Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pine Ridge Post Acute during CMS and state inspections, most recent first.
Improper Food Storage and Hand Hygiene Practices: Surveyors found multiple uncovered and unlabeled food items in the freezer, walk-in refrigerator, and dining room refrigerator, including desserts, sandwiches, banana bread, lemonade, and salsa that were out of date or not properly identified. In dry storage, several opened spices lacked use-by or expiration dates and one container of beef base was not fully closed. A Cook also failed to perform hand hygiene after removing gloves and when moving between dirty and clean tasks while preparing food.
A facility failed to develop and/or consistently follow person-centered care plans for four residents. One resident with dementia had no documented dementia-specific care plan when the MDS indicated cognitive loss should be addressed. Another resident’s call light was repeatedly out of reach despite a fall-risk care plan directing that it be kept within reach. A resident who used hearing aids was observed without them, and staff later found the devices in a nightstand drawer, with one broken. A resident requiring 1:1 feeding assist was left unsupervised during a meal even though the care plan required continuous assistance.
Respiratory equipment was not managed according to orders and policy for three residents. One resident on continuous O2 had a nasal cannula not properly applied, the tubing disconnected from the concentrator, and the flow rate set below the ordered level while CNA staff did not correct it. Two other residents had nasal cannulas or a CPAP mask left on the nightstand, in a drawer, or on the floor instead of being stored in a bag when not in use.
Expired meds and supplies were found in multiple med rooms and carts, including expired syringes, Actemra, a Tresiba insulin pen, a flu vaccine box, Calcium 600 plus D, and a lispro insulin pen. Surveyors also found non-food items and pills/vitamins stored in a unit refrigerator, and staff stated these items should not have been there.
Insufficient dietary staffing delayed meal service. The posted meal schedule showed lunch trays were to be served between 11:30 AM and 12:00 PM, but observations found tray lines still being completed after noon and meal carts delivered as late as 1:15 PM. A cook and dietary aide stated the work was too much for two staff, and an RN reported trays were usually delivered around 12:00 PM to 12:30 PM instead of on time.
Staff failed to follow contact precautions and hand hygiene/glove-use practices. An LPN and a CNA entered a resident’s contact precautions room without gown and gloves, and multiple staff members were observed moving between dirty and clean tasks without changing gloves or performing hand hygiene during peri-care, medication application, and insulin administration. Interviews confirmed staff knew the expected PPE and hand hygiene practices but did not follow them.
Call Lights Not Within Reach for Two Residents: Staff failed to keep call lights within reach for two residents who were observed in bed. One resident with substantial/maximal assist for sit-to-stand had the call light on a chair and later on the floor, and staff did not check it when leaving the room. Another resident’s call light was wrapped around the wall port and unreachable during multiple observations, despite the care plan directing that it be kept within reach.
Failure to Document Advance Directive Status on Admission: The facility did not document whether a resident had an advance directive at admission. The resident's EHR contained no note showing if an advance directive existed, and the Social Services Director, Social Worker, Administrator, and Regional Director of Clinical Services all confirmed that no documentation was present in the record.
Failure to Send Transfer/Discharge Notices to Ombudsman: The facility did not provide the required copy of the transfer/discharge notice to the State LTC Ombudsman for two residents who were hospitalized. The MDS records showed both residents were admitted to the facility and later discharged to an acute hospital, and the Medical Records Director acknowledged the notices were not sent even though the facility policy required sending them.
Failure to Complete SCSA After Significant Change in Condition: A resident with a right above-the-knee amputation had significant wt loss and functional decline affecting both lower extremities, but the MDS did not reflect the change and an SCSA was not completed when RAI criteria were met. Staff acknowledged the resident had significant wt loss and impairments to both lower extremities and stated an SCSA should have been done.
A resident who used hearing aids was repeatedly observed without them, despite a care plan directing staff to apply and ensure both hearing aids were in place and working. Staff reported not seeing the hearing aids, and an LPN later found them in a nightstand drawer, placed the left aid in the resident’s ear, and noted the right aid was broken. The RCM and Regional Director stated staff were expected to offer hearing aids daily and help with placement when needed.
Failure to Provide Ordered 1:1 Feeding Assist: A resident with a care plan for 1:1 feeding assist was observed eating breakfast without staff present after the CNA set up the tray and left the room. The resident later fell asleep with the meal still in front of them, and staff later acknowledged that 1:1 feeding assist meant staying with and actively assisting the resident throughout the meal.
Inconsistent code status documentation was found for a resident reviewed for advance directives. The POLST and EHR listed Attempt Resuscitation/CPR, while the care plan and PT note listed DNAR. Staff confirmed the records did not match and stated code status should be consistent across the POLST, EHR, care plan, and therapy notes.
Failure to offer and document COVID-19 vaccination for two residents. One resident had signed consent for the COVID-19 vaccine, but the EHR showed no proof it was administered. Another resident had previously declined the vaccine, but the record showed no evidence it was offered again after the last refusal. Staff acknowledged the missing documentation and that the vaccine should have been offered again per policy and CDC guidance.
A facility failed to keep the survey results binder complete by omitting the results and POC for 4 complaint surveys that had citations since the last annual survey. During record review, the Administrator acknowledged the binder should have included surveys, complaints, and revisits, but the complaint survey findings and associated POCs were missing and not available for residents and families.
A resident with dementia and severe cognitive impairment experienced a fall resulting in a hematoma and nasal fracture. The facility's investigation did not include required interviews with the social worker who reported the fall, the resident's representative present at the time, or all relevant staff, and contained conflicting information about the resident's cognition. This incomplete investigation did not meet the facility's policy for abuse and neglect investigations.
A resident with moderately impaired thinking and at risk of elopement was found away from the facility. A wander alarm was placed on the resident, but the care plan was not updated when the alarm was moved from the ankle to the wheelchair. Staff confirmed the care plan should have been revised to reflect this change.
A resident with moderately impaired thinking and a history of elopement attempts left the facility unsupervised and was found by law enforcement at a store 1.5 miles away. The resident, who used a wheelchair, fell and sustained a knee injury. Staff confirmed the resident's risk for elopement and the unsuitability of leaving unsupervised.
The facility failed to adequately monitor the use of diuretics, anticoagulants, and antibiotics for several residents, as evidenced by the lack of documentation in the MAR/TAR. Staff interviews revealed that monitoring was expected to occur through care plans and alert charting, but this was not consistently documented. Residents on medications such as furosemide, apixaban, and doxycycline were at risk due to insufficient monitoring practices.
