosocial Needs After Social Interaction Restriction
Penalty
Summary
The facility failed to address the psychosocial needs of one resident who was reviewed for abuse. Resident 128 was admitted with diagnoses including tremors and heart failure and was able to make needs known. The care plan identified that the resident was at risk for adjustment issues related to loss of social support network after moving into the center, with interventions to review the impact on social involvement, provide assistance to increase social involvement, monitor medical conditions that may contribute to social isolation, and evaluate mood state or behavioral symptoms impacting social isolation. Resident 128 stated that a facility staff member told them they were talking to reception staff for too long, interfering with staff work, and that they were no longer able to speak to facility staff unless it was related to care, with excessive social interaction limited to activity staff. The resident reported feeling depressed, confused, and isolated to their room for several days before filing a grievance. The grievance stated the resident had been told by business office, nursing, and social service staff not to socialize with reception staff or others in the reception area and described being isolated for 15 days. Progress notes showed social services and admissions staff later told the resident they were allowed to greet and talk to anyone in the building, but if they wanted longer one-on-one conversations they should check with activities. Interviews with the Social Service Director and Administrator indicated social services should have assessed for psychosocial outcomes from the misunderstanding, but that assessment was not documented as having been done at the time.
Failure to Document Nonpharmacological Interventions Before PRN Pain Medication
Penalty
Summary
The facility failed to provide nonpharmacological interventions before administering PRN oxycodone for Resident 16, who was admitted with diagnoses including bipolar disorder and dementia and was able to make needs known. The resident had a provider order for PRN oxycodone and a separate order to document non-pharmacological interventions such as heat, repositioning, relaxation breathing, food or fluid, massage, exercise, immobilization of a joint, or other interventions in the progress note. Review of the medication administration record for May 2026 showed the resident received PRN oxycodone on nine occasions, and review of the progress notes for that month did not show documentation that nonpharmacological interventions were used before the medication was given. During interviews, the Unit Manager stated the facility ensured PRN pain medications were necessary by providing NPI first, and the DON stated NPI should be attempted prior to giving PRN pain medications and that the resident’s lack of NPI prior to receiving PRN oxycodone did not meet expectations.
Delayed Dental Care and Inaccurate Oral Health Care Plan
Penalty
Summary
The facility failed to provide prompt dental care services and failed to ensure the care plan reflected the resident’s current dental status for one resident who was admitted with respiratory failure, generalized muscle weakness, and dysphagia. The resident was able to make needs known and stated in interview that they had no dentures and would not mind getting dentures, and that staff had not asked whether they wanted dentures. The admission MDS showed the resident had no natural teeth or tooth fragments, and a focused oral health care plan created later listed broken/missing teeth with interventions to brush and clean dentures and encourage brushing teeth and gums. The resident’s provider progress note documented that the resident was edentulous with chewing and swallowing difficulties. Staff interviews showed an internal referral for dental services was sent on 05/18/2026, but staff acknowledged it should have been made sooner. The Social Services Assistant stated the email request was forwarded to the Social Services Director the next day, and the Social Services Director stated the dentist was in the facility on 05/19/2026 but the resident was not seen, even though the resident should have been seen then. The DON stated the resident needed to be seen by a dentist for dentures and that this should have been addressed sooner, and also stated the care plan needed revision to reflect the resident’s current oral/dental status.
Failure to Honor Documented Food Allergy
Penalty
Summary
The facility failed to provide food that accommodated a documented onion allergy for Resident 1, who was admitted alert and oriented and had allergies listed in the EHR, admission diet order, and order summary. The resident’s record also showed a nutritional assessment noting the onion allergy, and the care plan addressed nutrition risk and large protein portions but did not include interventions related to the onion allergy. A dietary profile completed after admission documented that the Dietary Manager had met with the resident and noted an additional dairy intolerance. On 05/03/2026, Resident 1 was served onions in food from the kitchen and developed an allergic reaction with swelling of the tongue and throat and difficulty speaking. Nursing documented that epinephrine was administered and was effective, and the resident was monitored after the reaction; a telehealth provider was notified, and paramedics arrived onsite to assess the resident. During interviews, the resident stated staff frequently brought food with onions despite the allergy, and the DON stated the resident was served onions because new staff missed the allergy.
