Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Othello Post Acute during CMS and state inspections, most recent first.
Care plans were not updated for three residents with changed clinical needs. One resident with chronic pain and a pain pump had a care plan that addressed pain generally but did not include the pump or related monitoring, another resident with severe dysphagia and tube feeding still had outdated references to eating and drinking despite strict NPO status, and a third resident receiving enoxaparin after knee surgery had no care plan documentation for anticoagulant use or bleeding/bruising monitoring.
Food storage and meal service practices were not maintained according to standards. Uncovered and undated food was found in kitchen and resident-use refrigerators, some resident food was expired or missing dates, cold items were served above the required temp, fish was held below the required hot-holding temp, and a cook handled food and equipment with gloves but did not perform hand hygiene between tasks, creating cross-contamination concerns.
Failure to obtain consent before psychotropic medication administration: A cognitively intact resident with depression and anxiety was ordered mirtazapine for depression, but the record showed no informed consent was completed before the first dose was given. RN staff gave differing accounts of when psychotropic consent was due, and the DON stated it should have been signed before administration so the resident could be informed of the risks and benefits.
PASRR Level II evaluations were not completed for two residents after their exempted hospital stays expired. Both residents had positive Level I screens for SMI, and one had depression and PTSD while the other had depression and anxiety. The Social Service Director acknowledged the residents should have been referred for Level II PASRR evaluations once the exemption ended.
A resident with COPD and respiratory failure was observed receiving oxygen at 4 L instead of the ordered 3 L, and the oxygen tubing was dated inconsistently with the weekly change order. The resident also had SVN equipment dated weeks earlier, with no documentation to clean or change it, while MARs showed DuoNeb was given regularly. Staff acknowledged the ordered oxygen rate and the need to change tubing and SVN equipment to prevent bacterial growth, but the incorrect oxygen flow rate was observed and not corrected.
A resident with severe cognitive impairment and physical limitations was given a hot beverage without a temperature check, required lid, or supervision, leading to a spill and third-degree burns. Staff failed to document temperature checks for hot liquids, and the care plan did not specify the use of a spill-resistant mug prior to the incident.
A resident experienced a delay in treatment due to the facility's failure to ensure timely laboratory services and follow-up. Despite abnormal urinalysis results indicating a potential UTI, there was no evidence of review or communication with the resident. Subsequent orders for further testing were not documented, highlighting issues with continuity of care and communication among staff.
The facility failed to dispose of expired medications and maintain proper storage temperatures for vaccines. A hepatitis vaccine was found expired, and the refrigerator storing vaccines was at 50 degrees, outside the recommended range. Temperature logs had not been updated since July, and staff confirmed the oversight.
The facility failed to update care plans for three residents, leading to discrepancies between documented care needs and actual conditions. One resident's care plan did not reflect resolved skin issues and changes in mobility equipment. Another resident's care plan was not updated after a fall, reiterating an existing intervention. These failures risked unmet care needs and diminished quality of life.
The facility failed to implement the bowel management protocol for two residents, leading to recurrent constipation and inadequate care. Despite having provider orders, the facility did not consistently administer medications or notify providers of ongoing issues. Staff interviews confirmed the protocol was not followed, resulting in a deficiency.
A resident with COPD and other conditions experienced repeated falls due to inadequate supervision and ineffective interventions in an LTC facility. Despite being on hospice care, the resident fell nine times over 23 days, often found without oxygen and confused. Observations showed a lack of consistent supervision, and staff noted the resident would have benefited from 1:1 supervision, which was not provided.
The facility failed to secure rooms containing sharps, chemicals, and tools, with unlocked cabinets found in shower rooms and a resident room containing unsecured items like a box cutting knife. Additionally, a resident with severe cognitive impairments was observed in a wheelchair with a lap belt that was unclean, highlighting a lapse in maintaining hygiene and dignity.
A cognitively intact resident using a motorized wheelchair was denied the right to go on community outings independently, despite being alert and oriented with no safety concerns. The facility required an escort due to traffic concerns, contradicting their policy allowing independent outings for such residents. Staff acknowledged the resident's capabilities but insisted on an escort, leading to a violation of resident rights.
The facility failed to provide necessary ADL support and communication services for two residents. One resident with quadriplegia did not receive restorative nursing services as care-planned, with staff unclear on responsibilities. Another resident with aphasia faced communication challenges due to inadequate support and language barriers, impacting their care. Staff interviews confirmed these deficiencies, highlighting the need for improved restorative and communication services.