The facility failed to routinely check the dishwasher temperature and test the sanitizing solution, as required by professional standards for food service safety. The Dietary Director and Aide admitted to not logging the necessary information due to a lack of test strips, leading to incomplete records. This oversight placed residents at risk for foodborne illness.
The facility failed to implement Enhanced Barrier Precautions for a resident with a feeding tube, as required by policy. Additionally, clean linens were improperly handled, and medical equipment, including glucometers and vital signs equipment, was not disinfected after use with residents. Staff interviews confirmed lapses in following infection control guidelines.
A facility failed to obtain informed consent before administering psychotropic medications to a resident with depression, insomnia, and anxiety. Despite the facility's policy requiring informed consent, there was no documentation of consent for the prescribed medications, including Trazodone, Sertraline, and Buspirone. Staff interviews confirmed the expectation of obtaining consent, but records showed no evidence of informing the resident or their representative about the risks and benefits.
A resident requiring assistance for bed mobility reported discomfort due to the lack of fitted sheets on their air mattress, leading to sleepless nights. Despite requests, staff cited regulations against fitted sheets, yet observations showed other residents with fitted sheets on similar mattresses. Staff interviews revealed inconsistencies in practices and a lack of awareness of the resident's needs.
A facility failed to ensure a resident's advance directive was properly completed. The resident's DPOA form, signed in 2019, lacked notarization or witness signatures as required by state law. The Social Services Director acknowledged the oversight, noting the resident has a guardian. This failure risked the resident's healthcare preferences not being honored.
A facility failed to provide a written transfer or discharge notice to a resident and/or their representative, as required by regulations. The resident was discharged to an acute hospital twice due to a change in condition, but no documentation of the notice was found in the EHR. Interviews with staff confirmed the absence of the notice, despite the facility's policy requiring it.
A facility failed to provide a bed hold notice to a resident or their representative during a transfer to a hospital, as required by policy. The oversight was confirmed through record reviews and staff interviews, indicating a lapse in following the facility's procedures for informing residents of their rights during transfers.
The facility failed to accurately assess two residents' MDS, leading to omissions and inaccuracies. One resident's antibiotic use was not recorded, and another's MDS inaccurately marked surgical wound care. These errors were acknowledged by the MDS Coordinator, highlighting deficiencies in the assessment process.
A facility failed to complete a PASARR Level I for a resident with major depressive disorder, as the form did not indicate a mood disorder despite the resident's diagnosis and prescription for antidepressants. The Social Services Director admitted the oversight, and a new PASARR was only completed 22 days after admission, delaying necessary evaluations.
A facility failed to notify the State PASARR Coordinator after a resident with SMI experienced a significant change in condition, including electing hospice services and being certified with a terminal illness. Despite the facility's policy requiring notification, staff did not inform the state authorities, placing the resident at risk for unmet care needs.
The facility failed to develop and implement comprehensive care plans for two residents, leading to unmet care needs. One resident had incomplete plans for skin, pain, vision, antibiotic use, and urostomy, while another resident with diabetes and blindness had unaddressed nail care needs. Staff interviews confirmed the lack of necessary goals and interventions in the care plans.
A resident with diabetes and legal blindness did not receive necessary nail care, resulting in long, untrimmed fingernails with debris. Despite the facility's policy, staff failed to coordinate and provide timely nail care, as observed in multiple instances. Interviews revealed a lack of communication and missing physician orders for nail trimming.
A facility failed to follow physician orders for a resident discharged with abdominal drains, as the orders to empty and document drain output daily were not implemented until 19 days after admission. Staff interviews confirmed the oversight, acknowledging that the orders should have been followed from the time of admission.
The facility failed to properly maintain, label, date, and store respiratory equipment for three residents, leading to deficiencies in care. A resident's oxygen tubing was not changed as required, and another resident's nebulizer mask was improperly stored. Additionally, a resident received oxygen at a higher rate than ordered without proper documentation. Staff interviews confirmed these lapses in following physician orders and facility policies.
A resident with a history of falls and osteoporosis fell and fractured their right leg during therapy due to the therapist's failure to use a required gait belt and provide hands-on contact, as per facility policy.
Improper Food Storage and Hand Hygiene Practices
Penalty
Summary
The facility failed to ensure food was handled in accordance with professional standards in multiple kitchen and dining areas. During observation of the Kitchen Freezer, surveyors found one uncovered, unlabeled rectangular tray and one uncovered, unlabeled round tray containing an unknown food item. Staff G stated the food was leftover cake from the prior day and that it should have been covered and labeled. In the Kitchen Walk-in Refrigerator, surveyors observed multiple uncovered and unlabeled trays containing unknown desserts, three unlabeled sandwiches wrapped in plastic wrap, and a full unlabeled metal tray containing banana bread from the prior day. Staff G stated the sandwiches should have been labeled, the banana bread should have been labeled, and the dessert trays should have been covered and labeled. Further observations in the Kitchen Walk-in Refrigerator showed additional food items that were not properly labeled or covered, including a full uncovered metal tray labeled Jello with a use-by date of 03/20/26, an unlabeled and uncovered metal tray containing an unknown food item, and an unlabeled metal tray containing an unknown dessert in small bowls and a bowl of mixed salad greens. Staff G stated the Jello should have been covered and identified the unlabeled trays as cake made the prior day and leftover dessert from the prior day. In the Olympic Dining Room Refrigerator, surveyors observed a container of organic lemonade labeled "please enjoy by 03/11/2026" and an unopened container of salsa dated 02/11/2026. Staff G stated both items should have been discarded because they were out of date. In the Kitchen Mini Storage area, surveyors found one opened container of whole celery seed with a best-by date of 03/05/25, along with multiple opened spice containers that had no use-by or expiration date, including poultry seasoning, granulated garlic, parsley flakes, steak seasoning, whole basil leaves, whole bay leaves, coarse ground black pepper, whole thyme leaves, and salt. Surveyors also observed an opened container of beef base with the lid not fully closed. Staff G stated the expired celery seed should have been thrown away, the opened spices should have had use-by dates, and the beef base lid should have been closed. Surveyors also observed Staff M, Cook, pureeing food and handling used equipment without performing hand hygiene after removing gloves or when moving between dirty and clean tasks. Staff M worked with beef stroganoff and carrots, handled used equipment at the dishwasher, returned to the preparation station, and continued food preparation without hand hygiene after glove removal or after handling dirty dishes. Staff M later stated hand hygiene should have been performed when moving from dirty to clean tasks and when gloves were removed. Staff G, the Infection Preventionist, and the Administrator each stated that staff were expected to perform hand hygiene during these transitions and between glove use.
