Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
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 Port Washington Post Acute during CMS and state inspections, most recent first.
Unsafe and disorganized storage room with contaminated equipment and unsecured sharps. The storage room near the nurses' station was unlocked and crowded with rusted, dirty, and unstable IV poles, along with scattered bedside commodes, feeding pumps, and nebulizers. Some equipment was visibly soiled, clean and dirty items were stored together, biohazard boxes were stacked, and a full sharps container was left open on the edge of a box. The DON acknowledged the room needed to be cleaned out and reorganized and that sharps containers should be closed and locked.
A resident with a new PEG tube and swallowing problems did not receive ordered PEG feedings, residual checks, or multiple scheduled medications because the meds had not been delivered and the facility lacked needed supplies. Another resident with OSA did not receive timely CPAP setup or accessories; staff were aware of the request but had not obtained the sleep study documentation or orders, and the machine at bedside was not connected or ready for use.
A facility failed to train staff on a newly installed WanderGuard/elopement alarm system, and staff did not recognize or respond promptly when a resident at risk for wandering and severe falls exited through the front doors in a wheelchair. The resident rolled down a hill, fell onto the street, and was transported to the hospital with multiple facial fractures. Interviews showed the DON said staff had not been educated on the new system, the Social Services Director did not know how it worked, and an LPN reset the alarm without understanding it or checking outside.
A resident with a history of aggressive behavior and ordered 1:1 supervision entered the smoking shack without the assigned staff member and confronted another cognitively intact resident. The resident pushed the other resident's wheelchair, waved a lit cigarette in the resident's face, and grabbed the resident's hand, causing both residents to fall from their wheelchairs; staff also reported confusion about supervision in the smoking area.
The facility reduced CNA staffing on all shifts, leaving as few as one aide to care for many residents, including two requiring 1:1 supervision. A resident with a Foley catheter reported their urine bag remained full most of the time and that they rarely saw aides. Another resident described a recent drop in aides and nurses, needing to leave their room to find help when call lights were unanswered. A paraplegic resident who needed a Hoyer lift and had a colostomy reported not being gotten out of bed as care planned and having to empty their own colostomy bag and throw it on the floor when no staff responded. CNAs confirmed they were responsible for up to 16 residents, could not complete showers or many required ADL tasks, and were unable to take breaks or lunch.
Surveyors found that the facility failed to ensure effective discharge planning for two residents, including coordination with community agencies and medication management. The discharge policy lacked guidance on pre-discharge needs such as medication ordering, medication teaching, arranging home care services, equipment, and follow-up appointments. One resident with diabetes and dementia was discharged home with family caregivers but without documented medication teaching or scheduled follow-up, and the community case manager was not notified, preventing caregiver scheduling and leaving the family without insulin administration training. Another resident with cognitive impairment and prior documented safety concerns at home was discharged without in-home care ordered, medication refills sent, or a follow-up physician appointment arranged, and the resident later returned after not receiving care and running out of medications. The SSD reported not handling medication re-ordering or teaching and typically not making follow-up appointments, while leadership staff acknowledged they were unaware of the lack of discharge coordination.
Surveyors found that meals were unappealing, poorly prepared, and not consistently served in a timely manner. A sample tray showed mixed and run-together vegetables, burnt bits in creamed corn, stringy green beans, bland unseasoned chicken, thin gray pudding with minimal flavor, and no butter for the roll. A resident with tracheal cancer and a pureed diet refused an untouched tray of unidentifiable pureed food, stating it looked unappealing and had no flavor. Another cognitively intact resident received a delayed lunch tray from a cart left in the hall and reported the food was cold and consistently terrible, citing past breakfasts of a glob of eggs, an unpalatable muffin, and dry cereal without milk. A third cognitively intact resident reported that food quality, consistency, and flavor had declined and that liquid eggs were used excessively, including at dinner, while the nutrition manager reported being unaware of these complaints and relying on meetings and floor staff to convey concerns.
The facility failed to provide ordered altered-consistency liquids and adequate hydration for two residents with post-stroke dysphagia. One cognitively intact resident was observed with an untouched meal tray lacking any fluids, had dry skin and chapped lips, and reported receiving unpalatable meals and dry cereal without milk, while staff were unclear about the "no drinks on the tray" diet slip and only later identified the need for Level 2 (nectar thick) liquids. Another cognitively intact resident with an order for Level 2 liquids received a tray with no liquid texture information and regular juices, and reported that CNAs bring regular juice on request despite disliking thickened fluids and recognizing inadequate fluid intake. The RD/Kitchen Manager acknowledged that residents should receive correct-consistency fluids, be monitored for hydration and compliance, and have their fluid consistency needs clearly communicated to floor staff.
A resident with encephalopathy related to glioblastoma and moderate cognitive impairment was started on Seroquel by the DON for anxiety and depression despite a psychiatry note stating there was no obvious need for psychotropic intervention and without documentation of behaviors to justify use. No psychopharmacologic informed consent was obtained, and the care plan misidentified Seroquel as an anxiolytic, lacking appropriate assessment, non-pharmacologic interventions, antipsychotic-specific monitoring, or a plan for gradual dose reduction. The DON later acknowledged not knowing why the medication had been started and that there was no documentation supporting the drug regimen.
The facility did not identify or address dementia-related behaviors for several residents, including one with severe cognitive impairment who exhibited wandering, yelling, and sexually inappropriate actions. Two residents reported repeated uninvited room entries and distressing incidents, while another resident's frequent yelling and aggression disrupted others. Staff documentation and care plans lacked interventions or guidance for managing these behaviors, and staff were unaware of or did not investigate reported incidents.
Two residents did not receive scheduled care and services as ordered, including timely weight monitoring and bathing, with care plans lacking directions for staff on refusals and specific care needs. Documentation was incomplete, and staff were unaware of equipment status and proper documentation practices.
A resident with a fractured femur, legal blindness, and moderate cognitive impairment did not receive the full number of occupational and physical therapy sessions as outlined in their care plan, receiving significantly fewer therapy visits than ordered before being discharged after insurance coverage ended.
A resident with a dehisced abdominal surgical wound and amputated toes was admitted with orders for wound vac therapy and dressing changes, but the facility failed to assess, monitor, or document care for the abdominal wound for over three weeks. The resident also developed a new lower extremity ulcer that was not identified until it required debridement. Staff were unaware of the abdominal wound, and necessary orders were not transcribed or implemented, resulting in the abdominal wound worsening in size before it was finally addressed.
The facility did not ensure timely and accurate receipt, dispensing, and administration of medications for all residents reviewed, resulting in multiple missed doses of critical medications such as anticoagulants, antibiotics, and cardiac drugs. These failures were due to inadequate staff training, lack of awareness of pharmacy procedures, and insufficient use of emergency medication access systems.
A resident who was cognitively intact reported that cash was stolen from their unsecured nightstand drawer after returning from a hospital stay. Despite requests for a lock and staff awareness of the cash, no secure storage was provided, and the incident was not properly investigated or reported to authorities.
Failure to Log and Investigate Resident Grievances: A resident reported filing a grievance about a CNA-related toileting issue, but it was not found in the grievance log and staff were unaware of it. Resident Council minutes also included multiple resident concerns, such as missing clothing, delayed call lights, staff competency concerns, and a missing plant, yet these items were not logged as grievances or fully documented in the official minutes.
Psychotropic medications were not adequately monitored for several residents. One resident had repeated behaviors and reported memory loss, but the TAR did not document the behaviors, side effects, or NPIs. Other residents receiving divalproex, Namenda, levetiracetam, and Seroquel lacked required behavior monitoring, side effect monitoring, consent, or NPIs. A resident on sertraline had mismatched target behaviors between the care plan and TAR, and the record did not support the continued use of the medication based on suicidal ideation documentation.
Failure to Report Abuse, Neglect, Misappropriation, and Accidents: Staff did not timely report multiple allegations and incidents involving residents, including missing money, alleged mistreatment, a prolonged call light wait after a fall with bleeding, an allegation of being told to have a BM in bed, and a fall with injury and hospital transfer. Several events were not entered in the incident log, and the DON/Administrator confirmed the incidents were not reported to the State Agency as required.