A resident with severe cognitive impairments did not receive consistent showers as required for their ADLs. Despite needing total assistance and having a care plan to be kept clean, the resident was only given bed baths on specific dates, and observations noted greasy hair. The DON stated showers should be given twice weekly, but staff hesitated due to the resident's spastic movements and did not assess for a suitable bath chair.
A resident with quadriplegia developed a pressure ulcer on their pinky finger, but the facility failed to update the care plan with treatment goals and interventions. Despite being at high risk for skin breakdown, the resident's blister was not treated, and there was a lack of communication about new findings. The Director of Nursing admitted that skin checks might not have been thorough.
A resident with severe cognitive impairment and limited ROM developed contractures due to the facility's failure to implement necessary interventions. Despite policies for contracture prevention, the resident did not receive passive or active ROM exercises, nor were splints or braces used. Observations showed the resident's hands clamped shut without protective measures, and staff confirmed the lack of intervention. The Director of Therapy and DON acknowledged the oversight, leading to the resident's contracture development.
The facility failed to maintain clean respiratory equipment for two residents, one with heart failure and pneumonia, and another with COPD. Despite records indicating regular cleaning, observations showed the oxygen concentrator filters were covered in dust and debris. Staff interviews revealed inconsistencies in maintenance practices, highlighting a risk for respiratory issues.
A facility failed to reassess the use of PRN antipsychotic medication for a resident after 14 days, as required. The resident, who was cognitively intact and receiving hospice services, was prescribed haloperidol lactate for agitation. Despite the need for reassessment, the resident's records lacked necessary documentation, and staff interviews confirmed the oversight. This placed the resident at risk for unintended medication side effects.
A facility failed to maintain a medication error rate below five percent, resulting in a ten percent error rate. Errors included administering the wrong form of aspirin and an unauthorized antacid to a resident, and failing to apply a prescribed Lidocaine patch to another resident. The errors were due to improper documentation and adherence to standing orders.
The facility failed to store food according to professional standards, with expired items found in refrigerators and dry storage, and no open dates on freezer items. Expired foods included grits, cake mix, biscuit mix, pizza crust mix, canned peaches, oatmeal, pork, powdered sugar, pie filling, sprinkles, tortillas, peppers, and cinnamon. The kitchen refrigerator had wilted celery and cabbage, and outdated lettuce. The conference room refrigerator contained expired yogurt, rice pudding, spinach, and salad. The Dietary Manager acknowledged the importance of discarding expired foods to prevent illness.
The facility failed to explain the arbitration agreement in a language and manner understandable to a resident with severe cognitive impairment and their Spanish-speaking spouse. The agreement, only available in English, was signed by a different family member, and staff did not document explanations or confirm understanding, despite the high population of Spanish-speaking residents.
The facility failed to implement enhanced barrier precautions for a resident with an indwelling catheter, as staff did not wear required PPE during high-contact activities. Additionally, a nurse did not perform hand hygiene before administering medications to residents, despite facility policies. These actions placed residents at risk of acquiring infections.
A resident with diabetic foot ulcers did not receive a follow-up with a podiatrist as ordered, and changes in their wound condition were not reported to the medical provider. The resident's condition worsened, leading to hospitalization with sepsis and gangrene, requiring surgeries and amputations. Facility staff were unaware of the necessary follow-up appointments and failed to communicate changes in the resident's condition.
The facility failed to provide antiviral treatment for a resident who tested positive for COVID-19 and exhibited symptoms such as increased lethargy and decreased intake. Despite recommendations from the local public health authority and CDC guidelines, the facility did not notify the resident's medical provider or discuss possible antiviral treatment.
Care plans not updated for pain pump, NPO status, and anticoagulant therapy
Penalty
Summary
The facility failed to complete and update care plans timely for 3 sampled residents, including a resident with chronic pain and a pain pump, a resident with severe cognitive impairment and tube feeding, and a resident receiving anticoagulant therapy after bilateral knee fractures. The deficiency was identified through observation, interview, and record review, and involved care plans that did not reflect current resident conditions, treatments, or monitoring needs. For Resident 6, the record showed diagnoses including low back pain and infection of the bone of the right foot and ankle, with regular and as-needed opioid pain medications. The resident stated they had a pain pump that now contained morphine instead of fentanyl, and provider documentation noted the resident was to be seen at a pain clinic and the pump was to be refilled. However, the care plan addressed pain in general and did not include goals, interventions, or monitoring related to the pain pump, and there were no provider notes in the record detailing the pain clinic visit or instructions regarding pump use. Staff stated the care plan should have been updated to address the pump. For Resident 7, the record documented traumatic brain injury, dysphagia, gastroparesis, and feeding tube dependence, with multiple hospitalizations related to tube removal, vomiting, aspiration pneumonia, and intestinal bleeding. The care plan still contained references to eating and drinking, including instructions for swallowing and remaining upright after oral intake, even though staff stated the resident was not safe to swallow and was strict NPO. For Resident 47, the admission record showed bilateral knee fractures with surgical repair and a physician order for daily enoxaparin prophylaxis, but the care plan did not document the anticoagulant or monitoring for bruising and bleeding, and there were no side effect monitors in the MAR or TAR. Staff stated anticoagulant use should have been reflected in the care plan.