Care plans not developed or followed for dementia, call lights, hearing aids, and feeding assistance
Penalty
Summary
The facility failed to develop and/or consistently implement comprehensive person-centered care plans for 4 of 16 residents reviewed. The report states that the facility’s policy required care plans to include measurable objectives and timetables to meet residents’ physical, psychosocial, and functional needs, and that the interdisciplinary team should develop the plan with resident and family or legal representative input. The deficiency involved Resident 11, Resident 24, Resident 4, and Resident 8, with issues related to dementia, call light access, hearing aids, and dining assistance. For Resident 11, the admission MDS showed a diagnosis of dementia with other behavior disturbance and indicated that cognitive loss/dementia-functional status would be addressed in the care plan. However, the comprehensive care plan printed on 03/19/2026 did not contain a person-centered care plan with resident-specific interventions addressing dementia. Staff interviews confirmed that staff expected residents with dementia to have such a care plan, and the MDS Coordinator stated that a “yes” response on the MDS would mean a care plan addressing cognitive loss/dementia was expected. A later review showed a cognitive impairment care plan initiated on 03/24/2026, and the MDS Coordinator stated there should have been a care plan before that date. For Resident 24, the fall-risk care plan included the intervention to keep the call light within reach and encourage use for assistance as needed. Observations on three separate occasions showed the resident lying in bed with the call light wrapped around the wall-mounted call light port and not within reach. Staff interviews showed that the CNA, RN, RCM, and other leadership staff expected the care plan to be followed and expected the call light to be within reach, although one CNA stated the resident did not use the call light. For Resident 4, the MDS showed use of hearing aids, and the hearing care plan directed staff to apply hearing aids to both ears and ensure they were in place and working. Observations showed the resident was not wearing hearing aids, and the resident stated they had not used them for quite a while and were unsure where they were. Staff later found hearing aids in the nightstand drawer, placed one hearing aid in the resident’s ear, and learned the right hearing aid was broken. For Resident 8, the ADL care plan identified the resident as needing 1:1 feeding assistance. During breakfast observation, staff set up the tray and then left the room while the resident ate unsupervised; later the resident was found lying in bed with the meal still in front of them. Staff stated that 1:1 feeding assist meant staying with the resident for the entire meal and acknowledged that the resident needed assistance at times because they fell asleep or were unable to feed themselves. Multiple staff members stated they expected care plans to be followed, and one RN and other leadership staff confirmed that staff were expected to follow the resident’s care plan.
Respiratory equipment not maintained and stored properly
Penalty
Summary
The facility failed to provide respiratory services according to professional standards of practice for three residents receiving oxygen therapy or CPAP treatment. The facility’s respiratory treatment policy required licensed nurses to check oxygen therapy each shift to confirm the regulator was set for the correct liter flow and required oxygen cannulas, masks, and tubing to be stored in a bag when not in use. The policy also required CPAP masks to be cleaned, dried, and stored in a bag when not in use, and if a mask was found on the floor, it was to be cleaned before being placed on the resident. Resident 39 had diagnoses including COPD and acute respiratory failure with hypoxia and had an order for continuous oxygen at 3 L/min via nasal cannula. During observation, the resident’s nasal cannula was not properly positioned, with one prong inside the right nostril and the other outside, the tubing was not connected to the oxygen concentrator, and the concentrator was set at 1.5 L/min and later observed at 2.5 L/min instead of the ordered 3 L/min. CNA staff entered the room on two occasions, provided care, and left without adjusting the cannula or connecting the tubing. Staff later stated the cannula should have been connected and adjusted, and the RN stated the oxygen should have been connected at all times and set at the ordered flow rate. Resident 21 had diagnoses including acute and chronic respiratory failure with hypercapnia and an order for continuous oxygen at 2 L/min via nasal cannula. The resident’s nasal cannula was observed hanging on top of the nightstand drawer, then lying on top of the nightstand, and later lying on the floor rather than being stored in a bag. Resident 83 had obstructive sleep apnea and used CPAP; the resident’s CPAP mask was repeatedly observed lying on top of the nightstand or placed in the top drawer instead of being stored in a bag. Staff interviews confirmed that oxygen and CPAP equipment should have been stored in plastic bags when not in use, and staff stated that Resident 21’s cannula should not have been on the floor and Resident 83’s CPAP mask should have been stored in a bag.
Expired Medications and Improper Storage in Medication Rooms, Carts, and Refrigerator
Penalty
Summary
The facility failed to ensure expired medical supplies and medications were removed from storage in the East Medication Room, West Medication Room, Cart 3, and Cart 1. In the East Medication Room, surveyors observed three Medline Safety Syringes with expiration dates of 03/04/2026 and one syringe with an expiration date of 02/03/2026, along with four boxes of Actemra for Resident 9 with an expiration date of January 2026. Staff F stated the syringes and Actemra were expired and should not have been in the medication storage room, and Resident 9 was still a current resident. In the West Medication Room, surveyors observed a Tresiba insulin degludec pen with an open date of 10/26/2025 and a flu vaccine injection box dated 05/02/2024; Staff U stated both were expired and the resident who owned the Tresiba had discharged. On Medication Cart 3, surveyors found an opened container of Calcium 600 plus D tablets with a best before date of February 2026 and a glargine insulin pen with an open date of 02/08/2026, and Staff T stated both should not have been in the cart. On Cart 1, surveyors observed a lispro insulin pen for Resident 74 with an open date of 02/18/2026, and Staff I stated it had been more than 28 days and would be discarded. Surveyors also found the Snohomish Den Refrigerator contained a box of Gel Pack Instant and Reusable Cold or Heat Therapy labeled for room 218 and an unlabeled flower pill box containing pills or vitamins; Staff G and Staff F stated these items should not have been stored in that refrigerator.