Incomplete investigations of abuse, neglect, and misappropriation allegations. The facility did not thoroughly investigate multiple resident incidents involving alleged rough handling, shower-room misconduct by an SSD, missing money, a debit card/missing funds issue, a delayed response to a fall with bleeding, and a dignity-related toileting concern. Records showed missing incident log entries, absent or incomplete resident and staff interviews, no documented follow-up for some allegations, and in some cases no state report or care plan update, despite residents being cognitively intact or able to describe the events.
Failure to provide written transfer notice for 3 residents. The EHR and MDS showed hospital transfers and readmissions for 3 sampled residents, but there was no documentation that each resident received a written transfer/discharge notice. The SS Director said the transfer/bed hold form was completed electronically, but residents were not given a copy, and the Administrator stated residents were expected to receive a written copy in a language they understood at the time of transfer or within 24 hours.
Failure to provide written bed hold notices for 3 residents transferred to the hospital. The EHR showed hospitalizations and readmissions for the residents, but there was no documentation that a bed hold notice was given. The SS Director said the bed hold form was completed electronically, but residents were not given a copy, and the Admin stated residents were expected to receive a written copy in a language they understood at transfer or within 24 hours.
Inaccurate MDS coding affected four residents. One resident’s restorative walking and ROM programs were coded even though the programs had not been periodically evaluated. Another resident was receiving sertraline for depression, but the MDSs did not code depression as an active dx. A third resident’s MDSs listed obstructive uropathy and a Foley, while the record showed a complex urology history and the MDS Director said the dx was not active. A fourth resident’s mobility status was coded as needing max assist with sit-to-stand, but the resident had not stood in nearly two years and staff said the resident did not get out of bed.
PASRR Level 1 screenings were inaccurate or incomplete for several residents with MH diagnoses. One resident with depression and sertraline had no serious mental illness marked on the PASRR, two residents were left on exemption PASRRs without a new Level 1 after staying beyond the initial 30 days, and another resident’s PASRR did not include personality disorder despite that diagnosis being added to the chart.
Care plans for multiple residents were inaccurate, incomplete, or inconsistent with current assessments, orders, and treatment records. Examples included a wound care plan that did not reflect a changed pressure ulcer status, missing dental and restorative details, a catheter plan without supporting diagnosis, a dementia care plan that incorrectly listed the resident as their own decision maker, and care plans that omitted mobility bars and pain documentation noted in the EHR.
Multiple residents were affected by failures to follow ordered medication parameters, oxygen therapy instructions, and required monitoring. Staff gave BP meds despite hold parameters, documented meds and treatments as completed when they were not, failed to keep oxygen at the ordered rate, did not ensure ordered equipment and supports were in place, and rarely obtained vitals for a resident receiving scheduled pain meds and a lidocaine patch order that lacked a location.
Multiple residents had care needs that were not carried out or documented as ordered, including cognitive follow-up, lab testing, bowel protocols, fluid restriction monitoring, repositioning assistance, dialysis communication, podiatry referral follow-through, and PICC line care. Staff interviews and record review showed missed bowel meds after days without BM, incomplete fluid intake reconciliation, delayed response to a call light, missing dialysis paperwork, an overdue podiatry visit for a painful foot lesion, and a PICC dressing change and measurements that were not completed as ordered.
Failure to Provide Assessed ROM and Restorative Services: A resident with hand contracture, pain, and prior OT/splinting had a prolonged gap before later OT services, and the hand splint was lost and not replaced. Three other residents were assessed for ROM and ambulation programs up to 6-7 days per week, but restorative records showed the programs were offered fewer times than assessed. Staff said the programs were split into 3-day groups because of time, dining duty, and staff convenience.
Incomplete fall investigations and missing documentation. The facility did not thoroughly investigate falls for three residents. One resident with cognitive impairment and smoking-related concerns had incomplete fall packets after falls in the smoking area and while transferring, with blank root-cause sections, missing scene details, and no clear review of contributing factors or updated smoking evaluation. A cognitively intact resident reported a fall from bed with delayed staff response, but the packet lacked immediate measures, staff names, resident input, and root-cause analysis. Another cognitively intact resident described slipping in a shower room and being unable to reach the call light, yet the fall was not logged and the packet lacked a resident interview, 5 Whys analysis, and interdisciplinary documentation.
A facility failed to provide enough qualified nursing staff to meet resident needs. Multiple residents reported long waits for call lights, toileting, incontinence care, and help getting out of bed, with some left on the toilet or in feces for extended periods. Staff confirmed delays occurred when they were busy or not on the floor, and restorative staff said extra duties took 2 to 3 hours per shift away from restorative care, limiting their ability to provide RNPs as scheduled.
The facility failed to complete annual performance reviews for 3 sampled CNAs. The Administrator stated staff were reviewed annually, but the last documented reviews for the CNAs were all the same and were not current for each aide.
Incomplete GDR documentation for psychotropic meds. A resident with depression, anxiety, and bipolar disorder had a provider note citing weekly panic attacks, but the chart did not support that claim and staff were unaware of the issue. Two other residents had GDRs declined as clinically contraindicated, but the required resident-specific rationale was blank or missing from the record. The DON confirmed the documentation gaps.
Unlabeled and unsecured medications were found in the medication room, on a medication cart, in an unattended treatment cart, and at a resident’s bedside. Multiuse PPD vials were opened without proper dating or were expired, a Spiriva inhaler and lispro insulin pen were opened and undated, an unlocked treatment cart contained medications and supplies, and two bottles of Nystatin powder were left at bedside despite staff confirming they should not have been stored there.
Kitchen sanitation and food prep deficiencies were observed when undated bread was found, uncovered rolls were exposed to a debris-filled fan, and kitchen personnel entered without proper hair restraints. A Dietary Asst. Director also prepared pureed pork using a blender with unmeasured water and thickener instead of following the facility recipe, and leadership stated the practices did not meet expectations.
The facility failed to fully track antibiotic use through monthly line lists and did not consistently document symptoms, reassess continued ABO use, or follow up on urine culture collection issues. One resident was started on ABO with conflicting screening criteria and no documented reevaluation after negative urine results, while another resident had a UA but no culture because the specimen was submitted improperly. The DON confirmed the April line list lacked a field showing whether criteria were met and that no antibiotic line lists were available for later months.
No designated IP was consistently identified, and infection control surveillance documentation was incomplete. The Administrator gave conflicting names for the IP role, an LPN said infection control was being handled by unit managers, and the DON said nurses were pitching in after the shared IP was lost with an ownership change. Facility-wide antibiotic line listings, infection control summaries, and organism maps were available only for earlier months, with none provided for later months, and the DON confirmed the missing monthly documentation.
Failure to Ensure COVID-19 Vaccination Offer and Documentation: The DON confirmed that COVID-19 vaccines were expected to be offered on admission and in the early fall, with consent or decline documented in the chart. However, three residents reviewed had gaps in vaccination status: one resident had no facility record of receiving the vaccine despite prior immunization history and later requested it, one resident was vaccinated only after testing positive for COVID-19, and one resident consented to the vaccine but did not receive it before later testing positive.
The facility failed to keep a freezer in safe, functional condition. A thermometer was not present in the freezer, yet the temperature log showed zero-degree readings, and the Dietary Manager could not identify who documented them. Corporate Maintenance later found the walk-in freezer at 15-17 degrees, and the Administrator stated the freezer was inoperable and awaiting vendor repair.
Failure to document AD education and resident/family choices for two residents. One cognitively intact resident had no EHR evidence of being offered or accepting/declining an AD, and a second resident with severe cognitive impairment had no POA document in the EHR despite a care plan note referencing one; the SSD said the family did not want to formulate an AD, but supporting documentation could not be found.
