Above average — CMS composite of the measures below.
The next survey window likely opens around November 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 Park Shore during CMS and state inspections, most recent first.
Unsafe bathroom fixtures and non-homelike medication administration: A facility failed to keep bathroom handrails/support bars secure for three residents and used plastic bags as makeshift light switch pullcord extensions for two residents. Staff observed one handrail pulling away from the wall and another loose/wobbly, while the bags were tied to pullcords above beds. The facility also administered morphine to a resident in the dining room without documentation in the resident’s orders, care plan, or nursing tasks allowing meds to be given there.
Unlocked Medication Carts: Two medication carts were observed unlocked, parked, and unattended at the nurse's station. The facility policy required carts to be kept closed and locked when out of sight of the med nurse or aide, and both the RN and DON stated the carts should have been locked when not in use.
Food items were not properly date-marked or discarded in multiple refrigerators after their use-by/best-by dates had passed. Surveyors found uncovered or unlabeled items, including vegetables, sauces, yogurt, and puddings, in several kitchen and resident supplement refrigerators. Staff, including the Exec Chef, Dietary Manager, ADON, and Administrator, acknowledged the items should have been labeled or discarded.
Staff failed to follow EBP and droplet precaution requirements for three residents. An OT provided high-contact ROM to a resident with an IV antibiotic and central line without gown or gloves and left without hand hygiene. A CNA and an LPN caring for a resident with pressure ulcers did not perform hand hygiene between glove changes or after touching a contaminated trash bin. An RN and a housekeeper entered a resident’s droplet precaution room without the full PPE directed by the posted signage.
A resident with an indwelling urinary catheter was observed with an uncovered drainage bag containing yellow urine visible from the hallway, with no privacy bag covering it. A CNA stated catheter drainage bags should be covered and not visible from the hallway, and the DON stated the bag was expected to be covered and the resident's urine should not be visible.
Failure to Provide Required Transfer/Discharge Notice Information: The facility did not provide two residents with a written transfer/discharge notice containing required appeal rights and Ombudsman contact information. One resident was transferred to the hospital after a change in condition, and another was discharged to the community; in both cases, the records and discharge paperwork reviewed did not show the required notice information.
A resident admitted with insomnia was prescribed Trazodone at bedtime, but the admission MDS did not code the medication as an antidepressant in Section N0415. The MDS nurse and DON stated Trazodone should have been coded as an antidepressant per the RAI Manual, but it was omitted from the assessment.
The facility failed to include comprehensive care plan entries for two residents. One resident received IV and oral antibiotics for bacteremia and a skin and soft tissue infection, but the care plan did not address antibiotic use or monitoring for adverse effects. Another resident’s care plan did not document long-term stay or discharge goals, even though staff stated the representative wanted the resident to remain in the facility long term.
Failure to monitor weights and abdominal girth for residents on diuretics. A resident with CHF had major weight fluctuations while taking furosemide, and staff acknowledged the changes were inconsistent and should have prompted reweighing and provider notification. Another resident on bumetanide had a 9% weight gain, was not weighed per protocol after admission, and the provider was not notified of the gain. A third resident with ascites and orders for weekly weights and abdominal girth monitoring was not weighed as ordered, had incomplete refusal documentation, and staff confirmed abdominal girth was not measured.
A resident with pulmonary fibrosis, lung transplant status, and a cold received ordered O2 via an undated nasal cannula, while an undated, uncovered nebulizer mouthpiece/tubing was found exposed on top of a hamper. Staff stated the equipment was not routinely dated, changed, or stored in a bag when not in use, despite facility policies requiring clean, dated, and properly stored respiratory equipment.
Two residents had significant medication errors related to missing MAR documentation and unavailable medications. One resident with CHF, HTN, and behavioral symptoms had several ordered meds not signed for on the MAR and no nursing note explaining why they were not given or that the provider was notified. Another resident receiving hydroxychloroquine for RA missed multiple doses because the med was unavailable, with incomplete progress note documentation and no record that the provider or resident representative was notified.
Incomplete Daily Nurse Staffing Posting: The facility’s daily nurse staffing posting did not include the total number or actual hours worked by RN, LPN, and CNA staff directly responsible for resident care across the reviewed period. Observations and record review showed the posting displayed outside the therapy gym lacked actual hours, and the Medical Records Coordinator stated they expected scheduled hours rather than actual hours; the Administrator confirmed the postings did not reflect staff actually on duty in real time.
The facility failed to properly administer and document routine and as-needed medications for several residents, including not accurately accounting for or timely discarding controlled drugs. An LPN documented a medication as given before administration, and two residents received controlled medications without proper logbook documentation. Discrepancies were found between actual and recorded amounts of controlled substances, and discontinued medications were not destroyed as required.