Food Storage, Temperature Control, and Hand Hygiene Deficiencies
Penalty
Summary
Food was not stored in accordance with professional standards in the facility kitchen and in the employee lounge refrigerator used for resident food. During an initial kitchen tour, the main refrigerator contained nine bowls of cooked apples with cinnamon that were uncovered and had no date. In the employee lounge refrigerator, food for Resident 18 included a bowl marked to be used by 12/20/2025 and another bowl without a date, and seven ice cream bars in the freezer had no date. Resident 35 also had a bag of tamales dated 12/28/2025 and a pizza pocket with no date. The Dietary Manager stated food in the refrigerator had to be dated and covered for food safety, and that food brought in by family members was to be dated and placed in the refrigerator. During lunch meal service, cold foods were found above the required temperature, including milk at 48 degrees Fahrenheit, coleslaw at 44.3 degrees Fahrenheit, and peaches at 42 degrees Fahrenheit. The coleslaw was discarded and milk was removed from resident trays, but four glasses of milk remained on trays and the cart with the milk was later ready to be served to residents. A plain piece of fish was also observed at 141 degrees Fahrenheit instead of the required 145 degrees Fahrenheit and was placed on the cart for service. During another observation, a cook handled the meal cart and food with gloved hands, touched a fish and a hamburger bun, removed gloves without hand hygiene, checked the temperature of milk, and then put on new gloves without washing hands. The cook stated hand hygiene should have been performed after touching the cart and after checking the milk temperature to prevent cross contamination.
Failure to Obtain Consent Before Psychotropic Medication Administration
Penalty
Summary
The facility failed to obtain consent for a psychotropic medication before administering the first dose for Resident 47. Resident 47 was admitted with diagnoses including depression and anxiety, was cognitively intact, and was taking medication for depression. The record also documented depression in the nutritional care plan, and there were no instructions to nursing staff regarding the antidepressant medication. On 12/12/2025, a provider ordered mirtazapine daily, and the medical record showed no informed consent had been completed for this medication before it was given. According to the December 2025 MAR, Resident 47 received the first dose of mirtazapine on 12/26/2025 without documented consent. During interviews, Staff C, RN, stated psychotropic medication consent needed to be obtained within three to five days of administration, while Staff D, RN, stated consent needed to be obtained prior to the first dose. The DON stated the consent should have been signed before the medication was administered so the resident could be informed of the risks and benefits and make an informed decision.
PASRR Level II evaluations not completed after exempted hospital stays
Penalty
Summary
The facility failed to ensure PASRR Level II evaluations were completed after the 30-day hospital exempted stay expired for two residents. Resident 6 was admitted with diagnoses including depression and PTSD, and a PASRR Level I screen documented a positive screen for severe mental illness. The Level II evaluation was not indicated at the time because the resident was under an exempted hospital discharge, but the record showed the resident remained in the facility after the 30-day exemption expired and there was no documentation that a Level II PASRR was completed. Resident 34 was admitted with diagnoses including depression and anxiety, and the Level I PASRR screen was positive for severe mental illness. The Level II PASRR was also not indicated initially because the resident met the guidelines for an exempted hospital stay, with the form stating additional assessments were to be completed if the resident remained after the exemption expired. Record review showed Resident 34 did not discharge within 30 days and was still a resident, yet there was no documentation that a Level II PASRR was completed. The Social Service Director stated they were responsible for the PASRR process and acknowledged both residents should have been referred for Level II PASRR evaluations after the exempted hospital stay was completed.