Failure to provide privacy during shower care. A cognitively intact resident reported that the SSD, UM/RN, and a CNA were present in the shower room during personal care, and that the SSD used the shower nozzle to spray the resident while instructing the CNA. The resident said they did not want the SSD in the room. Interviews confirmed the SSD was not a CNA, LPN, or RN and acknowledged being present in the shower room while the resident showered.
Failure to maintain ordered pressure redistribution and weekly wound monitoring: A resident with an unstageable left heel PI had orders for a low air loss mattress, heel protector, and wound treatments, but surveyors observed the resident on a standard mattress instead of the ordered surface. The record also showed no weekly wound assessments or measurements for several weeks, and the wound consult later documented progression of the heel PI from unstageable to stage III.
A resident with an indwelling Foley catheter had no documented clinical justification for continued use, no timely assessment for removal, and no securement device in place. The resident had a history of prostate cancer, prostatectomy, radiation, urethral stricture, and bladder neck contracture, but staff stated there was no current diagnosis or wound issue supporting the catheter and acknowledged there was no clinical justification for it.
Pain management was not consistently addressed for two residents. One resident with chronic pain had repeated 0/10 pain entries despite an EHR alert that 0/10 was not accurate, refused restorative services because of pain, and had a pain eval showing significant hip and sacral ulcer pain; staff were not aware of the refusals or did not notify the RN/DON. Another resident receiving scheduled hydromorphone had no side effect monitoring order and no documented NPIs, and the DON confirmed staff were not documenting NPIs.
A resident who could make needs known was served foods that conflicted with documented allergies/dislikes on the tray card, including cheese, dairy items, and whipped topping. The resident stated staff had repeatedly given foods they had said they did not like, and the Dietary Manager and Administrator acknowledged the foods were not appropriate and that resident preferences should have been honored.
Therapeutic diets were not provided as ordered for two residents on a CCHO diet. During lunch tray service, a Cook prepared the residents’ trays and served the primary meal with a dinner roll instead of the wheat bread indicated on the tray cards, and the Dietary Mgr confirmed wheat bread should have been provided. One resident had diabetes and severe cognitive impairment, and the other resident had diabetes.
The facility did not complete comprehensive skin assessments or proper documentation for three residents with wounds or skin conditions. For example, a resident with chronic wounds lacked ongoing wound measurements and documentation, another did not receive prescribed skin treatments as ordered and had undocumented wounds, and a third had wounds that were not properly assessed or described until seen by a wound management company. Staff interviews revealed confusion and inconsistent practices regarding skin assessment documentation.
A resident with a history of heart disease received multiple doses of 81mg aspirin for chest pain from an agency LPN without a provider's order, resulting in a total of 324mg administered in addition to the prescribed daily dose. The LPN acted based on agency training rather than facility protocol, and facility leadership confirmed that no protocol or physician order authorized this medication administration.
A resident with paraplegia who depended on staff for transfers was not provided with a standing frame needed to maintain or improve mobility, as the equipment had been loaned to another facility and was not returned promptly. Despite repeated requests and communication between nursing and therapy, the standing frame was not made available or set up for use, and the care plan lacked specific interventions or restorative services to address the resident's mobility needs.
The facility did not ensure that two residents who smoked were properly assessed and that required safety interventions were followed, resulting in residents smoking outside the designated area, not using required protective equipment, and cigarette smoke entering resident rooms. Staff and leadership were unaware that interventions were not being followed and that unsafe smoking practices were occurring.
A resident with a history of gastric ulcers, type 2 diabetes, and anemia was found to have multiple pills stored in a seasoning bottle at their bedside, despite facility policy requiring an assessment before allowing medications at bedside. The resident had refused all medications except for a weekly diabetes injection, and both the LPN and DON confirmed that no assessment had been completed to permit bedside storage.
Mechanical beds in several rooms were not maintained in safe, working order, resulting in one resident experiencing a bed collapse and others using beds with malfunctioning controls or components. Staff reported frequent breakdowns, lack of routine audits, and inconsistent reporting of maintenance issues, leading to unresolved equipment problems.
Unsafe and disorganized storage room with contaminated equipment and unsecured sharps
Penalty
Summary
Storage room [ROOM NUMBER] located diagonally across from the nurses' station was found to be unsafe, unclean, and disorganized during observation and interview. The door was not locked and, when opened, knocked into 3 IV poles that were rusted, dirty, and very unstable when tested. Portable bedside commodes, feeding pumps, and nebulizers were scattered and piled around the small room, and some equipment was visibly soiled while it was not possible to tell whether other items were clean or dirty. Biohazard boxes for sharps containers were stacked on top of each other, and a full sharps container was observed sitting on the edge of one box, not closed or locked. The DON stated the room needed to be completely cleaned out and reorganized, that clean and dirty equipment should not be stored together, that sharps containers needed to be closed and locked, that the old IV poles needed to be thrown away, and that all storage rooms needed to be locked to prevent residents from entering them.
Failure to Provide Ordered Medications, PEG Feeding Support, and CPAP Equipment
Penalty
Summary
The facility failed to identify and provide needed treatment and services in a timely manner for two residents. One resident was admitted with a new PEG tube, a history of esophageal obstruction, and difficulty swallowing, and was documented as cognitively intact. The resident stated they stayed only one night because they did not receive all medications and did not receive them through the PEG tube, and reported that only one feeding was given and that it was not done correctly. The hospital discharge orders required Jevity 1.2 bolus feedings via PEG every 6 hours, with residual volume checks before each feeding, but the residual volume was not tested before the 8 PM bolus. The medication record showed 16 medications due between 4:30 PM and noon the next day were not given, including medications for pain and GERD. Staff stated the medications had not been delivered, only one medication could be obtained from the Omnicell during the night shift, and the facility did not have syringes to check residuals or administer PEG medications. A second resident admitted with obstructive sleep apnea and documented as cognitively intact said the facility had been told by the hospital that a CPAP machine and accessories would be available on arrival, but the resident continued to wake up gasping for air and crying without it. The resident reported speaking with social services, the ADON, and the charge nurse, but nothing was done. A CPAP machine was observed at the bedside but it was not plugged in and had no mask or tubing attached or nearby. Staff said they were not aware the resident needed a CPAP, did not know one was in the room, had not obtained the sleep study documentation, and did not have orders for the CPAP at the bedside.
Failure to Train Staff on New WanderGuard System Led to Resident Elopement
Penalty
Summary
The facility failed to ensure staff were adequately trained on a newly implemented WanderGuard/elopement alarm system, and staff did not recognize or respond timely to resident elopement alarms for a resident assessed as at risk for wandering and elopement. The resident was cognitively intact but had a history of a large left-sided stroke that affected safety awareness. The resident’s care plan documented that staff were to remind the resident to remain within eye contact and that the resident was not allowed in the patio or parking lot areas because of severe fall risk, with a WanderGuard attached to the wheelchair to alert staff if the resident tried to enter the front patio. An incident report documented that the resident wheeled through the front doors and an alarm sounded at the nurse’s station, but it was turned off by an LPN. Video surveillance showed the resident leaving the patio area and proceeding toward a bus stop at the top of a significant hill, then rolling down the hill in the wheelchair, falling onto the street, and being discovered by a passerby who called 911. The resident was transported to the hospital after a brief roadside assessment by facility staff. Hospital records documented multiple sinus fractures and a fracture under the left eye with bruising. Staff interviews showed the DON said the new system had been installed and staff had not been educated about how it worked, the Social Services Director was not aware how the new system functioned, and the LPN said they did not know what the alarm was for and had been told to reset it without looking outside.