The facility did not conduct thorough investigations into medication errors involving three residents, failing to interview other residents assigned to the involved RNs or document whether abuse or neglect was ruled out, despite policy and regulatory requirements. The incidents included missed or incorrect doses of pain medications for residents with severe cognitive impairment and one with intact cognition, with incomplete documentation and investigation steps.
The facility failed to properly label, date, and discard food items in two refrigerators and one freezer, risking foodborne illness. Unlabeled hollandaise sauce, expired coleslaw dressing, butter, heavy whipping cream, cheese, and inaccurately dated diced carrots were found. The Health Services Administrator expected adherence to food safety policies.
The facility failed to maintain an effective pest control program, leading to fruit flies in the kitchen. Observations revealed flies in dishwashing, hand wash, and fridge areas. A trash can was overflowing, and another was unclean, with flies on nearby walls and utensils. The Executive Chef and other staff acknowledged the issue as unacceptable.
The facility failed to properly disinfect glucometers, adhere to insulin administration protocols, and implement Enhanced Barrier Precautions for residents. Staff used alcohol wipes instead of EPA-registered disinfectants, did not clean insulin pen seals, and neglected hand hygiene and glove use. Additionally, gowns were not worn during high-contact care, increasing infection risk.
A facility failed to accurately assess a resident's anxiety diagnosis in the MDS. Despite having a physician's order for an antidepressant for anxiety and pain, the resident's quarterly MDS did not reflect anxiety in the diagnoses section. Facility staff confirmed the oversight, acknowledging the expectation for accurate MDS assessments.
The facility failed to complete PASARR forms accurately for three residents, leading to potential risks in their care. A resident's PASARR form omitted an anxiety diagnosis, preventing a necessary Level II evaluation. Another resident's form was incomplete, and a third resident's form contained conflicting information about SMI. Staff acknowledged these oversights, highlighting a lack of proper review and adherence to guidelines.
The facility failed to implement comprehensive care plans for three residents, leading to unmet care needs. A resident with severe cognitive impairment did not receive scheduled showers, another on diuretic medication lacked a timely care plan, and a third on antidepressants had an incomplete care plan. Staff interviews confirmed these deficiencies in care planning.
A facility failed to update a care plan for a resident receiving diuretic and psychoactive medications. The care plan lacked documentation for the diuretic medication and non-pharmacological interventions for antipsychotic use. Staff interviews confirmed the oversight, which violated the facility's policy requiring care plan updates after changes in medication or interventions.
A resident with severe cognitive impairment did not receive the scheduled showers as required, with documentation showing only sporadic showers over several months. Staff acknowledged the discrepancy but cited issues with documentation, leading to unmet care needs.
The facility failed to ensure proper communication and documentation for a resident receiving hospice care, as there was no documentation of hospice care referral orders or visit notes in the EHR. Additionally, the facility did not monitor adverse side effects or edema for a resident on diuretic medication, lacking necessary orders for monitoring. Staff confirmed these deficiencies, highlighting a lack of coordination and oversight.
The facility failed to identify and monitor target behaviors and non-pharmacological interventions for two residents on psychotropic medications. One resident on an antidepressant and another on an antipsychotic lacked documented interventions and monitoring, contrary to facility policy. Staff acknowledged these deficiencies, which risked unnecessary medication use and adverse effects.
The facility failed to properly label and store medications and biologicals, including controlled substances and vaccines, in accordance with its policies. An unlocked medication refrigerator contained a non-affixed narcotic box with controlled substances, and a plasma specimen was improperly stored in the same refrigerator. Additionally, the facility did not consistently monitor the refrigerator temperature as required.
Unsafe bathroom fixtures and non-homelike medication administration
Penalty
Summary
The facility failed to maintain safe bathroom handrails/support bars for three residents and failed to keep light switch pullcords free of plastic bags for two residents. Observations showed Resident 23’s bathroom handrail/support bar was not secured and was coming away from the wall. In the room shared by Residents 24 and 25, the bathroom handrail/support bar was loose and wobbly, and the light switch pullcord above Resident 24’s bed had a plastic bag tied to it. In Resident 11’s room, the light switch pullcord above the bed also had a plastic bag tied to it. During interview and joint observation, a CNA stated that loose or wobbly bathroom handrails should be reported to the nurse and a maintenance request should be submitted, and that the plastic bags were being used to extend the pullcord so residents could reach it. The Maintenance Supervisor later observed Resident 23’s bathroom handrail/support bar and stated it was not safe and that the wall needed replacement. The same supervisor observed the handrail in the bathroom used by Residents 24 and 25 and stated it was loose and needed to be tightened, possibly replaced. The supervisor also stated that plastic bags had been added by CNAs to make the light switch easier to pull, but that connectors were available and the plastic bags should not be used. The facility also failed to maintain a homelike environment when a nurse administered Morphine Sulfate to Resident 2 in the dining room while the resident was seated at a dining table with food in front of them and another resident nearby. The nurse stated the medication should not have been administered in the dining room. The DON later stated that medication could be given in the dining room only if the resident agreed and it was care planned, but Resident 2’s physician orders, care plan, and nursing tasks did not show that medication administration in the dining room was authorized.