Delay in care and incomplete response to resident rash
Penalty
Summary
The facility failed to ensure Resident 2 received necessary care and services when the resident developed a skin rash and there was a delay in care. Resident 2 was admitted with multiple diagnoses for medical management, nursing care, and rehabilitative services, was alert and aware, and was their own decision maker. The nursing evaluation on 03/19/2026 documented the resident was continent of bowel and bladder and noted scrotal swelling, but did not document a rash. On 03/25/2026, a provider note documented scrotal edema and a diffuse rash, and zinc oxide was ordered to be applied to the groin and genitals every 12 hours as needed for rash. The MAR showed the zinc oxide order, but no doses were documented as given, and the care plan did not reference the change in skin condition or treatment of the rash. A collateral contact reported that Resident 2 had a two-hour wait for a bedpan, urinated and defecated while waiting, and then developed a rash in the peri area. Staff C stated there should have been an assessment, provider notification, resident and/or family notification, an order for treatment, and care plan updates, but said they were not familiar with the resident's rash and found no alert charting. Staff B stated the zinc oxide order may have been entered directly by the provider without nursing being updated about the rash or treatment order, and said the resident should have been assessed and the rash documented and monitored. Staff A stated the situation seemed straightforward.
Resident Discharged With Other Residents’ Medications
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when the resident was discharged home with medications prescribed to two other residents in addition to the resident’s own discharge medications. The resident had multiple diagnoses, including a history of stroke with one-sided paralysis and weakness, and was alert, oriented, and their own decision-maker at the time of discharge. The discharge plan documented furosemide 20 mg twice daily and warfarin 4 mg at bedtime until the following day. After discharge, the resident reported that the facility sent them home with two different people’s medications and stated they took the medications until realizing they were not theirs. The resident identified the medications received as furosemide 20 mg and Xarelto 20 mg, both labeled with other persons’ names. The resident also stated that when facility staff called after discharge, they were told about receiving someone else’s pills and were asked to return the medications or send a picture so they could be refilled. Staff later stated they expected medication safety procedures to be followed, and the administrator recalled the resident’s report that they had been sent home with other residents’ medications.
Failure to Report Unwitnessed Falls to State Agency and Incident Log
Penalty
Summary
The deficiency involves the facility’s failure to report unwitnessed falls to the State Survey Agency within 24 hours and to enter these incidents into the facility’s incident reporting log for two residents. One resident, admitted for nursing care and rehabilitation after a fall requiring hip and femur surgery, was alert, oriented, and able to make their needs known. This resident reported attempting to transfer into a chair at night, falling to the floor, and being unable to reach the call light, then crawling to the door to yell for help. A nurse’s progress note documented hearing the resident calling for help, finding the resident on the floor, and noting that the wheelchair and walker were far from the fall position, consistent with the resident’s report of having pulled themself to the door. The resident was assisted back to bed, had a hip x-ray, and the fall was documented by the provider and reviewed by the interdisciplinary team, but there was no corresponding entry in the facility’s incident reporting log and no report submitted to the State Survey Agency for this unwitnessed fall. The second resident, admitted with dementia, chronic kidney disease, and pressure ulcers for respite nursing and palliative care, was cognitively impaired but able to make needs known and required staff assistance with ADLs. A collateral contact stated the resident was bedridden, questioned how the resident could have fallen out of bed, and expressed concern that staff could not say how long the resident had been on the floor. A nursing note documented that the resident was found on the floor next to the bed, was unable to verbalize how the fall occurred, and was returned to bed via Hoyer lift with two-person assist, with no injuries identified. The provider and family were notified, and the fall was reviewed by the interdisciplinary team with care plan updates, but the incident was not entered into the facility’s incident reporting log and was not reported to the State Survey Agency. Staff later stated that both residents’ falls had been reported in the internal system but were not added to the State reporting log, resulting in the failure to meet the reporting requirements under WAC 388-97-0640(7)(a)(b)(i).