Failure to Prevent Resident-to-Resident Altercation in Smoking Area
Penalty
Summary
The facility failed to prevent an altercation between two residents reviewed for freedom from abuse. Resident 2 was admitted with diagnoses including anxiety, major depression, schizophrenia, and nicotine dependence, and the quarterly MDS showed Resident 2 was cognitively intact. The record documented a history of verbally and physically attacking other residents in behavior notes dated 11/13/2025, 02/11/2026, and 03/21/2026. After the 11/13/2026 incident, Resident 2 was assigned a staff member to provide 1:1 supervision while awake. Resident 3 was admitted with nicotine dependence, and the quarterly MDS showed Resident 3 was cognitively intact. A behavior note dated 04/18/2026 documented a verbal confrontation between Resident 2 and Resident 3 at the smoke shack, with Resident 2 cussing at Resident 3. An incident report dated 04/19/2026 stated Resident 2 went into the smoking shack without the assigned staff member, parked the wheelchair in front of Resident 3, spoke confrontationally, pushed Resident 3's wheelchair, waved a lit cigarette in Resident 3's face, and grabbed Resident 3's hand. Both residents fell out of their wheelchairs, and no injuries were sustained. Staff reported confusion about staffing responsibilities in the smoking area, and the DON stated Resident 2 should not have been outside without the assigned staff member.
Insufficient CNA Staffing Leading to Unmet ADL and Supervision Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet residents’ Activities of Daily Living (ADL) needs and to adequately supervise care, as evidenced by resident and staff interviews and observations. One resident with an indwelling Foley catheter, cognitively intact and requiring partial to moderate assistance with ADLs per the quarterly MDS, was observed with a full urine bag hanging at the bedside and reported the bag was full most of the time. This resident stated they had not seen an aide all day except when lunch was delivered. Another cognitively intact resident, who required minimal assistance with ADLs, reported a noticeable decrease in the number of aides and nurses in recent weeks and said they often had to leave their room to find help because call lights were not answered, expressing concern for other residents needing more help. A third cognitively intact resident with paraplegia, substantial ADL assistance needs, and a colostomy reported that their care plan called for them to be out of bed by 9 AM, but they were often not out of bed until lunchtime. This resident stated that two aides were needed to use a Hoyer lift for transfers, but aides repeatedly told them another aide could not be found, and the resident emptied their own colostomy and frequently threw the feces-filled bag onto the floor because no one would come to collect it. CNAs reported being the only aide on a unit, caring for up to 16 residents, and stated that showers could not be completed, many required care tasks were not done, and they were unable to take breaks or lunch. The staffing coordinator reported that, about three weeks earlier, the interim Administrator had directed reductions in CNA staffing on all shifts and that two residents required 1:1 supervision on all shifts, with the expectation that floor aides would rotate this responsibility.
Failure to Coordinate Discharge Planning, Community Services, and Medication Management
Penalty
Summary
Surveyors identified a deficiency in the facility’s discharge planning process related to lack of coordination with community agencies and inadequate medication management for two residents. The facility’s Discharge Policy, revised 12/16/2026, did not address pre-discharge needs such as medication ordering, medication teaching, coordination of home care services, equipment needs, or ensuring follow-up appointments were made before discharge. For Resident 1, who had diabetes and dementia but was assessed as cognitively intact, the Discharge Plan of Care documented that assistance with bathing, toileting, and dressing would be provided by family and personal caregivers, but there was no documentation of medication teaching or follow-up appointments. The Home and Community Services case manager reported they were not notified of this resident’s discharge, so caregivers could not be scheduled, and the family later called with questions about sliding scale insulin administration because they had not received training from facility nurses before discharge. For Resident 2, who had unspecified cognitive impairment, adult failure to thrive, and needed assistance with personal care, the admission documentation included prior hospital case management concerns about safety at home and the family’s ability to provide care. The Discharge Plan of Care stated the resident was cognitively intact and would receive assistance with most ADLs from family, but in-home care was not ordered, medication refills were not sent to a pharmacy, and no follow-up appointment with the primary physician was made. The resident was later readmitted after not receiving care at home and running out of medications about a week after discharge. The Home and Community Services case manager stated they had not been notified of this resident’s discharge and indicated that, based on identified concerns, involvement would have been expected upon referral. The Social Services Director acknowledged not knowing about medication re-ordering or teaching for discharges and reported typically not making follow-up appointments, while leadership staff acknowledged lack of awareness of the coordination issues and that the discharges for these residents were not safe.
Failure to Provide Palatable, Attractive, and Properly Served Meals
Penalty
Summary
Surveyors observed that the facility failed to provide attractive, palatable, and flavorful food at safe and appetizing temperatures. A sample tray from the kitchen contained creamed corn and green beans running together on the plate, with the corn showing burnt bits and the green beans containing tough strings that had to be removed. The baked chicken breast was unseasoned and bland, the pudding was light gray, thin, and dripping off the spoon with only a faint chocolate taste, and there was no butter provided for the roll. The facility’s Registered Nutritionist/Kitchen Manager stated they were unaware of food complaints and relied on food council meetings and floor staff to communicate resident concerns. One resident with tracheal cancer, a voice box removal, moderate cognitive impairment, and a pureed diet had an untouched lunch tray consisting of a large pile of unidentifiable pureed food and reported the food looked unappealing, had no flavor, and they had no desire to eat it. Another cognitively intact resident did not receive their lunch tray when the cart was first passed; the tray remained on the cart in the hall until a CNA was prompted to deliver it, and the resident then reported the food was cold and terrible, describing prior breakfasts as a glob of eggs and an unpalatable muffin, and receiving two bowls of dry cereal without milk. A third cognitively intact resident reported that the food was terrible, that quality, consistency, and flavor had declined after a period of improvement, and that the facility used too many liquid eggs, including at dinner. The Administrator stated they believed food quality was improving and that managers would increase tasting and post-meal rounds to assess satisfaction.
Failure to Provide Ordered Thickened Liquids and Adequate Hydration
Penalty
Summary
The facility failed to ensure residents received liquids consistent with their ordered altered consistencies and hydration needs. One resident with post-stroke swallowing difficulties, cognitively intact per an admission MDS, was observed with an untouched lunch tray that had no fluids. The resident had chapped lips and dry facial skin and reported that meals had been cold and unpalatable since admission, describing breakfast as a glob of eggs and an unmanageable muffin, and receiving dry cereal without milk on two mornings. A CNA, upon checking the diet slip, noted it stated no drinks on the tray and did not know what that meant, indicating they would need to ask the nurse. An LPN then reviewed the orders and identified that the resident required Level 2 (nectar thick) liquids, retrieved a single carton of nectar thick juice from a locked nourishment room, and provided it, with no other Level 2 beverages observed in the refrigerator. The LPN stated that aides would need to ask the nurse to know what type of liquid to give a resident. Another resident, also admitted with post-stroke swallowing difficulties and cognitively intact per the admission MDS, had a dietary order for Level 2 liquids. During a meal observation, this resident’s tray diet slip contained no information about liquid textures, and the tray included two containers of normal-consistency juice. Later, the resident was observed in bed drinking normal-consistency cranberry juice and reported that aides bring juice containers upon request, expressing dislike for nectar thickened fluids, especially water, but acknowledging not getting enough fluids. The Registered Dietician/Kitchen Manager stated that all residents should receive sufficient fluids of the correct consistency, that residents with altered fluid consistency should be monitored for compliance and hydration, and that there should be a quick reference system to communicate residents’ fluid consistency needs to floor staff. The report states that these failures placed residents at risk for dehydration, aspiration, and decreased quality of life.
Antipsychotic Medication Initiated Without Assessment, Consent, or Proper Care Planning
Penalty
Summary
Surveyors found that the facility failed to ensure a resident’s drug regimen was free from unnecessary drugs when Seroquel, an antipsychotic medication, was initiated and continued without proper assessment, diagnosis, or monitoring. The resident was admitted with encephalopathy related to glioblastoma, was moderately cognitively impaired, and required extensive assistance with most activities of daily living. A psychiatry note documented that the resident was confused and minimally engaged, with an impression of unspecified cognitive disorders worsening due to recent medical events, and specifically stated there was no obvious need for psychotropic intervention. Despite this, the former Director of Nursing Services obtained an order for Seroquel 50 mg every morning and 150 mg at bedtime for anxiety and depression, without documentation of behaviors or other clinical justification explaining why the medication was started. There was no Psychopharmacologic Medication Informed Consent signed by the resident to show that risks, benefits, side effects, or the need for gradual dose reduction had been reviewed. The care plan later identified Seroquel incorrectly as an anxiolytic medication and, even when revised, did not include an appropriate assessment, non-pharmacologic interventions, or monitoring specific to an antipsychotic medication, nor did it address a plan for gradual dose reduction. When interviewed, the Director of Nursing Services stated they did not know why Seroquel had been started and acknowledged there was no documentation to support the drug regimen. The report states that this failure to complete a thorough evaluation before starting the medication and to provide necessary monitoring during therapy placed residents at risk for sedation, decreased quality of life, and death.