Unlocked Medication Carts
Penalty
Summary
The facility failed to ensure medications were secured for 2 of 2 medication carts reviewed, Medication Cart 1 and Medication Cart 2. The facility policy titled, Medication Administration-General Guidelines, revised in January 2023, stated that the medication cart is kept closed and locked when out of sight of the medication nurse or aide. On 12/02/2025 at 11:21 AM, Medication Cart 1 and Medication Cart 2 were observed unlocked, parked, and unattended at the nurse's station. During a joint observation at 11:26 AM, Staff F, RN, stated the medication cart should have been locked when not near them and confirmed both carts were unlocked. On 12/03/2025 at 2:05 PM, Staff B, DON, stated that when the nurse leaves the medication cart, it should be locked and expected both carts to have been locked because any resident or someone could get into the cart and access it if it was unlocked.
Food items were not properly labeled or discarded after expiration
Penalty
Summary
The facility failed to ensure foods were handled in accordance with professional food safety standards in 5 of 5 refrigerators reviewed: the PM Production Floor Refrigerator, Walk-in Main 2 Refrigerator, Dairy HC/AL Dressing 3 Refrigerator, Second Floor Kitchen Refrigerator, and Second Floor Resident Supplement Refrigerator. The facility policy titled Date Marking for Food Safety stated that food must be clearly marked with the date or day by which it should be consumed or discarded, that the person opening or preparing the food is responsible for date marking it, and that the Head or designee is responsible for checking refrigerators daily for expiring items and discarding them accordingly. During observations and interviews, surveyors found multiple food items without labels or with use-by/best-by dates that had passed. In the PM Production Floor Refrigerator, one uncovered container of green peas had no label or use-by date. In the Walk-in Main 2 Refrigerator, celery, casserole sauce, lemon, pepperoncini, and pico de gallo were all past their use-by dates. In the Dairy HC/AL Dressing 3 Refrigerator, romaine lettuce and mandarin oranges were past their use-by dates, and an opened container of Dannon vanilla low fat yogurt had a preparation date but no use-by date and had a best-if-used-by date that had passed; additional unopened yogurts were also past their best-by dates. In the Second Floor Kitchen Refrigerator, one Yoplait red raspberry yogurt was past its best-by date. In the Second Floor Resident Supplement Refrigerator, four unopened Swiss Miss butterscotch puddings had a use-by date of 10/07/2025. Staff members interviewed stated these items should have been labeled or discarded, and the Administrator stated that food items past the used-by/best-by date should have been discarded.
Failure to Follow EBP, Hand Hygiene, and Droplet Precautions
Penalty
Summary
The facility failed to follow Enhanced Barrier Precaution practices for two residents and failed to follow Transmission Based Precautions for one resident during observed care and room entry activities. The report states that Enhanced Barrier Precaution was ordered for residents with indwelling devices or wounds, and that staff were expected to use gown and gloves during high-contact care and perform hand hygiene after leaving the room. It also states that droplet precautions were ordered for a resident with pneumonia due to MSSA, with signage at the door directing staff and visitors to clean hands and wear full PPE before entering and to remove face protection before leaving. For one resident on Enhanced Barrier Precaution due to an IV antibiotic and central line, an occupational therapist provided range of motion exercises in the resident’s room and touched the resident’s arms, wrists, hands, and a gauze bandage on the left arm without wearing a gown or gloves. After leaving the room, the therapist did not perform hand hygiene and went to the nurse’s station, where they touched the counter with their hands. The therapist stated they should have worn gloves and a gown and should have performed hand hygiene after leaving the room. The infection preventionist and the DON stated that range of motion with the resident was high-contact care and that PPE and hand hygiene were expected. For another resident on Enhanced Barrier Precaution for a left outer ankle and coccyx pressure ulcer, a CNA transferred the resident with another CNA while wearing gown and gloves, then touched and moved a trash bin before providing peri-care and did not remove gloves or perform hand hygiene between glove use. During wound care for the same resident, an LPN performed hand hygiene before donning PPE, then changed gloves multiple times during care but did not perform hand hygiene between glove use. Staff stated they should have performed hand hygiene between tasks and between glove use, and the infection preventionist and DON stated that hand hygiene was expected before and after resident care and between glove use. For the resident on droplet precautions, an RN entered the room wearing a mask but not a face shield, despite signage directing staff to wear full PPE including eye protection before entry and to remove face protection before leaving. A housekeeper also entered the room wearing gloves only, cleaned the room, and did not wear a mask or face shield. Staff stated they should have followed the signage and used the appropriate PPE when entering the room, and the infection preventionist and DON stated that staff were expected to follow the posted precautions and properly apply and remove PPE.