Oxygen and Nebulizer Equipment Not Maintained or Administered as Ordered
Penalty
Summary
The facility failed to ensure oxygen and nebulizer delivery equipment were maintained as ordered and failed to administer oxygen per provider orders for Resident 34, who had diagnoses including COPD and respiratory failure. On observation, the resident was found lying in bed asleep while wearing oxygen set at 4 liters, although the physician order dated 10/23/2025 directed oxygen at 3 liters continuously for shortness of breath and weekly tubing changes. The oxygen tubing was observed dated 12/17/2025 on multiple occasions, and later dated 01/06/2026, while the MARs showed staff initialed weekly that the tubing had been changed and that the resident received 3 liters daily. The resident also had a small volume nebulizer on the tray table with tubing and equipment dated 11/25/2025. The physician order directed DuoNeb 3 milliliters via inhalation every 6 hours as needed for shortness of breath, and the December 2025 and January 2026 MARs showed the medication was given on a consistent basis. However, the record contained no documentation to clean or change the nebulizer equipment, and staff interviews confirmed the importance of changing oxygen tubing and SVN equipment to prevent bacterial growth. During an interview, an LPN entered the room, verified the resident was on 4 liters instead of the ordered 3 liters, and left without correcting the oxygen flow rate.
Failure to Supervise and Ensure Safe Hot Beverage Service Results in Resident Burn
Penalty
Summary
The facility failed to ensure adequate supervision and safe practices when serving hot beverages to a severely cognitively impaired resident who required assistance with activities of daily living, including setup of food and drink. The resident, who also had hemiplegia, hemiparesis, and aphasia, was given a cup of hot cocoa that had not been checked for temperature, was not provided with the required lid, and was left unsupervised in a hallway. The resident subsequently spilled the hot beverage on their lap, resulting in third-degree burns to their thighs and a blister between the right thigh and buttocks. Interviews and record reviews revealed that staff did not consistently check or document the temperatures of hot liquids before serving, as required by facility policy. The dietary manager confirmed that temperature checks were supposed to be performed and documented, but there was no record of such checks for the evening snack cart. Additionally, the specific mug with a heavy lid, intended to prevent spills for this resident, was not used at the time of the incident, and the care plan did not document this requirement prior to the incident. Temperature logs showed that hot liquids were often above the facility's maximum allowable temperature.
Failure to Ensure Timely Laboratory Services and Follow-Up
Penalty
Summary
The facility failed to ensure timely laboratory services and follow-up for a resident who exhibited urinary symptoms. On October 7, 2024, the resident complained of a burning sensation during urination and urinary frequency, prompting a medical provider to order a urinalysis (UA). The UA lab report, dated October 8, 2024, showed multiple abnormal results, but there was no indication that the report was reviewed by a provider or nursing staff. The resident was seen by a Nurse Practitioner on October 9, 2024, but the UA results were not addressed. On October 10, 2024, a representative for the resident reported concerns about a urinary tract infection (UTI) and the lack of communication regarding the results. Further review revealed that on October 17, 2024, a Physician Assistant noted the concerning UA results and ordered another UA. However, the Medication Administration Record (MAR) showed no documentation of the UA being obtained on the specified dates. Interviews with facility staff indicated a lack of continuity in care and communication issues regarding the follow-up of lab results. The Director of Nursing and Infection Preventionist acknowledged that the abnormal UA results should have been communicated to the provider immediately, but it was unclear if the second UA was obtained or if the resident received follow-up information on their health status.
Expired Medications and Improper Vaccine Storage
Penalty
Summary
The facility failed to ensure the timely disposal of expired medications and proper storage of vaccines, as observed in the medication storage room. During an inspection, a vial of hepatitis vaccine was found to have expired on 08/24/2024, yet it had not been discarded. Additionally, the refrigerator in the medication room was found to be at 50 degrees, which is outside the recommended temperature range of 36-46 degrees for storing vaccines such as Covid-19, Prevnar, and Tubersol. The temperature logs indicated that monitoring had not been conducted since July 2024, with only nine checks recorded that month. Interviews with staff confirmed the oversight, with a Registered Nurse acknowledging the importance of monitoring temperatures to maintain vaccine viability. The Director of Nursing also confirmed that the refrigerator temperature should have been monitored and the expired hepatitis vaccine should have been discarded. These lapses placed residents at risk of receiving compromised or ineffective medication.
Failure to Update Care Plans for Three Residents
Penalty
Summary
The facility failed to effectively review and update care plans for three residents, leading to discrepancies between documented care needs and actual resident conditions. For Resident 3, the care plan was not updated to reflect the resolution of a laceration and pressure injury, the removal of IV access, and the use of an alternating air mattress instead of a perimeter mattress. Despite these changes, the care plan continued to include outdated interventions, such as enhanced barrier precautions and IV site care, which were no longer necessary. Resident 6's care plan also contained inaccuracies, as it did not reflect the resolution of skin issues and the switch from a Broda chair to a tilt-in-space wheelchair. The care plan continued to list enhanced barrier precautions and the use of a Broda chair, despite the resident's improved skin condition and the change in mobility equipment to better support their therapy and independence. For Resident 12, the care plan failed to implement a new fall intervention after the resident rolled out of bed, instead reiterating an existing intervention to position the resident in the center of the bed. This lack of timely and effective care plan updates placed residents at risk of unmet care needs and diminished quality of life, as staff relied on outdated information to provide care.