Failure to Address and Manage Dementia-Related Behaviors
Penalty
Summary
The facility failed to identify, address, and adjust care needs for five residents who exhibited dementia-related behaviors or were negatively impacted by such behaviors. One resident with a history of Neurocognitive Disorder with Lewy Bodies demonstrated severe cognitive impairment and exhibited behaviors such as yelling, wandering, and sexually inappropriate actions, as documented on behavior monitoring forms. Despite these documented behaviors, no interventions were added or recorded, and the resident's care plan and Kardex lacked any mention of these behaviors or guidance for staff on how to manage them. Other residents were directly affected by these deficiencies. Two cognitively intact residents reported that the resident with dementia repeatedly entered their room uninvited, with one incident involving urination on a bed and another involving an attempted sexual contact. Both residents expressed anger, frustration, and helplessness, and staff interviews revealed a lack of awareness or investigation into these incidents. Staff relied on the Kardex for intervention guidance, but it did not provide any relevant information for managing the behaviors. Another resident with dementia and behavioral disturbances was documented as frequently yelling, screaming, and exhibiting aggressive behaviors such as kicking, hitting, grabbing, and using abusive language. These behaviors were noted by staff and affected nearby residents, one of whom reported significant distress and sleep disruption. However, the care plan for this resident only addressed medication interventions and did not include strategies for managing the documented behaviors. Staff confirmed that the care plans and Kardexes did not provide adequate or person-centered interventions for these residents' behavioral needs.
Failure to Provide Scheduled Care and Services per Orders and Resident Preferences
Penalty
Summary
The facility failed to provide scheduled care and services according to physician orders and resident preferences for two residents reviewed for quality of care. One resident, admitted with a fractured femur and legal blindness, required extensive assistance with activities of daily living (ADLs) and was assessed as moderately cognitively impaired. Orders specified that weights should be obtained weekly for four weeks, but documentation showed that weights were not recorded until nearly two weeks after admission, with only one additional weight recorded before discharge, revealing a 10-pound loss. The resident's care plan, completed two days before discharge, did not address care needs such as bathing, obtaining weights, or instructions for staff regarding refusals of care, despite the resident being at nutritional risk due to multiple co-morbidities. No documentation was provided regarding showers or bathing during the resident's stay. Another resident, who was cognitively intact and required extensive assistance with ADLs, had a care plan indicating a bath should be provided twice weekly and as needed, with a sponge bath as an alternative if a full bath or shower could not be tolerated. The care plan lacked directions for staff on how to handle refusals. Documentation showed inconsistent bathing records, with some days marked as "not applicable" and others as "refused," and only one shower documented during the review period. Orders for weekly weights were not consistently followed, with only three weights documented and no further records. Staff interviews revealed a lack of awareness regarding the functionality of the wheelchair scale and uncertainty about documentation practices for showers and baths. The administrator confirmed that care plans should reflect personalized care needs, including interventions for refusals, but these were not present.
Failure to Provide Consistent Rehabilitative Services per Care Plan
Penalty
Summary
The facility failed to provide consistent specialized rehabilitative services as required by the care plan for a resident admitted with a fractured femur and legal blindness, who was moderately cognitively impaired and required extensive assistance with activities of daily living. According to the care plan and therapy orders, the resident was to receive occupational therapy (OT) and physical therapy (PT) five times per week for four weeks. During the certification period, the resident received only nine OT visits and fourteen PT visits, which was eleven OT visits and six PT visits fewer than planned. The resident was notified that insurance coverage would end and was discharged before the end of the planned therapy period. The administrator confirmed that all residents should receive specialized services according to their care plan.
Failure to Assess and Monitor Wounds Resulting in Wound Deterioration
Penalty
Summary
The facility failed to assess, monitor, and provide appropriate care for a resident with a non-pressure abdominal wound and a newly developed lower extremity (LE) ulcer. Upon admission, the resident had a dehisced surgical wound to the midline abdomen and amputated toes on the right foot, with diagnoses including peripheral vascular disease and diabetes. The admission assessment noted the presence of the abdominal wound and wound vac, but did not include wound measurements or detailed wound characteristics. Hospital transfer orders specified wound vac settings and dressing change frequency, but these were not transcribed into the facility's records, and no care plan interventions were developed to address the wound or minimize further breakdown. From admission, there was no documentation of wound care, assessment, or monitoring for the abdominal wound until 24 days later, nor for the right calf wound until 13 days after admission. The Treatment Administration Records (TARs) and electronic medical record (EMR) lacked any entries regarding the abdominal wound, wound vac, or required dressing changes during this period. The resident developed a new ulcer on the right posterior calf, which was not present on admission and was only identified after it had progressed to 75% slough and required mechanical debridement. Staff interviews confirmed that the abdominal wound was not assessed or treated because staff were unaware of its presence, and the necessary wound care orders were not implemented. When the abdominal wound was finally assessed 24 days after admission, it had increased in size, indicating a worsening condition. The wound care consult documented the wound's increased area and provided new treatment recommendations. The Director of Nursing acknowledged that the facility failed to identify and treat the wounds in a timely manner, and that the right LE ulcer should have been detected earlier, especially given the resident's need for maximal assistance with lower body dressing.
Failure to Ensure Timely Medication Administration Due to Inadequate Pharmacy Procedures
Penalty
Summary
The facility failed to develop and implement effective pharmacy procedures to ensure that medications were timely and accurately received, dispensed, and administered to meet the needs of all seven residents reviewed for admission medication reconciliation. The pharmacy delivery schedule required that medications ordered before 10:00 AM would be delivered in the evening, and those ordered after 10:00 AM but before 7:30 PM would be delivered overnight. If medications were needed before the next scheduled delivery and the cutoff time was missed, staff were expected to request STAT delivery and utilize emergency access systems such as Omnicell. However, there was no documentation that staff followed these procedures, resulting in multiple missed doses of critical medications for several residents. Residents admitted with time-sensitive and high-risk medication needs, such as anticoagulants, antibiotics, cardiac medications, and antipsychotics, experienced significant omissions. For example, one resident with a history of blood clots did not receive scheduled doses of rivaroxaban, despite the medication being available in the Omnicell system. Another resident with a C. difficile infection missed 12 out of 25 scheduled vancomycin doses due to failures in transcribing a formulary interchange and lack of staff follow-through. Additional residents failed to receive IV antibiotics, anticonvulsants, and other essential medications due to similar lapses in order entry, pharmacy communication, and emergency medication access. Interviews with staff revealed a lack of training and awareness regarding pharmacy ordering deadlines, STAT medication requests, and the use of emergency medication systems. Some nurses were unaware of the need to fax certain medication orders or the existence of pharmacy order cutoff times. The Director of Nursing confirmed that several staff members did not have access to the Omnicell system, further contributing to the delays and omissions. These systemic failures in medication management and staff competency led to repeated missed doses and inadequate medication administration for all residents reviewed.
Failure to Protect Resident's Property from Theft
Penalty
Summary
A cognitively intact resident was admitted to the facility and, according to the quarterly Minimum Data Set, was able to make independent decisions. The resident reported being unable to lock the top drawer of their nightstand and stated that they had made at least two requests for maintenance to install a lock, which were not fulfilled. The resident kept $376 in the top drawer, with another resident as a witness to the amount. After being hospitalized for several days, the resident returned to find only one dollar remaining in the drawer. The missing money was immediately reported to the Social Services Director. Facility staff interviews revealed that the Social Services Director received the complaint and reported it to their supervisor but did not notify law enforcement or initiate a formal investigation, only speaking to the witness who denied seeing the money. The Business Office Manager was aware the resident had cash in the room and encouraged the use of a facility trust account, but did not verify the security of the drawer. The Maintenance Director was unaware of any request for a lock and confirmed the drawer was not lockable. The administrator, newly in position, acknowledged the incident should have been investigated and reported. Documentation confirmed the resident's report of theft and the lack of a secure storage solution for their belongings.