Uncovered Catheter Drainage Bag Visible in Hallway
Penalty
Summary
Resident 8 had an indwelling urinary catheter documented on the admission MDS dated 11/21/2025. During observations on 12/02/2025 at 9:57 AM and 1:36 PM, Resident 8 was seen with an uncovered catheter drainage bag containing yellow urine visible from the hallway, and there was no privacy bag covering the drainage bag. During a joint observation and interview at 3:30 PM, a CNA stated that residents with urinary catheters are supposed to have the drainage bag placed in a privacy bag and covered so it is not visible from the hallway. The CNA observed that Resident 8's catheter drainage bag was uncovered and visible from the hallway and stated it should be in a privacy bag, then went to get one to cover it. The DON later stated that the catheter drainage bag was expected to be covered and that a resident's urine should not be visible from the hallway.
Failure to Provide Required Transfer/Discharge Notice Information
Penalty
Summary
The facility failed to provide a written transfer/discharge notice with the required information for 2 of 3 residents reviewed for discharge process. Review of the facility policy showed that transfer/discharge notices were to be provided in a language and manner the resident and representative could understand and were to include an explanation of the right to appeal the transfer or discharge to the State, contact information for the State entity receiving appeal requests, information on how to obtain an appeal form, assistance with completing and submitting the appeal request, and the name and contact information for the State Long-Term Care Ombudsman representative. For one resident, records showed a change of condition and transfer to the hospital, with discharge documentation in the EHR not showing that a written transfer/discharge notice was provided to the resident or representative. The facility’s Transfer/Discharge Report also did not include the required appeal rights or Ombudsman contact information. For another resident, records showed discharge to the community, but the EHR did not show a written transfer/discharge notice, and the facility’s Recapitulation of Stay did not include the required appeal rights or Ombudsman contact information. Staff stated that the Transfer/Discharge Report and Recapitulation of Stay were the documents provided, and acknowledged that these documents did not contain the required appeal rights and Ombudsman information.
Inaccurate MDS coding for antidepressant use
Penalty
Summary
The facility failed to accurately assess 1 of 8 residents reviewed for the Minimum Data Set (MDS), Resident 10. The resident was admitted with a diagnosis of insomnia, and the physician orders showed Trazodone was started at bedtime for insomnia. The facility’s admission MDS Section N0415, completed on 11/07/2025, did not code antidepressant use for this resident. The facility policy required assessments to be completed accurately using the RAI and Chapter 3 of the RAI Manual. The Long-Term Care RAI 3.0 User’s Manual instructed that high-risk drug classes be coded by pharmacological classification, not by how the medication is being used. During record review and interview, the MDS nurse stated Trazodone is an antidepressant and should have been coded as such, and the DON also stated Trazodone should be coded as an antidepressant in the MDS.
Failure to Develop Comprehensive Care Plans for Antibiotic Use and Discharge Goals
Penalty
Summary
The facility failed to develop comprehensive care plans for 2 of 8 residents reviewed for comprehensive care plans. For Resident 5, the record showed a readmission with diagnoses including bacteremia, and the November and December 2025 MARs showed orders for ceftriaxone 2 grams IV daily for bacteremia for 28 days starting 11/07/2025 and metronidazole 500 mg by mouth twice daily for purulent skin and soft tissue infection for 28 days starting 11/06/2025. The MARs showed the resident received both antibiotics from 11/07/2025 through 12/04/2025, but the comprehensive care plan printed on 12/04/2025 did not show a care plan for antibiotic use. For Resident 16, the comprehensive care plan printed on 12/02/2025 did not show whether the resident and/or representative wished for the resident to stay long-term in the facility or any discharge care plan. Social services staff stated the resident's representative wished for the resident to stay in the facility long term and that discharge goals would be documented in care conference notes and the care plan, but the care plan did not reflect this. The DON stated Resident 16 was a long-term care resident and expected staff to follow the comprehensive care plan policy.