Failure to Implement Restorative Nursing Program for ROM and Mobility
Penalty
Summary
The deficiency involves the facility’s failure to initiate and provide a restorative nursing program for a resident with limited range of motion (ROM) and mobility needs after discharge from skilled therapy. The resident was admitted with diagnoses including stroke, aphasia, malnutrition, and depression, and the admission MDS documented that the resident did not walk, required partial to maximal assistance with ADLs, and was always incontinent of bowel and bladder. An observation showed the resident in bed with the right leg demonstrating full ROM while the left leg, hand, and arm appeared contracted. The PT discharge summary, dated mid-January, indicated that the resident was discharged from skilled PT services and had goals to improve active/passive ROM of the left hip and knee using splinting and ROM techniques, and to tolerate right knee splinting with functional ROM carryover. The PT discharge recommendations included continuing the resident’s splint and brace. The care plan, dated late February, identified the resident as having limited physical mobility related to contractures and documented a referral to a Restorative Nurse Assistant. However, during interviews, the COTA stated that although a restorative nursing program had been written for the resident, it could not be located. The DNS reported that there was a restorative nursing program referral for right knee splinting three times per week, but the facility was unable to locate the referral or any documentation showing that a restorative nursing program was implemented for the resident between the PT discharge date in mid-January and the early March observation. This lack of implementation and documentation of the restorative nursing program led to the cited deficiency for failure to provide appropriate care to maintain or improve ROM and mobility.
Failure to Integrate Wound Specialist PI Interventions Into Resident Care Plan
Penalty
Summary
Facility staff failed to develop and implement an individualized comprehensive care plan incorporating wound care specialist recommendations for a resident at risk for pressure injuries (PIs). The facility’s Skin Integrity Management policy, dated 05/26/2025, directed staff to develop comprehensive, interdisciplinary plans of care for prevention and wound treatments, including offloading devices, turning and repositioning, special wound care techniques, and appropriate support surfaces, and to review and revise care plans as indicated. The resident was admitted with diagnoses including diabetes, malnutrition, and muscle weakness, was identified on the admission MDS as being at risk for PIs, admitted with existing PIs, and totally dependent on staff for turning and repositioning in bed. A wound care specialist documented progress notes on 10/08/2025 listing nine specific recommended interventions and preventive measures related to the resident’s PIs, including turning every two hours, keeping skin clean and dry, avoiding massage of bony prominences, using positioning devices, keeping the head of bed as low as possible to reduce shearing, keeping sheets dry and wrinkle-free, and removing all fragranced products in favor of chemical-free, fragrance-free disposable washcloths. On 10/22/2025, the wound care specialist added a tenth recommendation for aggressive offloading. Review of the resident’s care plans and Kardex on 11/19/2025 showed that none of these ten recommendations had been added to the care plan or Kardex. On 12/17/2025, the DON confirmed that there were no provider orders for the recommended interventions, none of the ten recommendations were care planned or present on the Kardex, and stated that CNAs rely on the Kardex and verbal shift report to know resident care needs.
Failure to Implement Wound Care Recommendations and Prevent Worsening Pressure Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate pressure injury (PI) prevention and treatment for a dependent resident with multiple existing wounds and high risk for skin breakdown. On admission, the resident had bilateral heel wounds and wounds to the right lower extremity and required substantial/maximal assistance for bed mobility and was totally dependent on staff for turning and repositioning. The MDS documented the resident was not on a turning/repositioning program, and the care plan, while noting bilateral heel pressure ulcers and wounds to the right lower extremity with a goal for healing, did not include a turning schedule or pressure-relieving mattress. Staff interviews confirmed the resident could not turn without assistance, that CNAs relied on the Kardex for care instructions, and that there was no order or care plan for a pressure-relief mattress. The facility used a contracted wound care and treatment company (WCTC) to manage the resident’s PIs. WCTC progress notes documented a right heel/foot Stage 4 PI that initially measured 15.75 cm² pre-debridement and 19.11 cm² post-debridement, with 100% necrotic tissue. Subsequent weekly assessments showed fluctuating but generally worsening wound characteristics, including increasing necrotic tissue, maceration, erythema, and a significant increase in wound size to 48 cm². WCTC notes over several visits identified peri-wound maceration and erythema and recommended multiple PI-related interventions, including aggressive offloading. However, review of the resident’s EHR, orders, care plans, and Kardex showed no documentation that any of the ten WCTC-recommended interventions were implemented. The resident completed an initial course of antibiotics shortly after admission, and no further antibiotics were ordered prior to hospital transfer, despite ongoing wound issues and later-confirmed osteomyelitis. Additional wounds were not identified or documented by facility staff prior to the resident’s transfer to the hospital. WCTC documentation showed a left 4th toe wound first described as a non-pressure chronic ulcer with 100% necrotic tissue and fragile peri-wound skin with mild erythema and maceration, later reclassified as an unstageable PI with persistent 100% necrotic tissue and progression to severe erythema and severe maceration. The facility’s EHR contained no documentation that this left 4th toe PI was present on admission or that it was