Failure to Log and Investigate Resident Grievances
Penalty
Summary
The facility failed to log and investigate grievances for Resident 22 and for multiple concerns raised in Resident Council meeting minutes. Resident 22 was admitted to the facility and, on the quarterly MDS assessment dated 04/06/2025, was documented as cognitively intact and requiring substantial to maximal assistance with toileting hygiene. During an interview, Resident 22 reported filing a grievance related to a brief change by a CNA on the night of 07/14/2025, but review of the grievance log showed no grievance was logged for Resident 22. Resident 22 later identified Staff H, Medication Technician, as the staff member who filled out the grievance, and Staff H stated the incident occurred several days earlier, that they wrote the grievance, and that Resident 22 confirmed it before it was turned in. Staff B, DNS, stated grievances should be logged soon after receipt that shift, and Staff F, Social Services Director, said the incident should have been brought to them or Staff B, discussed in stand up, and investigated. However, when the grievance log for July 2025 was reviewed, no grievance was found for Resident 22, and both Staff B and Staff F said they were unaware of the incident. The facility’s grievance policy stated grievances were intended to assure concerns are quickly and thoroughly evaluated and acted upon to resolve issues affecting residents’ quality of life and care. Review of Resident Council meeting minutes and the grievance log showed additional concerns were discussed in March, May, and June 2025 without being logged as grievances. These included missing clothing, call lights not being answered in a timely manner, concerns about a nurse on B hall, reservations about a night shift nurse, an unspecified issue from a resident identified by room number, and a missing plant. Staff A, Administrator, stated several of these items should have been grievances or missing property documentation, and Staff CC, Activities Director, said individual grievances from Resident Council were not usually transcribed into the official minutes and that handwritten notes were not fully available. Staff A stated this did not meet expectations and that grievances worthy of documentation should have been written up.
Psychotropic Medications Not Properly Monitored or Documented
Penalty
Summary
The facility failed to adequately monitor psychotropic medications, document non-pharmacological interventions, and obtain consent for several residents receiving psychotropic or behavior-related medications. The deficiency involved 5 of 7 residents reviewed for unnecessary medication or behaviors and was cited under WAC 388-97-1060 (3)(k)(i). The report described missing behavior documentation, missing side effect monitoring, missing consent, and mismatches between care plans and behavior monitoring records. One resident with anxiety, depression, and an unspecified adult personality/behavior disorder was moderately cognitively impaired and receiving a scheduled antidepressant and antianxiety medication. The resident had target mood monitors for depression and anxiety with instructions for licensed nurses to document behaviors and non-pharmacological interventions such as talking with the resident, redirecting, offering activities, or involving social services. The record also included side effect monitors for impaired memory, concentration, increased confusion, and confusion. However, the resident reported that medications were causing memory loss, CNA documentation showed multiple behaviors including yelling, screaming, abusive language, threatening behavior, and rejection of care, and the July TAR did not document behaviors, side effects, or any attempted NPIs. Staff later acknowledged the behaviors and NPIs were not being documented on the TAR. Another resident receiving divalproex for bipolar disorder had no behavior monitor or adverse side effect monitor in place, and staff confirmed those monitors were absent. A different resident with severe cognitive impairment and dementia-related behavioral disturbance was receiving Namenda and levetiracetam, but the EHR contained no consent and no side effect monitoring for either medication. Staff stated consent should have been obtained on admission and acknowledged the missing monitoring. A cognitively intact resident receiving Seroquel for bipolar disorder also had no behavior monitoring, target behaviors, side effect monitoring, or NPIs documented, and staff confirmed those elements were missing. A resident with no psychiatric diagnosis and a PHQ-9 score of 0 was receiving antidepressant medication on seven of seven days during the assessment period. The record showed an initial note that the resident reportedly said he wanted to die, was placed on q15-minute checks, and was started on sertraline with a psychiatric referral. However, the care plan and TAR listed different target behaviors for sertraline, and neither included suicidal ideation as a target behavior. Staff acknowledged the target behaviors did not match and agreed suicidal ideation should have been included. The record also showed a pharmacy recommendation for gradual dose reduction of sertraline, but the provider declined it citing frequent suicidal ideation and grief, even though subsequent documentation repeatedly stated the resident denied suicidal thoughts, had no plan, and the EHR contained no additional documentation supporting suicidal ideation.
Failure to Report Abuse, Neglect, Misappropriation, and Accidents
Penalty
Summary
The facility failed to report allegations of abuse, neglect, misappropriation of resident property, and accidents to the State Agency within 24 hours, and failed to log the allegations and/or accidents in its reporting log for 6 of 8 residents reviewed. The facility policy titled, "Abuse, Neglect, Exploitation and Misappropriation Prevention Program," revised September 2024, stated the facility was to identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property and report allegations within required federal time frames. For Resident 61, who was moderately cognitively impaired, the grievance log showed an entry that the resident gave another resident a debit card and $800 was missing from the account. The facility’s Accident and Incident Log had no record of the incident, and the Administrator stated the incident should have been logged, thoroughly investigated, and reported to the State Agency and law enforcement, but none of that was done. For Resident 33, who was severely cognitively impaired, the grievance log documented that the resident said a blonde-haired girl was mean to her and grabbed her arm. The Accident and Incident Log had no record of the incident, and the Administrator stated it was not reported to the State Agency and should have been. For Resident 58, who was cognitively intact, the resident reported during a council meeting that they had fallen out of bed, hit their head, and had ear bleeding after lying on the floor for about half an hour before staff responded to the call light. A CNA confirmed the call light had been on for 35 minutes and that she found the resident on the floor with blood on the ear, but the facility did not conduct a resident interview, grievance form, or call light wait-time investigation, and the incident was not reported to the State Agency. For Resident 60, who was cognitively intact, the resident reported that staff told them to have a bowel movement in bed despite stating they could stand and needed help to the bathroom; the resident said the DNS was told and said she would handle it, but the allegation was not reported to the State Agency. For Resident 20, who was cognitively intact, the resident reported a fall in the shower room and later described a prior fall earlier in the year that dislocated the right shoulder and required hospital transfer. A progress note documented the shower-room fall, severe pain, resistance to the right arm, and EMS transport to the hospital, but the incident was not entered in the Accident and Incident Log and was not reported to the State Agency. For Resident 63, who was cognitively intact, the resident reported that $375 stored in a locking bedside drawer was missing after previously receiving and cashing a check from the father’s estate. Staff acknowledged being told about the missing money, but the Administrator was not notified, no missing property report was initiated, the incident was not logged, and the alleged misappropriation was not reported to the State Agency.