Failure to Monitor Weights and Abdominal Girth for Residents on Diuretics
Penalty
Summary
The facility failed to monitor weights and related fluid status for residents receiving diuretic medications and, in one case, failed to measure abdominal girth for a resident with ascites. The deficiency involved Residents 4, 10, and 11, all of whom had conditions or medications requiring weight monitoring. The facility policy stated residents were to be weighed regularly, compared to prior weights, and the physician notified if there was a significant gain or loss. The medication guideline also identified diuretics as medications requiring close monitoring for adverse effects. Resident 4 had an order for furosemide for CHF and had multiple recorded weights showing large fluctuations, including a drop from 186.3 lbs to 166.4 lbs, later a weight of 196.2 lbs, and then a decline to 164 lbs, which was documented as a 12% loss from the earlier weight. Staff acknowledged there were inconsistencies in the weights, that the resident had both significant gain and loss, and that they would have expected more monitoring, reweighing, and provider notification when the weights were not stable. The DON also stated the weight changes were a red flag and that staff should have reweighed the resident and notified the doctor. Resident 10 had an order for bumetanide and a care plan calling for weight monitoring per facility protocol, but the record did not show an order for weights. The resident’s weights increased from 139.4 lbs to 152 lbs, a 9% gain, and staff stated the resident was not weighed per protocol for the first three days after admission. Staff also stated a reweight had been recommended at a nutrition meeting but was not obtained before the next weight, and the provider was not notified in the progress notes of the significant weight gain. Resident 11 had ascites and orders for daily weights for three days upon admission, then weekly weights, along with furosemide and spironolactone. The resident was last weighed 15 days before review, a refusal was documented on one MAR entry without follow-up documentation in the progress notes, and another MAR entry indicated other/see progress note without supporting documentation. Although the physician noted plans to monitor weight and abdominal girth, staff and observation confirmed the resident’s abdomen was distended and abdominal girth had not been measured.
Respiratory Equipment Not Properly Stored or Dated
Penalty
Summary
Safe and appropriate respiratory care was not provided for one resident who had idiopathic pulmonary fibrosis, lung transplant status, and acute nasopharyngitis. The resident had physician orders for HyperSal nebulizer treatment once daily and oxygen at 1 to 2 liters per minute via nasal cannula every shift. Observations on multiple occasions showed the resident lying in bed receiving oxygen via an undated nasal cannula, and an undated, uncovered nebulizer tubing/mouthpiece was found laying on top of a hamper. During interview and joint observation, staff stated the nasal cannula was changed only when soiled and that the nebulizer mouthpiece/mask was cleaned and left to dry on a table, not stored in a bag when not in use. Staff also stated the resident did not have a physician order to regularly change the tubing, while other leadership staff stated they expected the nebulizer equipment and nasal cannula to be dated, changed weekly, cleaned after use, dried, and stored in a bag when not in use. The facility's policies required oxygen tubing to be dated and changed weekly and nebulizer equipment to be kept clean, disinfected, and stored in accordance with infection-control standards.
Medication administration errors and missing documentation
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors when it did not document and/or provide ordered medications for 2 residents. The facility policy required medications to be administered according to prescriber orders and documented on the MAR at the time given, with explanatory notes and physician notification when a dose was withheld, refused, unavailable, or given at a different time. For one resident with CHF, high blood pressure, and use of an antipsychotic medication, the October MAR showed missing documentation for day shift administration of furosemide, losartan, Metamucil, vitamin D3, and quetiapine. Nursing progress notes did not show why these medications were not administered or that the physician was notified. Facility staff stated the day shift nurse did not sign for the medications and that if they were not signed, they were not given. Staff also stated the resident had behaviors documented that evening and that the missing documentation placed the resident at risk for behaviors, constipation, and effects on blood pressure. For another resident receiving hydroxychloroquine for rheumatoid arthritis, the September MAR showed the medication as unavailable on multiple days and held on one day. Progress notes documented that the medication was on order or that pharmacy had been contacted on some days, but there was no documentation for two of the missed days and no documentation that the resident’s representative or provider was notified that the medication was unavailable. Staff stated the medication was not available, that staff should have notified the doctor and the resident’s representative, and that missing five doses in a row was significant and constituted a medication error.
Incomplete Daily Nurse Staffing Posting
Penalty
Summary
The facility failed to ensure the posted daily nurse staffing information included the total number and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift for 30 of 30 days reviewed, from 11/08/2025 through 12/08/2025. The facility policy titled, Nurse Staffing Posting Information, revised 03/28/2025, required the daily posting to include the facility name, current date, current resident census, and actual hours worked by categories of licensed and unlicensed staff per shift. Observations on 12/02/2025, 12/03/2025, 12/04/2025, 12/05/2025, and 12/08/2025 showed the staffing posting outside the therapy gym did not include the total number and actual hours worked by RNs, LPNs, and CNAs. During interview and record review, the Medical Records Coordinator stated they were responsible for the posting and did not expect actual hours to be posted, believing scheduled hours would be used instead because actual hours would not show until after the shift occurred. Record review of the facility’s staffing posting documents for 11/08/2025 through 12/08/2025 also did not show the total number and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift. The Administrator later confirmed the documents did not reflect the total number and actual hours worked and stated the daily posting should reflect staff actually on duty in real time.