identified or treated by the facility before transfer. Hospital records documented, at the time of admission, an unstageable right heel PI, a deep tissue PI to the left lateral ankle, and an unstageable sacral PI, all present on admission, yet the facility’s EHR contained no documentation that the left lateral ankle PI or sacral PI had been identified or treated. Hospital podiatry and provider notes later confirmed right calcaneal osteomyelitis with a non-salvageable right lower extremity and concern for osteomyelitis in the left calcaneus. Facility nursing and management staff acknowledged that WCTC recommendations had not been entered as orders or care-planned and that direct care staff relied on the Kardex, which did not reflect these interventions. Provider follow-up notes from the facility documented the resident’s reports of stabbing pain in both feet, heels, and sometimes up to the knees, and a decrease in effectiveness of gabapentin, with discussion of increasing the dose. These notes did not include any documented physical examination of the resident’s feet or foot wounds. A nurse’s progress note later recorded the resident’s transfer to the hospital for a non-pressure injury/pain-related care need. At the hospital, wound nurse and podiatry consults documented multiple PIs, including those not previously documented by the facility, and confirmed severe infection and osteomyelitis. Throughout this period, the facility’s failure to implement WCTC recommendations, to provide documented offloading and pressure-relief measures, to identify and document new or worsening PIs (left 4th toe, left lateral ankle, sacral area), and to conduct and document appropriate wound assessments and follow-up contributed to the identified deficiency in providing pressure ulcer care and preventing new ulcers from developing.
Fire watch not performed as required after fire alarm malfunction
Penalty
Summary
The facility failed to maintain a safe environment when the fire alarm panel malfunctioned and fire watch was not performed as directed. Review of the facility’s August 2018 Emergency Procedure - Fire Watch policy showed that fire watch procedures were to be initiated if the fire alarm system failed, with tours occurring every 30 minutes, 24 hours a day, by assigned and trained staff who were solely dedicated to fire watch and had no other facility-related duties. According to the facility-reported incident, on 08/06/2025 the fire alarm system malfunctioned and displayed error codes. The fire alarm company determined faulty wires needed replacement, turned the system offline, and the facility implemented fire watch protocols every 15 minutes until the system was repaired. The work order showed technicians were onsite from 3:15 PM to 5:00 PM and placed the facility on modified fire watch. The Maintenance Director stated the fire alarm company disconnected the D Hallway on the [NAME] side of the facility from the fire alarm panel so the trouble alarm would no longer sound, and said fire watch was only required on the D Hall. Observation and interviews showed fire watch was not being carried out as described in the policy. On 08/07/2025, the investigator observed no one methodically going in and out of rooms looking for fires during a continuous observation on D Hall. The Administrator and Maintenance Director gave conflicting statements about who was assigned fire watch, and the assigned staff member initially described fire drill actions rather than fire watch. The LPN later stated they were told only to walk down the hall, check each room for smoke and fire, and record findings, while the Maintenance Director stated dedicated staff were expected to make rounds every 15 minutes, open doors, and walk into rooms. The log sheet also showed fire watch entries that the LPN later said were in error. Several residents stated staff were not entering rooms or making frequent rounds, and multiple NACs were documented as performing fire watch while also assigned resident care duties.
Failure to Prevent Accidents, Elopement, and Falls Due to Inadequate Supervision and Care Plan Implementation
Penalty
Summary
The facility failed to ensure that residents were free from accident hazards and did not provide adequate supervision to prevent accidents, resulting in multiple incidents of harm. One resident with severe cognitive impairment and a history of wandering was able to elope from the facility without staff knowledge. The front desk staff observed the resident leaving but did not intervene or follow elopement protocols, and there was a delay in calling 911 due to confusion about staff responsibilities. The resident was later found by a member of the public after experiencing a fall. Another resident at risk for elopement did not consistently have a Wander Guard device in place, as required, with documentation showing multiple missed opportunities to ensure the device was present and functioning. The facility also failed to provide the required level of assistance during care, resulting in avoidable injuries. One resident, who was totally dependent on staff for repositioning and required two staff members for bed mobility, was assisted by only one staff member, leading to a fall and a laceration near the eye that required hospital treatment. Despite care plan requirements, staff continued to provide care with only one person. Another resident with recent hip surgery and specific hip precautions experienced a dislocation and severe pain during a transfer when staff failed to follow the required precautions. The care plan and provider orders for hip precautions were not properly implemented or communicated. Additionally, the facility did not consistently assess the effectiveness of interventions or revise care plans in a timely manner following falls. One resident experienced three falls within a short period, resulting in injuries including a head laceration and hematoma, but the care plan was not updated with new interventions after the first two falls. Another resident, at high risk for falls and with a history of impulsivity, was left unattended after expressing intent to get out of bed, leading to a fall. In several cases, required safety equipment such as reacher tools and call lights were not kept within reach, and staff did not remain with residents at risk until help arrived.