Failure to Implement Bowel Management Protocol
Penalty
Summary
The facility failed to implement the bowel management protocol for two residents, leading to a deficiency in care. Resident 7, who had a diagnosis of neurogenic bladder and was on routine opioid pain medication, experienced recurrent constipation. Despite having provider orders for bowel interventions, the facility did not consistently administer the prescribed medications or notify the provider of the resident's ongoing constipation issues. The bowel records showed multiple instances where Resident 7 went several days without a bowel movement, and the medication administration records indicated that the effectiveness of the administered medications was often undocumented. Resident 16, who had diagnoses including kidney disease and depression, also experienced constipation. The resident was cognitively impaired and required assistance with toileting. Despite having provider orders for bowel management, the facility did not administer the as-needed medications consistently. The resident went several days without a bowel movement on multiple occasions, and the facility failed to follow the bowel management protocol, which included notifying the provider if there were no results from the enema. Interviews with staff revealed that the facility's bowel management protocol was not consistently followed. Staff acknowledged that Resident 7 had a history of routine constipation and that the bowel protocol was not implemented when indicated. The Director of Nursing confirmed that the bowel management protocol was not followed for residents experiencing routine constipation issues, leading to the deficiency cited in the report.
Repeated Falls Due to Inadequate Supervision and Intervention
Penalty
Summary
The facility failed to consistently implement appropriate interventions to reduce fall hazards and monitor for intervention effectiveness for a resident, resulting in repeated falls. The resident, who was admitted with diagnoses including chronic obstructive lung disease (COPD), kidney disease, and diabetes, was cognitively intact upon admission but experienced a significant change in condition, including increased confusion and anxiety. Despite being on hospice care for end-stage COPD, the resident sustained nine falls over a 23-day period, indicating a lack of effective fall prevention measures. The facility's policies on fall and injury prevention required revising care plans and assessing risk factors to prevent future falls. However, the resident's care plan interventions, such as ensuring the call light and needed items were within reach, and wearing non-skid socks or shoes, were not effectively preventing falls. The resident was found multiple times without oxygen, confused, and attempting to ambulate unassisted, leading to falls and injuries such as skin tears and bruising. Despite the addition of interventions like fall mats and signs to remind the resident to call for assistance, these measures were insufficient. Observations revealed that the resident was often left unsupervised, even when placed near the nurse's station for increased supervision. Staff interviews indicated that the resident would have benefited from 1:1 supervision, which was not consistently provided. The lack of adequate supervision and failure to ensure the resident wore oxygen contributed to the repeated falls and injuries, highlighting a deficiency in the facility's fall prevention and management practices.
Security and Cleanliness Deficiencies in Facility
Penalty
Summary
The facility failed to ensure the security of rooms containing sharps, chemicals, and tools, as observed in three out of four shower rooms and one resident room. In the shower rooms, unlocked cabinets were found containing items such as disposable razors, shampoo, and multi-purpose cleansers. Additionally, a tool chest with power tools and sharp objects was left unlocked in a shower room that was being used for storage. Staff interviews confirmed that these items should have been secured to prevent resident access. In one resident room, a project work sign was posted, but the door was left unlocked with no staff present. Inside, unsecured items such as a can of paint, a caulking gun, and a box cutting knife were found. The Maintenance Manager acknowledged that these items should not have been left unattended and unsecured, especially since the room could not be locked during ongoing work. Resident 2, who had a traumatic brain injury and quadriplegia, was observed in a wheelchair with a lap belt that was unclean and had food debris on it. This was noted on multiple occasions, and staff interviews revealed that the responsibility for cleaning the wheelchairs and lap belts fell to the night shift nursing assistants. The Director of Nursing emphasized the importance of maintaining cleanliness for hygiene and dignity.
Facility Fails to Honor Resident's Choice for Independent Outings
Penalty
Summary
The facility failed to honor a resident's choice for community outings, which was a violation of resident rights. The resident, who was cognitively intact and used a motorized wheelchair, expressed a desire to go to the store independently. Despite being alert, oriented, and having no history of elopement or safety concerns, the resident was informed they needed an escort for safety reasons. This decision was based on events from another sister facility, not on the resident's individual capabilities or history. The facility's policy allowed cognitively intact residents to leave independently, yet staff interviews revealed a practice of requiring escorts for all residents, regardless of cognitive status. Staff members, including a Nursing Assistant, LPN, Social Service Director, and Director of Nursing, acknowledged the resident's cognitive abilities and safe use of the wheelchair but insisted on an escort due to concerns about traffic and community environment. The Director of Therapy confirmed that the resident had not been recently assessed for wheelchair mobility, although they had previously passed a motorized wheelchair assessment. The resident expressed frustration, feeling imprisoned by the new rule, as they had previously been allowed to leave independently. The facility's actions were inconsistent with their policies and the resident's rights, as outlined in the facility's Resident Rights policy. The Director of Nursing admitted that requiring an escort without justification could be a resident rights issue, highlighting a disconnect between policy and practice.