Medication Administration and Controlled Substance Management Deficiencies
Penalty
Summary
The facility failed to provide routine and as-needed medications as prescribed by physicians for three residents, and did not ensure controlled drugs were accurately accounted for or timely discarded for two residents. Specifically, medication administration records (MARs) showed that prescribed doses of controlled pain medications such as morphine sulfate and oxycodone were not properly documented as being removed from the controlled drug box or signed out in the controlled drugs logbook. In one instance, a resident received a dose of oxycodone from another resident's supply, and the discontinued medication was not destroyed as required. Additionally, discrepancies were found between the actual amounts of controlled substances in medication bottles and the amounts recorded in the controlled substance record book. For example, a bottle of liquid morphine sulfate had more medication remaining than what was documented, and staff could not account for the difference. Staff interviews confirmed that controlled drug counts were not always accurate and that discontinued medications were not destroyed in a timely manner. The facility also failed to document medication administration in accordance with professional standards. In one case, an LPN documented that a resident received their scheduled medication before it was actually administered. The resident subsequently left the facility for a medical appointment without taking the medication, but the electronic MAR still reflected that the dose had been given. Staff acknowledged that documentation should only occur after administration, and that the error would need to be corrected in the record.
Failure to Conduct Thorough Incident Investigations Involving Medication Errors
Penalty
Summary
The facility failed to conduct thorough investigations for three out of four residents reviewed for incident investigations, as required by both facility policy and regulatory guidelines. In each case, the investigations did not include interviews with other residents assigned to the staff involved in the incidents, nor did they document whether abuse or neglect was ruled out. The facility's policy and the referenced guidelines require systematic evidence collection, including interviews with all involved parties, to determine if abuse, neglect, or misappropriation occurred and to prevent recurrence. For one resident with severe cognitive impairment and on hospice care, a scheduled dose of morphine was not administered, and the responsible RN was unaware of the missed dose. The investigation did not include interviews with other residents assigned to that RN. Another resident, also with severe cognitive impairment and on hospice, missed several doses of a pain medication on multiple days when cared for by different contract RNs. Although the staff involved were interviewed, there was no documentation of interviews with other residents those staff cared for, despite a collateral contact reporting an attempted medication error by an unknown contract nurse. A third resident, with intact cognition and a history of gout, received the wrong dose of oxycodone from another resident's supply. The investigation included a statement from the responsible RN but did not document whether the resident was informed of the error or if other residents assigned to that RN were interviewed. The Health Services Director confirmed that interviews with other residents were not documented, and in some cases, not conducted, particularly for non-interviewable residents. These omissions were contrary to both facility policy and regulatory requirements.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling, dating, and discarding of food items in accordance with professional standards for food safety, as observed in two refrigerators and one freezer. In the Dairy Refrigerator, an unopened coleslaw dressing with an expired manufacturer date and butter with a past use-by date were found. Additionally, four jugs of hollandaise sauce were observed without any dates. Staff M, the Lead Cook, acknowledged that the coleslaw and butter should have been discarded and that the hollandaise sauce should have been dated when unboxed. In the Main Walk-In Refrigerator, an opened and undated container of heavy whipping cream and a half can of cheese with an expired preparation date were found. Staff M admitted that the heavy whipping cream should have been dated upon opening and the expired cheese discarded. In the Walk-In Freezer, seven bags of diced carrots were found with questionable use-by dates, which Staff M believed were inaccurate but still considered the carrots usable. The Health Services Administrator, Staff A, stated that the expectation was for kitchen staff to adhere to State and Federal guidelines and the facility's food safety policies.
Pest Control Deficiency in Kitchen Area
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of fruit flies in the kitchen area. Observations on October 15, 2024, revealed fruit flies in the dishwashing and hand wash areas, as well as in the fridge area where ready-to-eat cold food was stored. During a joint observation and interview with the Executive Chef, it was noted that one trash can was full and overflowing, while another was unclean with dark stains on the lid. Flies were observed on the wall near the trash can and on unwashed utensils returned from breakfast. The Executive Chef acknowledged the issue and stated that the area would be cleaned immediately. The Assistant Director of Nursing/Infection Preventionist and the Health Services Administrator both stated that the presence of flies in the kitchen was unacceptable.