Insufficient dietary staffing delayed meal service
Penalty
Summary
The facility failed to ensure sufficient dietary support personnel were available to carry out food and nutrition services and serve meals on time. The facility policy stated that meals and/or nutritional supplements would be provided within 45 minutes of either resident request or scheduled meal time, and the posted dining meal times showed lunch in the dining room from 11:00 AM to 12:00 PM and room trays from 11:30 AM to 12:00 PM. During observation on 03/20/2026 at 1:15 PM, Staff M, Cook, was still preparing the last lunch tray and stated that the tray line was not finished until between 12:30 PM and 12:45 PM, that lunch was late, and that another person was needed in the kitchen when the assistant was off. Staff G, Assistant Dietary Manager, stated that the cook and dietary aide were doing the tray line and that it was a lot of work for two staff, and also stated that meals were expected to be served on time. Additional observations and interviews showed repeated late delivery of meal carts and trays. On 03/17/2026 at 12:51 PM, the meal cart was delivered to the 300 hall, and at 1:05 PM another cart was delivered to the 400/500 hall. On 03/19/2026 at 12:32 PM, Resident 91 stated lunch was supposed to come then and that they had been waiting for twenty minutes; the tray was observed delivered at 12:57 PM. On 03/20/2026 at 12:58 PM, Staff X, RN, stated lunch trays were usually delivered around 12:00 PM to 12:30 PM and that they were not there at that time. On 03/20/2026 at 1:05 PM and 1:15 PM, meal carts were again observed being delivered late to the 300 hall and the 400/500 hall. Staff A, Administrator, stated the facility expected meals to be delivered within scheduled mealtimes and would expect enough dietary staff to prepare meals on time, but also acknowledged that lunch trays were not expected to be delivered as late as 1:15 PM.
Failure to Follow Contact Precautions and Hand Hygiene Practices
Penalty
Summary
The facility failed to ensure Contact Precautions were followed for Resident 84, who was in a contact precautions room. Staff H, an LPN, entered the resident’s room on two separate observations without wearing a gown or gloves. During interview, Staff H stated they used a gown when giving care and initially said they did not give care to Resident 84, then acknowledged the mistake after being shown the signage at the door that required everyone to wear a gown and gloves before room entry. Staff V, a CNA, also entered Resident 84’s room without wearing a gown or gloves and stated they were unsure when PPE was needed for contact precautions before later stating that gown and gloves were required every time they entered such a room. The facility also failed to ensure hand hygiene and glove-use practices were followed during resident care. Staff V wore gloves while changing Resident 4’s brief and providing peri-care, then touched the resident, blanket, sheets, call light, and clean brief without changing gloves between dirty and clean tasks. Staff L, while assisting Resident 83 with toileting and peri-care, followed the resident back to bed and then lifted the resident’s legs, gave the call light and bed remote, and repositioned the pillow without removing gloves or performing hand hygiene between dirty and clean tasks. Additional observations showed Staff H applied diclofenac gel to Resident 89’s knee, removed gloves, put on new gloves, applied and removed the knee brace, and did not perform hand hygiene between glove use. Staff I, an RN, wiped the cap of Resident 92’s insulin, drew up the medication, removed gloves and locked the cart without hand hygiene, then applied gloves again without hand hygiene before administering insulin. Interviews with staff and the infection preventionist confirmed the expectation that staff should follow contact precaution signage, wear gown and gloves before entering contact precaution rooms, change gloves between dirty and clean tasks, and perform hand hygiene between glove changes.
Call Lights Not Kept Within Reach for Two Residents
Penalty
Summary
The facility failed to ensure call lights were within reach for 2 residents who were reviewed for accommodation of needs. The facility policy titled, "Answering the Call Light," stated that when a resident is in bed or confined to a chair, the call light should be within easy reach. Resident 87’s admission MDS dated 03/18/2026 showed substantial/maximal assistance was required for sitting to standing. During observations on 03/17/2026 and 03/18/2026, Resident 87 was found in bed with the call light on a chair next to the bed and later on the floor, both times not within reach. Resident 87 stated they were unsure where the call light was and were looking around the bed for it. Staff Y later entered the room to take the meal tray, and the call light remained out of reach. Staff Y stated they did not check the call light when they picked up the meal tray. Resident 24’s fall-risk care plan, initiated on 11/10/2023, directed staff to be sure the resident’s call light was within reach and to encourage use as needed. Observations on 03/18/2026, 03/23/2026, and 03/25/2026 showed Resident 24 lying in bed with the call light wrapped around the call light port on the wall and not within reach. During a joint observation, Staff O confirmed the call light was unreachable and stated it should always be within reach. Other staff members, including an RN, RCM, and the Regional Director of Clinical Services, stated they expected residents’ call lights to be within reach.
Failure to Document Advance Directive Status on Admission
Penalty
Summary
The facility failed to determine on admission whether Resident 1 had an advance directive. The facility policy titled, Advance Directives, stated that during the admission process the facility would identify if the resident had an advance directive and, if so, request a copy to keep in the medical chart for access by the physician and care staff. Resident 1 was admitted to the facility on [DATE], but review of the Electronic Health Record showed no documentation that the facility identified whether Resident 1 had an advance directive. During an interview and joint record review on 03/20/2026, the Social Services Director stated that the admission note would document whether a resident had an advance directive, but no such documentation was found for Resident 1. The Social Worker, who stated they were Resident 1's social worker, searched the EHR and also found no documentation showing whether Resident 1 had an advance directive. During a later interview and joint record review on 03/25/2026, the Administrator and Regional Director of Clinical Services stated they expected documentation showing whether a resident had an advance directive or not, and the record review again showed no documentation that the facility identified if Resident 1 had an advance directive.
Failure to Send Transfer/Discharge Notices to Ombudsman
Penalty
Summary
The facility failed to provide a copy of the transfer/discharge notice to the State Long Term Care Ombudsman office with the required information for 2 of 4 residents reviewed for hospitalization, identified as Residents 8 and 9. The facility policy titled, Notice of Transfer or Discharge, reviewed in April 2025, stated that the center sends a copy of the notice to the State Long Term Care Ombudsman. Review of Resident 8’s discharge MDS showed the resident was admitted to the facility and later discharged to an acute hospital. Review of Resident 9’s discharge MDS showed the resident was admitted to the facility and discharged to an acute hospital, with a second discharge MDS also showing discharge to an acute hospital. During interview, the Medical Records Director stated they were responsible for notifying the Ombudsman by fax or email when a resident was hospitalized or discharged, and stated they had recently started sending a copy of the notice of transfer/discharge when informed it was required. The Medical Records Director stated they had not sent the notice for Residents 8 and 9 and that they should have. The Administrator stated they understood the regulation was to send a copy of the notice of transfer/discharge to the Ombudsman.