Failure to Timely Investigate and Address Falls and Injuries
Penalty
Summary
The facility failed to thoroughly and timely investigate falls and injuries, and did not implement interventions to prevent repeat falls for several residents. For one resident with dementia and multiple comorbidities, there were repeated falls over several months, with delayed or incomplete investigations and unclear or delayed care plan interventions. Incident reports for some falls were completed days after the events, and some investigations were not completed at all. Another resident, also with dementia and mobility issues, experienced multiple falls, including one resulting in a head laceration and another in an occipital hematoma. The facility did not update the care plan with new interventions after one of the falls, and the incident report was completed several days late. Staff interviews confirmed that care plans were not revised and interventions were not implemented in a timely manner following these incidents. Additional deficiencies included a resident who sustained a head injury requiring sutures after falling from bed during repositioning, with the incident not recorded in the facility's logs and the investigation completed late. Another resident suffered a hip dislocation during a transfer, with no documentation of the incident in facility logs and no investigation completed. Staff interviews confirmed that these incidents were not reported or investigated as required.
Inaccurate Resident Assessments in Dental, Respiratory, and Restraint Care
Penalty
Summary
The facility failed to ensure accurate assessments for several residents in key areas, including dental conditions, respiratory care, and the use of restraints. For two residents with dental issues, staff observations and interviews revealed missing, broken, and discolored teeth, yet the Minimum Data Set (MDS) assessments did not accurately reflect these conditions. In one case, a resident with quadriplegia and malnutrition had multiple missing and stained teeth, which were noted in progress notes and the initial nursing evaluation, but the MDS incorrectly indicated no dental issues. Another resident with broken and discolored teeth was also inaccurately assessed in the MDS, which failed to document their dental problems. A resident receiving oxygen therapy for chronic obstructive pulmonary disease (COPD) was not properly coded for oxygen use in the modified quarterly MDS, despite having a provider order and being observed on oxygen during multiple visits. Staff interviews confirmed that the resident was receiving oxygen therapy and that the MDS should have indicated this, but it was marked incorrectly. Additionally, a resident was incorrectly documented as using a partial trunk restraint in the quarterly MDS, although staff later confirmed this was an error and the resident did not use such restraints. These inaccuracies in resident assessments were confirmed through interviews with staff, including the MDS nurse and the Director of Nursing Services, who acknowledged the errors and stated that the MDS should have accurately reflected the residents' conditions. The failures in assessment were identified through a combination of record review, direct observation, and staff interviews, and were not known to some staff members responsible for coordinating care, such as the social worker.
Failure to Follow Physician Orders for Oxygen Therapy
Penalty
Summary
The facility failed to provide respiratory care consistent with physician orders for oxygen therapy for two residents. For one resident with heart failure, COPD, and asthma, observations showed oxygen was administered at five and six liters per minute via nasal cannula, while the provider order specified three liters per minute continuously. Documentation in the treatment administration record indicated the order was being followed, but interviews with staff confirmed the resident was receiving a higher oxygen flow than ordered, and there was no documentation of a provider order change or notification. For another resident with encephalopathy, diabetes, and dementia, observations on multiple occasions showed oxygen was set at three liters per minute via nasal cannula, while the care plan required one liter continuously. Staff interviews confirmed the oxygen was set higher than ordered, and the expectation was that staff follow provider orders and monitor oxygen settings every shift. These failures resulted in oxygen being administered at rates inconsistent with physician orders for both residents.