Infection Control and Hygiene Deficiencies
Penalty
Summary
The facility failed to ensure proper disinfection of glucometers for two residents, as observed when a Licensed Practical Nurse (LPN) used alcohol wipes instead of EPA-registered disinfectant wipes due to a shortage of the latter. This practice was confirmed by the Director of Nursing, who stated that alcohol wipes were routinely used for cleaning glucometers, contrary to the facility's policy. Additionally, the facility did not adhere to its insulin administration protocol for two residents. The LPN was observed attaching needles to insulin pens without cleaning the rubber seals and administering insulin without performing hand hygiene or wearing gloves. The Director of Nursing acknowledged that staff should sanitize hands and wear gloves during insulin administration. The facility also failed to implement Enhanced Barrier Precautions (EBP) for two residents. Staff did not wear gowns when handling a PICC line or during high-contact care activities, despite signage indicating the need for such precautions. Furthermore, hand hygiene practices were not followed during medication administration and dining observations, as staff did not sanitize hands between tasks or after glove removal, increasing the risk of infection.
Inaccurate MDS Assessment for Resident's Anxiety Diagnosis
Penalty
Summary
The facility failed to accurately assess a resident's active diagnosis, specifically regarding anxiety, during the Minimum Data Set (MDS) assessment process. Resident 11, who was admitted to the facility, had a physician's order for an antidepressant medication prescribed for anxiety and pain. However, during the review of the resident's quarterly MDS, it was found that anxiety was not marked in the diagnoses section (Section I) of the MDS, indicating an inaccuracy in the assessment. Interviews with facility staff, including the Resident Care Manager/MDS Coordinator, Assistant Director of Nursing, and Director of Nursing, confirmed the oversight. Staff D acknowledged that anxiety should have been marked in Section I of the MDS for Resident 11, and both Staff C and Staff B expressed that they expected MDS assessments to be accurate, highlighting the deficiency in the assessment process.
Deficiencies in PASARR Form Completion for Residents
Penalty
Summary
The facility failed to ensure the completion of the Pre-Admission Screening and Resident Review (PASARR) forms for three residents, which is a federally required screening for individuals with Intellectual Disability (ID), Related Condition (RC), or Serious Mental Illness (SMI) prior to admission to a Medicaid-certified nursing facility. For Resident 11, the PASARR Level I form did not include the diagnosis of anxiety, which was necessary for the resident's antidepressant medication. This omission meant that the PASARR Level II evaluation was not conducted as required. Staff E, the Social Services Coordinator, acknowledged the oversight, and the Health Services Administrator confirmed that the form should have been accurate and referred for further evaluation. Resident 14's PASARR Level I form was incomplete, lacking the required four sections, which was identified during a joint record review with Staff E. The Health Services Administrator admitted that the form was not reviewed properly. For Resident 68, the PASARR Level I form contained conflicting information regarding the presence of SMI, with both 'yes' and 'no' marked in the SMI Indicators section. Staff E admitted to reviewing the form multiple times but missing the error. The Health Services Administrator stated that PASARR forms should be reviewed before a new resident's admission, especially for those with mental health diagnoses.
Deficiencies in Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents, leading to unmet care needs. Resident 2, who had severe cognitive impairment and required total assistance with showering, was scheduled to receive showers twice a week. However, documentation showed that Resident 2 received only two showers in July, none in August, and one in September, contrary to the care plan. Interviews with staff revealed inconsistencies in the shower schedule and a lack of proper documentation, indicating that the care plan was not followed. Resident 14 was prescribed a diuretic medication for edema starting in September, but a care plan for the medication was not developed until mid-October. Observations showed that Resident 14 had swelling in both legs, and staff interviews confirmed that a care plan should have been created immediately after the medication was prescribed. This delay in care planning for the diuretic use was a significant oversight in meeting the resident's medical needs. Resident 6 was on an antidepressant medication, but the care plan lacked target behaviors and non-pharmacological interventions. The care plan was revised in late August, but it did not include essential components required for managing the resident's depression. Staff interviews confirmed that these elements should have been included when the medication was initiated, highlighting a deficiency in the care planning process for psychoactive medication use.