Failure to Complete SCSA After Significant Change in Condition
Penalty
Summary
The facility failed to ensure a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) was completed for Resident 8 after a significant change in condition was identified. The RAI 3.0 User’s Manual and the facility policy both required a comprehensive assessment when the interdisciplinary team determined that a resident met significant change guidelines, and the assessment was to be completed 14 days after the determination date. Review of the record showed Resident 8 had a right above-the-knee amputation, significant weight loss, and functional limitations in range of motion affecting the lower extremities. Record review showed Resident 8 weighed 164.5 lbs. on 10/30/2025 and 136.2 lbs. on 01/29/2026, a 17.2% weight loss in three months. A dietary note documented a current weight of 146.9 lbs. and a 7.4% weight loss in 30 days related to variable intake. The Nutritional Risk Assessment noted a 10% weight loss over 90 days, partially related to loss of limb and variable intake. The admission and quarterly MDSs did not indicate weight loss, although the quarterly MDS showed functional limitation in range of motion to both lower extremities. Staff N, the MDS Coordinator, stated Resident 8 had significant weight loss and impairments to both lower extremities and that an SCSA should have been done, and Staff B, the Regional Director of Clinical Services, stated an SCSA was expected when the RAI manual criteria were met.
Failure to Provide Hearing Aid Support
Penalty
Summary
The facility failed to provide services to maintain hearing methods for one resident who used hearing aids. The resident’s admission MDS dated 12/30/2025 indicated hearing aid use, and the hearing care plan revised on 01/05/2026 directed staff to apply hearing aids to both ears and ensure the hearing appliance was in place and working. However, during observations on 03/19/2026 and 03/20/2026, the resident was not wearing hearing aids and stated they had some but were unsure where they were and had not used them for quite a while. During a joint observation and interview on 03/23/2026, a CNA stated they would help residents who needed assistance placing hearing aids but had not seen any hearing aid for the resident. An LPN later found hearing aids in the top drawer of the resident’s nightstand, confirmed the resident wanted to use them, and placed the left hearing aid in the resident’s ear; the resident stated they could hear and wanted to use both hearing aids. The LPN stated the right hearing aid was broken and that they would let the resident’s representative know. The RCM and Regional Director of Clinical Services both stated staff were expected to offer hearing aids daily and assist with placement when needed.
Failure to Provide Ordered 1:1 Feeding Assist
Penalty
Summary
The facility failed to ensure feeding assistance was provided for one resident who had a care plan intervention for 1:1 feeding assist. The facility policy stated that residents unable to carry out ADLs independently would receive services necessary to maintain good nutrition and that care would be provided according to the plan of care, including dining. Resident 8’s ADL care plan, revised on 02/28/2026, included 1:1 feeding assist for eating. During observation on 03/23/2026, Staff S set up Resident 8’s breakfast tray on the bedside table and then left the room shortly after. Resident 8 was observed eating unsupervised, later lying in bed with eyes closed with the breakfast still in front of them, and Staff S returned later, woke the resident, asked if they were done, and removed the tray. In interviews, Staff S stated that a 1:1 feeding assist meant staying with the resident for the entirety of the meal, and other staff, including the RN, Resident Care Manager, and Regional Director of Clinical Services, stated that staff were expected to follow the resident’s care plan and that 1:1 feeding assist meant actively assisting the resident during the meal.
Inconsistent code status documentation in resident records
Penalty
Summary
The facility failed to ensure clinical records were complete and accurate for 1 of 4 residents reviewed for advance directives, Resident 13. The facility policy on Advance Directives defined a POLST as a medical order that records a resident’s treatment wishes so emergency personnel know what treatments to provide in a medical emergency. Resident 13’s POLST form showed a code status of Attempt Resuscitation/CPR, while the comprehensive care plan printed on the same date showed Do Not Attempt Resuscitation (DNAR). A Physical Therapy note also listed the resident’s code status as DNAR under precautions. During interviews and joint record reviews, Staff V, a CNA, stated code status was checked in the care plan and confirmed the EHR showed Attempt Resuscitation/CPR while the care plan showed DNAR, noting they did not match. Staff U, an RN, stated code status was looked up on the main page of the EHR and confirmed the EHR showed Attempt Resuscitation/CPR, adding that the code status should match everywhere, including the care plan. Staff W, Director of Rehabilitation, stated therapy notes documented code status under precautions and acknowledged the PT note needed to be updated because it listed DNAR while the EHR listed Attempt Resuscitation/CPR. Staff F, Resident Care Manager, stated staff were expected to know code status from the EHR, POLST binder, and care plan, and Staff B, Regional Director of Clinical Services, stated the POLST and care plan should be consistent and records should be accurate.
Failure to Offer and Document COVID-19 Vaccination
Penalty
Summary
The facility failed to ensure the COVID-19 vaccine was offered and/or provided for 2 of 5 residents reviewed for immunizations. Resident 9 was readmitted to the facility and had an informed consent form signed by the resident’s representative on 12/29/2025 for the COVID-19 vaccine, but the electronic health record contained no documentation that the vaccine was ever administered. During interviews and record review, the Infection Preventionist and the Regional Director of Clinical Services both stated that if a resident consented to receive the COVID-19 vaccine, they would expect it to be given, but they could not find documentation showing Resident 9 received it. Resident 32 had declined the COVID-19 vaccine on 10/18/2023 and again on 10/04/2024, but the electronic health record showed no documentation that the vaccine was offered again after those refusals. During interviews and record review, staff stated they would expect the vaccine to be offered again to residents, including long-term residents, and acknowledged that the record did not show it was offered in 2025. The facility policy stated residents are offered recommended COVID-19 vaccinations upon admission and as eligible per CDC recommendations, but the records reviewed did not show that occurred for these two residents.
Survey Results Binder Missing Complaint Survey Findings
Penalty
Summary
The facility failed to ensure the survey results binder included the results and plans of correction for 4 of 4 complaint surveys that resulted in citations since the last annual survey, specifically the complaint surveys from 03/14/2025, 04/07/2025, 05/14/2025, and 07/10/2025. During review of the state inspection survey results binder on 03/25/2026, those complaint survey results and associated plans of correction were not present. In an interview and joint record review, the Administrator stated the survey results binder was expected to include surveys, complaints, and revisits, and acknowledged that the missing complaint survey results and plans of correction should have been in the binder and available for residents and families.