Improper Storage of Medications and Expired Supplies in Medication Room
Penalty
Summary
Surveyors observed that medication and medical supplies were not stored according to accepted professional standards in the East medication room. Specifically, a large plastic bag labeled with a resident's name containing an IV solution of liquid nutrition, two vials of infuvite, and an infusion kit was found stored in the resident's food refrigerator instead of the designated medication refrigerator. Additionally, multiple expired medical supplies and equipment were found in cabinets, including universal viral transport kits, ECOLAB peroxide test strips, cleansing towelettes, and a gel/wound vac therapy system package, with expiration dates ranging from November 2022 to March 2025. During interviews, both an LPN and the Director of Nursing Services confirmed that medications should not be stored in the food refrigerator and that expired supplies should not be kept in the medication room. Both staff members acknowledged that these practices did not meet facility expectations. The findings were based on direct observation, staff interviews, and record review, and were cited as not being in compliance with regulations regarding the proper storage and labeling of drugs and biologicals.
Failure to Honor Resident Food Preferences and Grievance Resolution
Penalty
Summary
The facility failed to provide food services that met the stated preferences of five out of eight sampled residents. Multiple residents reported that their menu selections and food preferences, such as specific meal choices and requests for double portions, were not honored. For example, one resident did not receive their ordered cheeseburger and had to request it directly from the kitchen, while another reported not receiving their requested hamburger, juice, and tea for lunch. Several residents filed grievances regarding not receiving double portions or specific meal items, but continued to experience the same issues despite the grievances being marked as resolved in the facility's log. Observations and record reviews confirmed that residents did not consistently receive the foods or portions indicated on their meal cards, such as double portions, condiments, or additional beverages. Interviews with dietary staff and the registered dietician revealed a lack of communication regarding residents' grievances and food preference changes, with the dietician unaware of several residents' requests for double portions. The administrator acknowledged that food preferences should be honored and that the ongoing issues did not meet facility expectations.
Failure to Report Covid-19 Outbreak and Inadequate Infection Surveillance
Penalty
Summary
The facility failed to report a Covid-19 outbreak to the local health department as required by its own policy. After one resident was diagnosed with Covid-19 at the hospital, testing was conducted for all residents and staff on the affected hall, resulting in a second resident, who was the roommate of the first, also testing positive. Despite this, the local health department was not notified of the outbreak. Interviews with facility staff, including the Infection Preventionist and Director of Nursing Services, confirmed that the required notification did not occur. Additionally, the facility did not maintain adequate infection surveillance and tracking for two of three months reviewed. There was no infection control data available for one month, and incomplete tracking and lack of a monthly summary for another. In one case, a resident with an open abdominal wound and chronic kidney disease had multiple provider orders for urine testing to check for infection, but the tests were not completed in a timely manner. When the test was eventually performed, an infection was found and treated, but this infection was not included in the facility's infection control line list or tracked on the infection map. Staff interviews confirmed these lapses in infection tracking and timely testing.
Failure to Provide Required Abuse and Dementia Training for CNAs
Penalty
Summary
The facility failed to ensure that each staff member received required training related to resident abuse prevention, dementia management, and annual continuing competencies for certified nurse aides. Review of training records revealed that one CNA had a blank training record, and another CNA had only one in-service training completed within the past year. During an interview, the Administrator confirmed that these staff members did not have the necessary training and that this did not meet the facility's expectations for staff education and competencies prior to working with residents.
Failure to Honor Resident Bathing Preferences
Penalty
Summary
The facility failed to honor and facilitate a resident's choice regarding their bathing schedule. A resident with cerebral palsy, urinary tract infection, and muscle weakness, who was able to communicate their needs, reported that they could not set their own shower time and that showers were only scheduled twice a week at specific times, which were not consistently followed. Observations and interviews revealed that showers were assigned based on room and bed location, and although the resident was scheduled for a shower on certain days, the showers were not provided as planned. Documentation review confirmed that showers were not given on the scheduled days. Staff interviews indicated that while the expectation was to ask for and honor resident preferences, this did not occur for the resident in question. The deficiency was identified through observation, resident and staff interviews, and review of shower documentation, showing a failure to support resident self-determination and choice as required.
Failure to Complete Baseline AIM Assessment for Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to conduct or document an initial or baseline abnormal involuntary movement (AIM) assessment for a resident who was prescribed an antipsychotic medication. The resident, who had diagnoses including dementia with psychotic disturbance and cognitive and communication deficits, was readmitted to the facility and received both antidepressant and antipsychotic medications on a routine basis. Despite the medication administration record indicating the need to monitor for extrapyramidal symptoms such as tardive dyskinesia, tremors, gait issues, and involuntary movements, there was no evidence in the electronic health record of a completed AIM assessment at admission or readmission. Observations showed the resident exhibiting various movements, such as moving legs and feet, and manipulating their gown, but staff were unable to locate any AIM assessment documentation. Interviews with both an LPN and the Director of Nursing confirmed that an AIM scale assessment should have been completed and documented for residents on antipsychotic medications, but this was not done for this resident. Both staff members acknowledged that this failure did not meet facility expectations.