Deficiencies in ADL Support and Communication for Two Residents
Penalty
Summary
The facility failed to provide necessary services to support activities of daily living (ADLs) for two residents, leading to deficiencies in their care. Resident 1, diagnosed with quadriplegia and cognitively intact, was not receiving the restorative nursing services as outlined in their care plan. The care plan required active and passive range of motion exercises to be performed regularly, but these were not being completed. Observations and interviews revealed that the staff believed therapy was responsible for these exercises, and there were no restorative aides available to carry out the program. Resident 22, who had suffered a stroke and was diagnosed with aphasia, faced communication challenges that were not adequately addressed by the facility. The resident, who primarily spoke Spanish, had difficulty expressing their needs due to a lack of appropriate communication tools and support. The care plan included strategies for communication, but these were not effectively implemented. Observations showed that signs in the resident's room were in English, and the resident struggled to communicate with staff, impacting the care they received. Interviews with staff confirmed the lack of restorative nursing care for Resident 1 and inadequate communication support for Resident 22. The Director of Therapy acknowledged the absence of restorative aides, and the Speech-Language Pathologist admitted to minimal treatment for Resident 22's communication skills. The Director of Nursing recognized the importance of improving communication methods for Resident 22 to meet their needs effectively.
Failure to Provide Consistent Showers to a Resident
Penalty
Summary
The facility failed to ensure that a resident with severe cognitive impairments received consistent showers, as required for their activities of daily living (ADLs). The resident, who needed total assistance for ADLs, was documented to have received only bed baths on specific dates between September and October 2024, despite not refusing to be bathed. The resident's care plan indicated the need to be kept neat, clean, and well-groomed daily, and it was somewhat important for them to choose between a bed bath and a shower. However, the resident's guardian reported that the resident had only been bathed in the shower room twice, and that was by the guardian themselves. Observations made over several days in October 2024 noted that the resident's hair was greasy, indicating poor hygiene. The Director of Nursing acknowledged that showers were supposed to be given twice weekly for hygiene and health promotion. However, staff hesitated to give the resident a shower due to their involuntary spastic limb movements and had not assessed the resident for a different type of bath chair that could facilitate showering. This oversight placed the resident at risk of not being bathed according to their preferences and maintaining proper hygiene.
Failure to Address Pressure Ulcer in Quadriplegic Resident
Penalty
Summary
The facility failed to develop treatment goals and care-planned interventions for a resident who developed a pressure ulcer. The resident, who had complete quadriplegia and was cognitively intact, was dependent on staff for all activities of daily living and was at risk for pressure ulcers. Despite this, the care plan only included general interventions such as weekly skin checks and notifying the charge nurse of any skin breakdown. A weekly skin evaluation showed no concerns, but a Physician Assistant later documented a blister on the resident's right pinky finger, likely due to pressure from the wheelchair. No new orders or interventions were added to the treatment plan following this discovery. Observations revealed that the blister was not being treated, and the resident reported no sensation in their fingers and no bandages or treatments for the blister. The Director of Nursing acknowledged that the resident was high risk for skin breakdown and that skin checks might not have been thorough. Additionally, there was a lack of communication regarding new findings from provider visits. This oversight placed the resident at risk for further skin deterioration.
Failure to Implement ROM Interventions for Resident
Penalty
Summary
The facility failed to implement necessary interventions to prevent reduced range of motion (ROM) and further decrease in ROM for a resident with limited ROM, identified as Resident 12. The resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living (ADLs), was observed to have developed contractures in both upper extremities over time. Despite the facility's policies and procedures for contracture prevention and management, including passive and active range of motion exercises, positioning, and use of splints or braces, these interventions were not applied to Resident 12. The resident's care plan and assessments indicated a need for monitoring and intervention, yet no restorative nursing program or therapy was initiated to address the resident's ROM impairments. Observations and interviews revealed that Resident 12's hands were clamped shut without any protective measures such as rolled-up washcloths, palm protectors, or splints in place. Staff interviews confirmed that the resident had not been receiving any hand stretching exercises or using any assistive devices for contracture prevention. The Director of Therapy acknowledged that therapy had not worked with Resident 12 on contracture prevention or management, and the Director of Nursing admitted that the resident's hands had been clamped shut for at least six months. This lack of intervention and oversight led to the development of contractures, highlighting a deficiency in the facility's care for maintaining and improving residents' ROM as per their own policies and procedures.