Failure to Thoroughly Investigate Resident Fall Incident
Penalty
Summary
The facility failed to thoroughly investigate a fall incident involving a resident with severe cognitive impairment and dementia. The resident, who was on a blood thinner, experienced a fall resulting in a hematoma and nasal fracture. The investigation report did not include interviews with key individuals such as the social services director who initially reported the fall, the resident's representative who was present at the time, or other staff who had contact with the resident during the incident. There were also conflicting statements regarding the resident's cognitive status and insufficient documentation of how the fall was discovered and managed. The facility's policy requires that all reports of abuse, neglect, or injuries of unknown origin be thoroughly investigated, including interviews with the person reporting the incident, the resident or their representative, staff on all shifts, and documentation of the investigation. However, the investigation into this incident lacked interviews from the social worker who reported the fall and the resident's representative, despite both being directly involved or present. The investigation also failed to clarify how the social worker became aware of the fall and did not include statements from all relevant staff. Staff interviews revealed uncertainty about the reporting process and the thoroughness of the investigation. The DON and other staff acknowledged that interviews with the social worker and the resident's representative would be expected, but these were not conducted. The investigation report contained inconsistencies and did not fully comply with the facility's own policy for abuse and neglect investigations, leading to an incomplete assessment of the incident.
Failure to Revise Elopement Care Plan
Penalty
Summary
The facility failed to revise the elopement care plan for a resident who was at risk of elopement. The resident, who had moderately impaired thinking and used a wheelchair for mobility, was found by local law enforcement approximately 1.5 miles away from the facility. Following this incident, a wander alarm was placed on the resident to alert staff when the resident approached monitored exit doors. However, the care plan was not updated to reflect changes in the placement of the wander alarm. Initially, the wander alarm was placed on the resident's left ankle, as indicated in the care plan. However, it was later moved to the arm of the resident's wheelchair at the resident's request. Despite this change, the care plan was not revised to reflect the new location of the wander alarm. Staff interviews confirmed that the care plan should have been updated to ensure consistency with the actual placement of the wander alarm.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide necessary supervision, resulting in the elopement of a resident with moderately impaired thinking who used a wheelchair for mobility. The resident, identified as being at risk for elopement upon admission, left the facility unsupervised and was found by local law enforcement at a store approximately 1.5 miles away. The resident had a history of elopement attempts and was known to sit by the door, indicating a desire to leave. Surveillance footage confirmed the resident left the facility at 12:47 AM by entering the code to open the door. Upon being found, the resident reported falling out of their wheelchair while attempting to navigate a curb, resulting in a bruise and scratch on their left knee. The resident was assisted by strangers and subsequently returned to the facility by law enforcement. Interviews with staff, including a CNA, LPN, Resident Care Manager, and Assistant Director of Nursing Services, confirmed the resident's risk for elopement and the unsuitability of leaving the facility unsupervised, especially at night.
Inadequate Monitoring of Medications
Penalty
Summary
The facility failed to ensure adequate monitoring for the use of diuretics, anticoagulants, and antibiotics for several residents, leading to potential risks of unnecessary medications and adverse side effects. Resident 3, who was on furosemide for congestive heart failure, was not adequately monitored for diuretic use as indicated by the absence of documentation in the Medication Administration Record (MAR) and Treatment Administration Record (TAR). Staff interviews revealed that monitoring was expected to occur for three days after initiating the medication, but this was not reflected in the records. Resident 26 was prescribed both furosemide and apixaban, yet there was no documentation of monitoring for either medication in the MAR/TAR. Staff indicated that monitoring was included in the care plan rather than the MAR/TAR, and residents were placed on alert charting for 72 hours when starting these medications. Similarly, Resident 28, who was on apixaban for atrial fibrillation, also lacked documentation of monitoring in the MAR/TAR, with staff stating that monitoring was part of the care plan. Resident 10, also on apixaban, showed no evidence of monitoring for anticoagulant use in the MAR/TAR, with staff indicating that monitoring was done through care plans and documented by exception. Resident 11 was on doxycycline without a stop date and lacked documentation of monitoring for antibiotic use. Staff interviews revealed that there was no active monitoring for adverse side effects, and Resident 11 did not have a care plan for antibiotic use, which should have included monitoring interventions.
Failure to Monitor Dishwasher Temperature and Sanitizer Levels
Penalty
Summary
The facility failed to ensure that the dishwasher temperature was checked and the sanitizing solution was tested routinely in accordance with professional standards for food service safety. This deficiency was identified during an observation and interview with the Dietary Director and Dietary Aide, who stated that they were responsible for checking the dishwasher temperature and sanitizer concentration three times a day. However, the December 2024 Dishwasher Temperature/Sanitizer Log form was found to be incomplete, with missing entries for specific dates. Staff K admitted that they had run out of test strips and were unable to test the sanitizing solution, leading to a lapse in the required safety checks. The facility's policy, adopted on August 1, 2024, mandates that dishes and other multi-use items be cleaned and sanitized properly after each use, with proper logging of temperatures. Despite this policy, the staff failed to log the necessary information, and the Dietary Director confirmed the expectation for staff to perform these checks and maintain records. The Administrator also acknowledged the expectation for staff to adhere to the facility's process for checking dishwasher temperatures and testing the sanitizing solution. These failures placed residents at risk for foodborne illness and a diminished quality of life.
Infection Control Deficiencies in EBP and Equipment Disinfection
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for Resident 119, who was admitted with a feeding tube. Despite the facility's policy requiring gown and glove use for residents with feeding tubes, observations revealed that no EBP signage or personal protective equipment (PPE) cart was present outside Resident 119's room. Staff members, including LPNs and the Resident Care Manager, acknowledged that Resident 119 should have been on EBP since admission, but they were not following the necessary precautions. Additionally, the facility did not adhere to proper infection control practices regarding the handling of clean linens. A Certified Nurse Assistant was observed carrying clean towels and linens against their body, contrary to the facility's policy that requires linens to be carried away from the body to prevent contamination. Interviews with staff confirmed that clean linens should not touch staff clothing, indicating a lapse in following established infection control guidelines. The facility also failed to disinfect medical equipment, such as glucometers and vital signs equipment, after use with residents. Observations showed that LPNs did not sanitize glucometers after checking blood sugar levels for two residents, and vital signs equipment was not disinfected after use with two other residents. Staff interviews revealed a lack of adherence to the facility's infection control policies, which require equipment to be cleaned and disinfected between resident uses to prevent the transmission of infections.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to inform a resident and/or their representative before administering psychotropic medications, which is a violation of their policy and regulatory requirements. The resident, identified as Resident 10, was admitted with diagnoses including depression, insomnia, and anxiety. The facility's policy on psychotropic medication use, revised in July 2022, mandates that residents or their representatives must be informed of the risks and benefits of such medications before administration. However, a review of the clinical records revealed that there was no documentation of informed consent for the psychotropic medications prescribed to Resident 10, which included Trazodone, Sertraline, and Buspirone. Interviews with facility staff, including the Resident Care Manager, Regional Clinical Nurse, and Assistant Director of Nursing, confirmed that informed consent was expected to be obtained and documented prior to administering psychotropic medications. Despite this expectation, the records lacked evidence of informed consent for Resident 10's medications. Staff acknowledged the absence of initial informed consents and the failure to provide information related to the risks and benefits of the medications to the resident or their representative, as required by the facility's policy and regulatory standards.