Failure to Complete Required PASARR Assessments for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that Pre-admission Screening and Resident Review (PASARR) assessments were accurately completed for two residents. For one resident with diagnoses including dementia, depression, and impaired memory, the record showed the resident was unable to make their needs known and was prescribed and administered multiple antidepressant medications. Despite indications for serious mental illness on the Level I PASARR, no Level II referral was completed. Staff interviews confirmed that the PASARR process was missed for this resident, and the lack of a Level II referral did not meet facility expectations. For another resident with multiple health conditions, including anxiety, depression, and PTSD, the Level I PASARR was marked as an exempted hospital discharge, allowing admission without a Level II review. However, the resident remained in the facility longer than 30 days, which should have triggered a correction of the PASARR and a Level II referral. Staff interviews confirmed that this step was not taken. The facility's policy required that all admissions have the appropriate PASARR completed and that state-specific guidelines be followed, but these procedures were not adhered to in these cases.
Failure to Individualize Care Plans for Oxygen Therapy and Oral/Dental Needs
Penalty
Summary
The facility failed to develop and implement individualized, comprehensive care plans for three residents regarding oxygen therapy and oral/dental status. For one resident with chronic obstructive pulmonary disease (COPD) and an order for supplemental oxygen, observations confirmed the resident was receiving oxygen therapy, but there was no corresponding care plan addressing this intervention. Both a Licensed Practical Nurse and the Director of Nursing Services acknowledged the absence of a care plan for oxygen use, despite the resident's ongoing therapy and provider orders. Another resident with cerebral palsy and multiple broken, discolored upper front teeth reported significant dental problems, but the care plan only included general oral care instructions and did not address the broken teeth or potential for oral pain. A third resident, dependent on artificial feeding and with a history of malnutrition and gastrointestinal hemorrhage, stated a need for lower dentures, but the care plan did not include any information or instructions regarding missing lower teeth. The Director of Nursing Services confirmed that care plans should have included details about broken or missing teeth.
Failure to Follow Provider Orders and Professional Standards of Care
Penalty
Summary
The facility failed to ensure that services provided to three residents met professional standards of quality. For one resident with diabetes, stiff joints, muscle weakness, and heart failure, there was a provider order for protective boots to be placed on both heels every shift. However, the resident was observed in a wheelchair without the boots, and both the resident and staff confirmed the boots were only worn in bed. There was no documentation of the resident's refusal to wear the boots while up, and staff did not notify the provider or clarify the order as required. Another resident with dementia, COPD, hypotension, and depression had a provider order for midodrine to be held if systolic blood pressure exceeded 120. Despite this, the medication was administered on two occasions when the resident's blood pressure was above the specified parameter. Additionally, a third resident dependent on artificial feeding via a central line had no provider order in place for the care of the central line, including monitoring for infection or dressing changes. Staff confirmed that care for the central line was not provided as expected.
Failure to Develop and Implement Individualized Activity Plan for Resident
Penalty
Summary
The facility failed to develop and implement an individualized activity plan for a resident who was admitted with diagnoses including encephalopathy, diabetes, and dementia. Observations over several days showed the resident sitting in a wheelchair near the nurse's station, and review of the electronic health record revealed that no activities assessment was completed upon admission and the care plan lacked an activities focus area. During interviews, the Recreation Director stated that no recreation assessment or activity care plan was completed because the resident was on isolation precautions at admission and was unaware of the resident's current isolation status. The Administrator confirmed that activity care plans are expected to be completed within 72 hours of admission and that residents on isolation should be offered one-on-one or in-room activities.
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 1,031 citations issued within 25 miles in the last 12 months — including the 5 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
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 Tacoma
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Birch Creek Post Acute & Rehabilitation | 0.5 mi | ★★★★★ | 35 | 0 |
| Agility Health And Rehabilitation | 1.5 mi | ★★★★★ | 24 | 0 |
| Park Rose Care Center | 2.1 mi | ★★★★★ | 0 | 0 |
| Alaska Gardens Health And Rehabilitation | 2.1 mi | ★★★★★ | 20 | 1 |
| Avamere Transitional Care Of Puget Sound | 3 mi | ★★★★★ | 56 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.