Incomplete investigations of abuse, neglect, and misappropriation allegations
Penalty
Summary
The facility failed to conduct thorough investigations for 6 of 7 sampled residents reviewed for incident investigations: Resident 45, Resident 2, Resident 58, Resident 60, Resident 61, and Resident 63. The report states the facility’s policy required abuse, neglect, exploitation, misappropriation, and injuries of unknown origin to be thoroughly investigated, including review of documentation and evidence, review of the resident’s medical record, observation of the alleged victim, interviews with the resident, witnesses, staff on all shifts, and other relevant persons, with complete documentation of findings. The facility’s own staff described expectations for reporting, suspending involved staff, interviewing residents and witnesses, involving the IDT, and updating care plans, but those steps were not consistently completed. For Resident 45, who was cognitively intact, the resident reported that Staff F, the Social Services Director, was in the shower room during a shower and sprayed the resident with the shower nozzle without permission. The resident said they did not want Staff F there. The facility’s investigation included some statements and records, but the report states the incident was not logged in the accident and incident log, the care plan was not updated, and the investigation did not include interviews with other residents or all relevant staff. Staff B and Staff A both acknowledged that additional interviews should have been completed and that Staff F should not have been in the shower room if the resident did not allow it. For Resident 63, who was cognitively intact, the resident reported that $375 was missing from a locked bedside drawer after previously receiving money from an estate. The resident said they notified staff, but there was no follow-up for eight days. Staff Q acknowledged the missing money but did not notify the Administrator, Staff F said a missing property report should have been initiated but was not, and the incident was not logged in the July incident log. Staff B stated the allegation had not been investigated and she was unaware of it. For Resident 61, who was moderately cognitively impaired, the grievance log documented that the resident reported giving another resident a debit card and that $800 was missing from the account, but there was no corresponding incident log entry. Staff A acknowledged the incident should have been logged, thoroughly investigated, and reported, but none of that was done. For Resident 58, who was cognitively intact, the resident reported falling out of bed and lying on the floor for about 30 minutes before staff responded to the call light, with bleeding from the ear. Staff X confirmed the call light had been on for 35 minutes and that she found the resident on the floor with blood on the ear, but the administrator stated no resident interview, grievance form, call light wait-time investigation, or state report had been completed. For Resident 2, who was cognitively intact, the resident reported rough handling during brief care by an unnamed CNA, with Staff Y present. The administrator confirmed that Staff Y was not interviewed, the unnamed CNA was not interviewed, and no other staff were interviewed; no additional resident interview documentation was provided. For Resident 60, who was cognitively intact, the resident reported being told by Staff W, a CNA, to have a bowel movement in bed despite stating they could stand and needed help to the bathroom. The social services note did not document that the resident was asked about that specific allegation, and the administrator stated the concern should have been narrowed to the specific problem; no additional resident interview documentation was provided.
Failure to Provide Written Transfer Notice
Penalty
Summary
The facility failed to provide written notice of transfer at the time of hospital transfer for 3 of 3 sampled residents reviewed for hospitalization. Resident 10 was admitted to the facility on [DATE], and the EHR and MDS showed hospitalizations on 06/10/2025 with readmission to the facility on [DATE] and again on 06/19/2025 with readmission on [DATE]; there was no documentation showing that a written notice detailing the transfer was provided to the resident. Resident 63 was admitted to the facility on [DATE], and the discharge MDS showed hospitalization with return anticipated on 07/07/2025 and readmission to the facility on [DATE]. Resident 68 was admitted to the facility on [DATE], and the discharge MDS showed discharge return anticipated on 05/30/2025. For both residents, there was no documentation showing that a written notice detailing the transfer was provided. During interview, the Social Services Director stated a WA Nursing Home Transfer or Discharge Notice/Notice of Voluntary Transfer (Bed Hold) form was completed electronically, but residents were not provided a copy of the transfer notice. The Administrator stated the expectation was that residents were provided a written copy of the transfer and bed hold in a language they understood at the time of transfer or within 24 hours.
Failure to Provide Written Bed Hold Notices
Penalty
Summary
The facility failed to provide a written bed hold notice at the time of transfer to the hospital for 3 of 3 sampled residents reviewed for hospitalization. Resident 10 had hospitalizations on 06/10/2025 and 06/19/2025 with readmission to the facility after each stay, but there was no documentation showing that a bed hold notice was provided. Resident 63 was hospitalized with return anticipated on 07/07/2025 and later readmitted, and there was no documentation showing that a bed hold notice was provided. Resident 68 had a discharge with return anticipated on 05/30/2025, and there was no documentation showing that a bed hold notice was provided. During interview, the Social Services Director stated that a WA Nursing Home Transfer or Discharge Notice/Notice of Voluntary Transfer (Bed Hold) was completed electronically, but residents were not provided a copy of the bed hold, and the Administrator stated the expectation was that residents received a written copy of the transfer and bed hold in a language they understood at the time of transfer or within 24 hours.
Inaccurate MDS Assessments for Restorative Services, Diagnoses, and Mobility
Penalty
Summary
The facility failed to accurately assess 4 of 18 residents on their MDS assessments, including inaccurate coding related to restorative services, active diagnoses, and mobility status. For one resident, quarterly MDSs showed restorative walking and active range of motion programs were coded during assessment periods, but the EHR did not show the restorative programs were periodically evaluated as required; the most recent restorative evaluation was on 11/04/2024, and the MDS Director acknowledged the programs should not have been coded on those assessments. For another resident, sertraline was started for depression and the psychotropic consent identified depression as the reason for the medication, yet three MDSs showed no psychiatric diagnoses while the resident was receiving an antidepressant. A third resident had quarterly MDSs that identified obstructive uropathy and an indwelling urinary catheter, but the record showed a history of prostate cancer, prostatectomy, radiation, urethral stricture, bladder neck contracture, and a long-term preference to keep the Foley catheter in place; the MDS Director confirmed obstructive uropathy was not an active diagnosis and the MDSs needed correction. For the fourth resident, the quarterly MDS assessed maximum assistance with sit-to-stand, but the resident said they had not stood in almost two years, staff reported they had not seen the resident get out of bed, and the MDS Director stated the mobility coding was not accurate and could not provide the documentation used to complete the assessment.
Incomplete PASRR screenings for residents with mental health diagnoses
Penalty
Summary
PASARR Level 1 screenings were inaccurate or incomplete for 4 of 7 residents reviewed. Resident 3 had a diagnosis of depression and was prescribed sertraline for depression, but the Level 1 PASRR dated 02/21/2024 showed no serious mental illness boxes selected, and no other Level 1 PASRR was found in the EHR. During interview, the Social Services Director reviewed the form and stated there were no serious mental illnesses selected and no Level 2 PASRR was required, but also acknowledged the PASRR should have been updated because of the depression diagnosis and sertraline order. Resident 22 had diagnoses including depression, anxiety, and bipolar disorder, but the Level 1 PASRR dated 09/22/2024 was completed as an exemption for hospital discharge with no Level II evaluation indicated at that time, and no other Level 1 PASRR was completed despite the resident remaining in the facility for almost one year. Resident 53 had major depressive disorder and a Level 1 PASRR dated 03/18/2025 that was also marked as an exemption, with no additional Level 1 PASRR completed after the initial 30 days. Resident 61 had diagnoses of anxiety, depression, and unspecified disorder of adult personality and behavior; two Level 1 PASRRs dated 07/24/2024 and 07/30/2024 selected mood disorders and anxiety disorders, but did not select personality disorders, and the Social Services Director acknowledged the PASRR should have been redone to include all diagnoses.
Care Plans Were Inaccurate, Incomplete, and Not Kept Current
Penalty
Summary
The facility failed to ensure care plans were reviewed, revised, and accurately reflected residents’ care needs for 7 of 18 sampled residents. The report identified that the comprehensive care plan was not kept current within 7 days of assessment and was not consistently prepared, reviewed, and revised by a team of health professionals, as shown by multiple resident records, observations, and staff interviews. For Resident 3, the pressure ulcer care plan remained inaccurate after the wound vac was discontinued and the left heel wound progressed from an unstageable ulcer to a full thickness stage 3 pressure ulcer. The resident’s ADL care plan also failed to identify that the resident was edentulous and had only upper dentures, and the oral care section was left incomplete. In addition, the antidepressant care plan listed target behaviors such as crying, isolation, and negative talk, while the TAR identified different behaviors being monitored for sertraline use, and staff acknowledged the mismatch. Other residents’ care plans were also incomplete or inconsistent. Resident 63’s dental care plan did not include the irregular white patch in the throat, the possible biopsy, teeth grinding, or the recommendation for a night guard. Resident 61 had conflicting restorative nursing goals in different care plans. Resident 31’s catheter care plan lacked the diagnosis and justification for the indwelling catheter, did not include pressure offloading boots, and the nutrition plan was not followed because a water pitcher was present despite a fluid restriction. Resident 1’s care plan incorrectly stated the resident was their own health care decision maker despite severe cognitive impairment. Resident 42’s care plan did not include mobility bars, and Resident 47’s pain care plan did not include the EHR banner stating that a 0/10 pain score was not accurate for that resident.