Failure to Maintain Clean Respiratory Equipment
Penalty
Summary
The facility failed to maintain respiratory equipment in a clean manner for two residents, placing them at risk for illness and decreased quality of life. Resident 8, who had heart failure and pneumonia, was dependent on supplemental oxygen. Despite documentation in the Medication Administration Records (MARs) indicating that the oxygen concentrator filter was cleaned weekly, an observation revealed the filter was covered in layers of lint and dust, obscuring its color. The facility administrator later confirmed the filter's unclean state and expressed surprise at the discrepancy between the MARs and the actual condition of the filter. Resident 18, diagnosed with chronic obstructive pulmonary disease (COPD) and chronic respiratory failure, also had an oxygen concentrator with a filter covered in dust and debris. The MARs indicated the filter was to be changed every six months, but there were no specific orders for regular cleaning. Interviews with staff revealed conflicting practices regarding the maintenance of oxygen filters, with some staff stating they were checked weekly and others indicating they were cleaned as needed. The Director of Nursing emphasized the importance of clean filters to prevent respiratory issues.
Failure to Reassess PRN Antipsychotic Medication Use
Penalty
Summary
The facility failed to have a practitioner reevaluate the continued use of antipsychotic medication for a resident after 14 days of use, as required. This deficiency was identified for one of the five sampled residents, who was prescribed haloperidol lactate, a PRN antipsychotic medication, for agitation. The resident, who was cognitively intact and receiving hospice services, had diagnoses including chronic obstructive pulmonary disease, respiratory failure, and diabetes. Despite the requirement for reassessment, the resident's records lacked progress notes or assessments from providers for the continued use of haloperidol lactate beyond the 14-day period. Interviews with facility staff confirmed the oversight. A Licensed Practical Nurse acknowledged that PRN psychotropic medications needed reassessment after 14 days. The Director of Nursing was unable to provide documentation of such reassessment for the resident, emphasizing the importance of evaluating whether the medication was still necessary and beneficial. This failure placed the resident at risk for unintended medication side effects and a decreased quality of life.
Medication Administration Errors Lead to 10% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a ten percent error rate during a survey. This was identified through the observation of medication administration for two residents. For Resident 176, a registered nurse administered safety-coated aspirin instead of the prescribed chewable aspirin and gave Geri-Mox liquid antacid without a provider order. The nurse justified the administration of Geri-Mox based on the resident's complaint of stomach pain, citing standing orders, but failed to document it in the resident's medical record as required. For Resident 23, the same nurse did not apply a prescribed Lidocaine patch for pain relief, as the resident frequently refused it. However, there was no documentation of the refusal or notification to the provider to potentially discontinue the order. The Director of Nursing confirmed that standing orders should be transcribed into the electronic health record and that medications should be administered as ordered by providers. These actions and inactions led to the identified medication errors, placing residents at risk of receiving incorrect medication treatments.
Failure to Adhere to Food Safety Standards
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety, as observed during a survey. Expired food items were found in two refrigerators and one dry storage area, and there were no open dates on food items in the freezer. Specifically, the pantry contained several expired items, including boxes of grits, banana cake mix, cheddar garlic biscuit mix, pizza crust mix, canned sliced peaches, boxes of oatmeal, shredded seasoned pork, powdered sugar, strawberry pie filling, cupcake sprinkles, corn tortillas, Chile peppers, and cinnamon. Additionally, the kitchen refrigerator contained brown and wilted celery and cabbage, as well as lettuce with outdated labels. The conference room refrigerator held expired yogurt, rice pudding, spinach, and a container of tossed salad. The freezer had opened packages of fillets, chicken strips, sausage, and bacon without open or expiration dates. Interviews with Staff M, the Dietary Manager, revealed that the dry storage was assessed weekly, and it was acknowledged that discarding expired foods was crucial to prevent serving contaminated food to residents, which could cause illness. Staff M also confirmed that the kitchen was responsible for cleaning the conference room refrigerators. These findings indicate a failure to adhere to food safety standards, potentially putting residents at risk for consuming expired food and food-borne illnesses.