Failure to Provide Comfortable Bed Sheets for Resident
Penalty
Summary
The facility failed to provide a comfortable bed sheet for Resident 10, who required maximum physical assistance for bed mobility and total assistance for transfers. Resident 10 reported discomfort due to the lack of fitted sheets on their air mattress, which caused the flat sheet to slip, leaving them lying on the cold vinyl surface. Despite the resident's repeated requests for a fitted sheet, staff informed them that it was against regulations to use fitted sheets on air mattresses, citing safety concerns. However, observations revealed that fitted sheets were available in the facility's linen rooms, and other residents with air mattresses were using fitted sheets. Interviews with staff members, including a CNA and the Assistant Director of Nursing, indicated a lack of awareness and inconsistency in the facility's practices regarding the use of fitted sheets on air mattresses. Staff members provided conflicting information about the safety and regulations concerning fitted sheets, and there was no evidence that Resident 10's preferences were adequately considered or addressed. This oversight placed Resident 10 at risk for unmet care needs and discomfort, as their concerns about the bed sheets were not communicated or resolved effectively.
Failure to Complete Advance Directive for a Resident
Penalty
Summary
The facility failed to ensure that an advance directive was properly obtained and completed for one of the residents reviewed. Specifically, Resident 4's Durable Power of Attorney (DPOA) form, which was signed and dated in 2019, was not notarized or witnessed by two different witnesses as required by Washington State law. This oversight was identified during a joint record review with the Social Services Director, who acknowledged the incomplete status of the DPOA form and mentioned that Resident 4 has a guardian. The facility's policy on advance directives, revised in September 2022, mandates that the social services director or designee inquire about the existence of any written advance directives prior to or upon a resident's admission. If a resident or their representative has not established an advance directive, the facility staff is expected to offer assistance in doing so. However, in this case, the staff did not ensure that Resident 4's advance directive was completed according to the legal requirements, placing the resident at risk of not having their healthcare preferences honored.
Failure to Provide Written Transfer/Discharge Notice
Penalty
Summary
The facility failed to provide a written transfer or discharge notice to a resident and/or their representative, as required by state and federal regulations. This deficiency was identified during a review of the facility's policy titled 'Notice of Transfer or Discharge,' which mandates the provision of written notice in accordance with regulations. The review of Resident 27's discharge Minimum Data Set and nursing progress notes indicated that the resident was discharged to an acute hospital on two separate occasions due to a change in condition. However, there was no documentation in the resident's Electronic Health Record (EHR) that a written notice of transfer or discharge was provided. Interviews with facility staff, including the Regional Nurse, Assistant Director of Nursing, and Administrator, confirmed that no written notice was given to Resident 27 or their representative. Staff F, the Regional Nurse, acknowledged the absence of the written notice in the EHR, and Staff B, the Assistant Director of Nursing, confirmed that no notice was provided. The Administrator stated that it was expected for staff to provide such notices, indicating a lapse in following the facility's policy and regulatory requirements.
Failure to Provide Bed Hold Notice During Hospital Transfer
Penalty
Summary
The facility failed to provide a bed hold notice to a resident or their representative during a transfer to an acute hospital. The facility's policy, revised on April 7, 2023, mandates that upon transfer, the resident and/or their representative should be offered the option to hold the bed, and a copy of the bed hold policy should be provided. However, a review of Resident 27's records, including the discharge Minimum Data Set and nursing progress notes, revealed no documentation that such a notice was offered or provided when the resident was transferred to the hospital on October 3, 2024. Interviews with facility staff, including the Regional Nurse, Assistant Director of Nursing, and Administrator, confirmed that the bed hold notice was not offered or provided to Resident 27 or their representative. This oversight placed the resident or their representative at risk of not being informed about their right to hold the bed during the hospital stay, as required by the facility's policy and regulatory standards.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to accurately assess two residents, leading to deficiencies in their Minimum Data Set (MDS) assessments. For one resident, the November 2024 Medication Administration Record (MAR) and Treatment Administration Record (TAR) indicated the use of bacitracin ointment, a topical antibiotic, over a five-day period. However, this antibiotic use was not marked in Section N of the resident's admission MDS. The MDS Coordinator, Staff J, acknowledged the omission and confirmed that the bacitracin should have been included, indicating an inaccurate assessment. For another resident, the admission MDS inaccurately marked surgical wound care in Section M, despite the absence of a surgical wound care treatment order during the look-back period. The November 2024 TAR showed orders to flush a drain, which Staff J clarified was not a skin treatment. This discrepancy further highlighted the inaccuracy in the resident's MDS assessment. These failures in accurate assessment placed the residents at risk for unidentified and/or unmet care needs, potentially affecting their quality of life.
Failure to Complete PASARR Level I for Resident with Depression
Penalty
Summary
The facility failed to ensure the completion of a Preadmission Screening and Resident Review (PASARR) Level I for a resident with a diagnosis of major depressive disorder. Upon admission, the resident's PASARR Level I form did not indicate the presence of a mood disorder, despite the resident having a diagnosis of depression and being prescribed an antidepressant medication shortly after admission. This oversight meant that the resident was not flagged for a Level II evaluation, which is necessary to determine if additional mental health services are required. The facility's policy requires that the Admissions Coordinator, Medical Records Director, or designee ensure a PASARR Level I is included in the admission paperwork and updated as necessary. However, the Social Services Director acknowledged that the PASARR form for the resident was not updated to reflect the diagnosis of depression, and a Level II evaluation was not requested in a timely manner. It was only 22 days after the resident's admission that a new Level I PASARR was completed and sent for a Level II evaluation, indicating a lapse in the facility's adherence to its own procedures.