Failure to Revise Care Plan for Medications
Penalty
Summary
The facility failed to revise a comprehensive care plan for a resident, identified as Resident 11, who was receiving diuretic and psychoactive medications. The care plan was not updated to include the use of a diuretic medication, which was ordered on August 6, 2024, and there were no non-pharmacological interventions documented for the antipsychotic medication, which was ordered on August 3, 2024. This oversight was identified during a review of the care plan printed on October 11, 2024, which showed the absence of necessary care planning for these medications. Interviews with facility staff, including the Resident Care Manager/Minimum Data Set Coordinator, Assistant Director of Nursing, and Director of Nursing, confirmed that the care plan should have included the diuretic medication and non-pharmacological interventions for the resident's targeted behaviors. The facility's policy on comprehensive resident-centered care plans, revised on February 9, 2024, mandates that care plans be reviewed and revised after each comprehensive and quarterly assessment, and updated upon changes in planned interventions, new diagnoses, and new medications. The failure to adhere to these policies placed the resident at risk for unmet care needs and a diminished quality of life.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to provide necessary assistance with showering/bathing for a resident with severe cognitive impairment, who required total assistance with these activities. The resident was scheduled to receive showers twice a week, with additional hospice services providing a shower every Monday. However, documentation showed that the resident received only two showers in July, none in August, and one in September, with no records of the resident refusing showers. Interviews with staff revealed inconsistencies in the shower schedule and a lack of proper documentation. Staff members, including the Assistant Director of Nursing and the Director of Nursing, acknowledged the discrepancy between the scheduled showers and the documented showers. They suggested that the resident might have received more showers than recorded, but were unable to provide evidence due to inadequate documentation. This lack of documentation and failure to adhere to the scheduled showering routine placed the resident at risk for unmet care needs and a diminished quality of life.
Deficiencies in Hospice Communication and Medication Monitoring
Penalty
Summary
The facility failed to ensure consistent communication and collaboration of care between the facility and hospice care for a resident receiving hospice services. Despite the resident being referred to hospice care, there was no documentation of the hospice care referral order or hospice visit notes in the resident's Electronic Health Records (EHR). Multiple staff members, including the Resident Care Manager, Medical Records Coordinator, Assistant Director of Nursing, and Social Services Coordinator, confirmed the absence of necessary documentation in the EHR. The Director of Nursing acknowledged that there should have been both verbal and written communication to coordinate care between the facility and hospice. Additionally, the facility failed to monitor adverse side effects for a diuretic medication and the monitoring of edema for another resident. The resident had an order for a diuretic medication, but there was no order to monitor the adverse side effects or the specific location of the edema. Staff members, including the Resident Care Manager and Assistant Director of Nursing, confirmed that there should have been an order for monitoring these aspects, and the Director of Nursing expected that diuretic medication side effects and edema were monitored.
Failure to Monitor Psychotropic Medication Interventions
Penalty
Summary
The facility failed to ensure that target behaviors and non-pharmacological interventions were identified and monitored for residents receiving psychotropic medications. This deficiency was observed in two residents. Resident 6, who was admitted to the facility and prescribed an antidepressant medication, did not have target behaviors identified or monitored, nor were non-pharmacological interventions in place as per the facility's policy. The Assistant Director of Nursing acknowledged the absence of these measures and updated the physician orders to include target behaviors only after the deficiency was identified. Similarly, Resident 11, who was prescribed an antipsychotic medication for dementia with combative behaviors, also lacked identified and monitored non-pharmacological interventions. The Resident Care Manager and the Director of Nursing both confirmed that these interventions should have been documented in the care plan and monitored in the Medication Administration Record (MAR) from the start of the medication. The absence of these measures placed the residents at risk for receiving unnecessary medications and potential adverse side effects.
Improper Storage and Labeling of Medications and Biologicals
Penalty
Summary
The facility failed to appropriately label and store drugs and biologicals, as observed in the medication refrigerator. An unlocked medication refrigerator was found in the medication room, containing a locked narcotic box that was not permanently affixed, which stored controlled substances such as liquid Ativan prescribed to a resident. Staff, including the LPN, Assistant Director of Nursing, and Director of Nursing, acknowledged that the narcotic box was not permanently affixed and that the refrigerator was not locked, contrary to the facility's policy and expectations for the safe storage of controlled substances. Additionally, a specimen tube of plasma was improperly stored in the medication refrigerator's freezer, which was against the facility's procedure for specimen collection and storage. The plasma specimen was later moved to the appropriate specimen refrigerator in the soiled utility room. Furthermore, the facility failed to monitor the refrigerator temperature twice daily as required when vaccines were present, as evidenced by the incomplete temperature log for several days. Staff acknowledged the failure to adhere to the facility's policies and procedures for the proper storage of vaccines.
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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.
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Nursing homes near Seattle
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bailey-boushay House | 1.2 mi | ★★★★★ | 0 | 0 |
| Seattle Medical Post Acute Care | 2.4 mi | ★★★★★ | 7 | 0 |
| Mirabella | 2.6 mi | ★★★★★ | 1 | 0 |
| Transitional Care Of Seattle | 2.9 mi | ★★★★★ | 2 | 0 |
| The Terraces At Skyline | 3 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.