Failure to Provide Arbitration Agreement in Understandable Language
Penalty
Summary
The facility failed to explain the arbitration agreement in a manner and language that was understandable to the resident and/or their legal representative. This deficiency was identified for one resident, who had severe cognitive impairment, no speech, and a preferred language of Spanish. The resident's spouse, who was the next of kin and only spoke Spanish, did not sign the arbitration agreement, which was instead signed by a different family member. The arbitration agreement was only available in English, and there was no documentation to show that it was explained in a language or manner that the resident or their spouse understood. Interviews with facility staff revealed that the Social Service Director attempted to verbally explain the English arbitration agreement in Spanish but did not document these explanations or confirm understanding. The Director of Nursing and the Administrator acknowledged the high population of Spanish-speaking residents but were unsure if arbitration agreements were available in other languages. The lack of documentation and language-appropriate materials contributed to the deficiency, as the facility did not ensure that the arbitration agreement was comprehensible to the resident and their representative.
Infection Control Deficiencies in PPE and Hand Hygiene
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for a resident with an indwelling catheter, which is a high-risk factor for multi-drug-resistant organisms (MDROs). Despite the presence of an EBP sign on the resident's door and readily available personal protective equipment (PPE), staff members did not wear the required gloves and gowns during high-contact activities such as transferring the resident from bed to wheelchair and assisting with toileting. Interviews with staff confirmed their awareness of the requirement to wear PPE, yet they did not comply during these interactions. Additionally, the facility did not adhere to its hand hygiene policy during medication administration. A registered nurse failed to perform hand hygiene before dispensing medications and interacting with residents. The nurse touched various surfaces and resident belongings without sanitizing their hands, only using alcohol-based hand rub (ABHR) after completing the tasks. This lack of hand hygiene was observed during medication administration for two different residents, indicating a pattern of non-compliance with infection control protocols. These deficiencies in infection prevention and control practices, including the failure to use PPE and perform hand hygiene, placed residents at risk of acquiring MDROs and other communicable diseases. The facility's policies clearly outlined the necessary precautions, yet staff did not consistently follow these guidelines, as evidenced by the observations and staff interviews.
Failure to Follow Up on Podiatry Referral and Report Wound Changes
Penalty
Summary
The facility failed to ensure a physician-ordered foot care referral for a podiatrist was followed up on, and a change in foot wound condition was reported to the medical provider for a resident reviewed for wound care. The resident, who was admitted with diabetic foot ulcers, required dressing changes and was mildly cognitively impaired. Upon admission, follow-up appointments with wound care, vascular surgery, and podiatry were ordered, but the facility did not adhere to these recommendations. The resident's foot wounds were initially assessed on 03/18/2024, and a follow-up with podiatry was recommended. However, no further wound care provider notes were found after this date. By 04/01/2024, the resident's foot wounds had worsened, with an increase in size and black tissue present, yet the physician was not notified of these changes. The resident's follow-up appointment with the vascular surgeon was rescheduled, and there was no documentation of a podiatry follow-up or notification to the wound care team about the decline in the resident's condition. The resident was hospitalized with sepsis and gangrene in the left foot, requiring intensive treatment and surgeries, including amputations. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's wound care needs and follow-up appointments. The facility's Director of Nursing acknowledged failures in documentation, routine wound assessments, and follow-up with ordered referrals.
Failure to Provide Antiviral Treatment for COVID-19
Penalty
Summary
The facility failed to ensure treatment of a viral illness was provided in accordance with professional standards of practice for Resident 2, who tested positive for COVID-19. Despite the resident showing increased lethargy, decreased responsiveness, and reduced intake after the diagnosis, there were no notes indicating that the resident's medical provider or their representative were notified of the decline, nor was there any discussion of possible antiviral treatment. The facility's response to the local public health authority's recommendation to start antiviral treatment was that the residents were not sick enough, which was not in line with CDC guidance. Interviews with staff revealed a lack of clarity on who notified the provider of the resident's COVID-19 diagnosis and the criteria for starting antiviral treatment. The Medical Director acknowledged that the resident's symptoms were indicative of the need for antiviral treatment, which should have been discussed with the resident and/or their representative. The Administrator confirmed that the resident was considered asymptomatic and did not receive antiviral treatment, despite the observed symptoms and the public health authority's concerns.
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 43 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Othello
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Columbia Crest Center | 20.3 mi | ★★★★★ | 32 | 0 |
| Lake Ridge Center | 21.1 mi | ★★★★★ | 11 | 0 |
| Richland Post Acute | 37.1 mi | ★★★★★ | 0 | 0 |
| Columbia Basin Hospital | 37.9 mi | ★★★★★ | 25 | 0 |
| Life Care Center Of Richland | 39.8 mi | ★★★★★ | 11 | 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 October 2026) and official state health department websites.