Failure to Notify State PASARR Coordinator of Significant Change in Resident's Condition
Penalty
Summary
The facility failed to notify the State PASARR Coordinator after a significant change in condition occurred for a resident with serious mental illness (SMI). The resident, who was admitted with diagnoses including bipolar disorder, anxiety disorder, and major depressive disorder, had a Level I PASARR indicating SMI and was referred for a Level II PASARR evaluation. Despite a significant change in status, as evidenced by the resident electing to receive hospice services and being certified with a terminal illness, the facility did not notify the appropriate state authorities as required by their policy. Interviews with facility staff revealed that the Social Services Director acknowledged the resident's Level II PASARR related to SMI but admitted to not notifying the state mental health authority or the PASARR Coordinator about the resident's significant change in status. The facility's administrator also confirmed the expectation that staff should notify the State PASARR Coordinator when such changes occur, indicating a lapse in following established procedures. This oversight placed the resident at risk for unmet care needs and a diminished quality of life.
Incomplete Care Plans and Unmet Care Needs for Two Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, leading to unmet care needs. Resident 11, who was admitted with an ostomy, antibiotics, and opioid use, had incomplete care plans for skin, pain/opioid use, vision, antibiotic use, and urostomy. Staff interviews confirmed that the care plans lacked necessary goals and interventions, which were required to address the resident's specific needs. Resident 20, admitted with type 2 diabetes and legal blindness, required assistance with personal hygiene. Observations revealed that the resident had long, untrimmed fingernails with debris, which were not addressed despite being part of the care plan. Staff interviews indicated that the responsibility for nail care was not properly executed, as the care plan specified that a nurse should trim the nails due to the resident's diabetes. The failure to follow the care plan resulted in the resident experiencing discomfort.
Failure to Provide Nail Care for Diabetic Resident
Penalty
Summary
The facility failed to provide necessary assistance with nail care for a resident, identified as Resident 20, who was unable to perform this activity independently. Resident 20, who was admitted with diagnoses including type 2 diabetes mellitus and legal blindness, required set-up assistance with personal hygiene. Observations on two separate occasions revealed that Resident 20 had long, untrimmed fingernails with brown debris underneath, which were causing discomfort. Despite the resident's requests and the facility's policy to maintain personal hygiene, the necessary nail care was not provided. Interviews with staff members revealed a lack of coordination and communication regarding the responsibility for nail care, particularly for residents with diabetes. Staff N, a CNA, indicated that shower aides typically cut residents' nails, but for those with diabetes, a nurse should perform the task. However, Staff O, an LPN, acknowledged the oversight and offered to cut the resident's nails. Further, Staff E, the Resident Care Manager, noted that a physician's order was required for nail trimming for diabetic residents, which was missing in Resident 20's records. The Assistant Director of Nursing, Staff B, confirmed that nurses should provide nail care for diabetic residents and expected CNAs to coordinate with nurses to ensure timely nail care, which did not occur in this case.
Failure to Follow Physician Orders for Drain Management
Penalty
Summary
The facility failed to implement and follow physician orders for a resident who was discharged from the hospital with abdominal drains. The hospital discharge orders required the facility to empty and record the output from the drains at least once a day and to document this information. However, upon review, it was found that there were no orders or documentation indicating that the resident's drain was emptied or that the drainage output was recorded daily until 19 days after the resident's admission to the facility. Interviews with facility staff, including the Resident Care Manager and the Assistant Director of Nursing, confirmed that the orders to manage the resident's drain were not followed as per the hospital's discharge instructions. The staff acknowledged that the orders should have been implemented from the time of the resident's admission, but they were only started much later. This oversight placed the resident at risk of not receiving necessary care services and having unmet care needs.
Deficiencies in Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to maintain, label, date, and properly store oxygen tubing, nasal cannula, and nebulizer masks for three residents, leading to deficiencies in respiratory care. Resident 5 had an order for oxygen at 2 liters via nasal cannula at bedtime for sleep apnea, but there was no documentation indicating that the oxygen tubing had been changed in November or December 2024. Observations revealed that Resident 5's nasal cannula was improperly stored and not labeled or dated. Interviews with staff confirmed that the nasal cannula should have been stored in a bag and dated, but it was not changed because there were no issues reported. Resident 32 had an order for oxygen at 2 liters per minute via nasal cannula, but their oxygen tubing was also not labeled or dated. During an observation, it was noted that Resident 32's nasal cannula was undated, and the oxygen concentrator had an undated bottle of distilled water attached. Staff interviews revealed that the facility had stickers for labeling, but the tubing was not dated, and there was no order to change the oxygen tubing documented in the MAR. Resident 120 had orders for inhalation medication via nebulizer four times a day and oxygen at 2 liters per minute continuously. However, the nebulizer mask was not properly stored, and the oxygen tubing and nasal cannula were undated. Observations showed that Resident 120 was receiving oxygen at a higher rate than ordered, and there was no physician order to increase the oxygen during activity. Staff interviews confirmed that the nebulizer mask should have been stored in a bag and that the oxygen orders were not followed correctly.
Failure to Use Required Assistive Device During Therapy
Penalty
Summary
The facility failed to ensure the use of a required assistive device, specifically a gait belt, and hands-on contact during therapy for a resident with a history of falls and osteoporosis. The resident, who required assistance for activities of daily living, experienced a fall in the therapy gym while working with a therapist. The resident's right knee gave out, leading to a fall on their right hip and back, resulting in a right leg fracture and subsequent hospitalization. Interviews with staff, including the Director of Rehabilitation and a Physical Therapy Assistant, confirmed that it was the policy and procedure of the therapy department to use a gait belt when working with residents on exercise equipment. The staff acknowledged that the therapist should have used a gait belt and provided contact guard assistance to stabilize the resident during the exercise. The failure to adhere to these policies placed the resident at risk for falls and injury.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,069 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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 Edmonds
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Edmonds Post Acute | 0.5 mi | ★★★★★ | 60 | 0 |
| Lynnwood Post Acute Rehabilitation Center | 1.9 mi | ★★★★★ | 1 | 0 |
| Bridges To Home | 2.9 mi | ★★★★★ | 9 | 0 |
| Alderwood Post Acute & Rehabilitation | 3.1 mi | ★★★★★ | 61 | 0 |
| Richmond Beach Rehab | 3.3 mi | ★★★★★ | 23 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Pine Ridge Post Acute.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.