Failure to follow medication orders, oxygen therapy, and required monitoring
Penalty
Summary
The facility failed to ensure services met professional standards of practice for multiple residents by not obtaining required vital signs, not following medication hold parameters, not notifying providers when medications were held, not administering oxygen at the ordered rate, not clarifying incomplete or conflicting orders, and signing for tasks that were not completed. The report identified deficiencies involving Residents 45, 41, 3, 31, 63, 47, and 22, based on observation, interview, and record review. Resident 45, who was cognitively intact and receiving oxygen therapy, was observed wearing a nasal cannula with oxygen tubing dated 05/25/2025 and the concentrator set at 1 lpm. The EHR showed an order for oxygen tubing to be changed, labeled, and dated every Sunday night, and for oxygen to be set at 2 lpm via NC as needed for shortness of breath and exertion. The Oxygen TAR documented tubing changes on 07/06/2025, 07/13/2025, and 07/20/2025, but staff could not identify who was responsible for the task, and the DON stated nursing staff should not have signed for things they did not complete. Resident 41, who was cognitively intact, had a metoprolol order to be held for SBP less than 120 and HR less than 50, yet the MAR showed the medication was given on multiple dates when SBP was below 120. Resident 41 also had scheduled morphine and oxycodone with ordered non-pharmacological interventions, but the TAR showed no documentation that those interventions were attempted. Resident 3 had an order for continuous oxygen at 2 lpm via NC, but was observed receiving oxygen at 3 lpm and later staff stated the concentrator was set at 3.5 liters. The TAR documented oxygen as being administered at 2 lpm, and staff acknowledged the documentation was erroneous. Resident 3 also had an order for a low air loss mattress, but was observed on a standard pressure reduction mattress instead; staff confirmed the ordered mattress was not in place and that nurses had signed that they checked its placement and function even though it was not present. Resident 31 had an order for catheter care every shift and for the catheter to be securely anchored, but the resident reported no securement device was present and staff confirmed the catheter strap was not in place even though the TAR had been signed as completed. Resident 31 also had orders for compression stockings and pressure offloading boots, yet observations showed the boots and stockings were not in use on multiple occasions while the TAR was signed as if the tasks had been completed. Resident 63 had carvedilol and amlodipine orders with hold parameters based on blood pressure and pulse, but the MAR showed both medications were administered on multiple occasions when the documented blood pressure values were below the ordered limits. Staff later confirmed the medications should have been held. Resident 47, who had COPD and could make needs known, reported not receiving Flonase even though it appeared on the medication list; staff checked the cart, found no Flonase available, and then verified that the MAR had been signed as administered even though it had not been given. Resident 22 had a scheduled lidocaine patch order without a location listed, and also had scheduled oxycodone with hold parameters. The resident’s blood pressures, heart rates, and respirations were infrequently obtained, with staff and the resident stating vitals were rarely taken; staff also stated the lidocaine order should have included a location and that vitals should have been obtained before pain medication was given.
Multiple Care Orders Not Followed or Documented
Penalty
Summary
The facility failed to provide care according to orders and assessed needs for multiple residents involving cognitive services, laboratory testing, bowel management, fluid restriction monitoring, repositioning assistance, dialysis communication, podiatry services, and PICC line care. The report identified deficiencies for 8 of 18 sampled residents, including residents with cognitive impairment, pain medication use, bowel care orders, fluid restriction orders, dialysis treatment, and invasive line care needs. For cognitive services, a resident with anxiety, depression, and behavioral concerns had provider documentation referencing vascular dementia and later unspecified cognitive disorder, with worsening confusion, limited insight, and inability to recall the psychiatry provider. The psychiatry provider recommended a SLUMS screening to better assess cognition, but the facility’s records did not show a cognitive disorder diagnosis in the electronic system or behavior monitoring tied to that diagnosis. Staff interviewed stated they were not aware of any implementation related to the provider’s cognitive findings. For laboratory testing, one resident reported ordered liver function testing had not been completed despite two ordered lab dates and unsuccessful attempts by lab staff. For bowel management, residents with bowel protocols and opioid or constipation-related medications had documented periods of three or more days without a bowel movement, yet the records showed no progress notes for bowel protocol activation and no as-needed bowel medications given when ordered. Another resident with a fluid restriction had nursing and dietary fluid amounts documented separately, but the facility did not reconcile the totals, and the reviewed days showed the restriction was exceeded on most days or had incomplete documentation. A resident who required assistance repositioning reported staff only turned them when changing briefs and described delayed response to a call light, with staff not returning for more than an hour after the resident requested help.
Failure to Provide Assessed ROM and Restorative Services
Penalty
Summary
The facility failed to provide appropriate care to maintain and/or improve range of motion and mobility for four sampled residents with limited ROM. The deficiency involved Resident 61, Resident 47, Resident 2, and Resident 53, and surveyors found that restorative and therapy services were not consistently provided as assessed or ordered. The report states these failures placed residents at risk for decline in functional abilities, discomfort, and diminished quality of life. Resident 61 had a history of right hand problems, including prior OT services, a right index finger amputation, and later documentation of right hand contracture, stiffness, pain, and finger locking. The resident reported that the right-hand fingers had become more contracted and said repeated requests to see the Medical Director were denied. Records showed OT referrals, x-rays, and later OT services with splinting, but there was a prolonged gap between the resident’s complaints and the start of the later OT services. After OT discharge, the mobility care plan documented ROM services for the upper extremities and lower extremities, but it did not document the right hand contracture or the splint, and staff interviews confirmed the hand splint was lost and not replaced. Staff also acknowledged the ROM equipment in use would not range the fingers. For Resident 47, the restorative evaluation required upper extremity ROM six to seven days per week, lower extremity ROM six days per week, and ambulation six days per week. The June 2025 restorative record showed ambulation was offered 12 times and ROM 19 times instead of the minimum 24 times assessed, and the July 2025 record showed ambulation offered seven of 18 times and ROM 13 of 18 times. Resident 2’s restorative evaluation called for active ROM up to six days weekly, but the June and July restorative records showed the program was offered fewer times than assessed. Resident 53’s restorative evaluation and care plan called for ambulation and lower extremity ROM up to six times weekly, yet the June and July restorative records showed the programs were offered fewer times than scheduled. Staff interviews stated the restorative programs were divided into two groups and scheduled only three times per week because of staff convenience, availability, dining room duty, and lack of time, despite the assessed frequencies being higher.
Incomplete fall investigations and missing documentation
Penalty
Summary
The facility failed to ensure that fall investigations were thoroughly completed for three residents, including review of contributing factors, resident interviews when appropriate, and documentation of root cause. The report states that the facility did not adequately investigate potential accident hazards and falls for Resident 61, Resident 58, and Resident 20, and that the incomplete investigations were documented in fall packets and related records. For Resident 61, who was admitted with weakness and was moderately cognitively impaired, the record showed smoking-related concerns and prior Smoking Evaluation forms that were inconsistent with the chart. After an unwitnessed fall in the smoking area, the fall packet did not include a complete scene drawing, root cause, immediate measures, or documentation about the resident’s blood thinner status and provider response. The packet also did not address whether the resident’s hand condition contributed to the fall, and the most recent Smoking Evaluation was not referenced. A later fall packet for the same resident was also incomplete, with blank sections for why the fall happened, contributing factors, and the Post Fall Analysis Tool. Staff interviewed acknowledged the investigations were not thorough and that an updated Smoking Evaluation should have been completed after the smoking-related fall. For Resident 58, who was cognitively intact, the resident reported falling out of bed and waiting on the call light for about half an hour before staff responded, with head injury and bleeding from the ear. The Accident and Incident Log showed the fall, but the fall packet lacked immediate measures, names of staff involved, a resident explanation for the fall, a scene drawing, and a completed 5 Whys Worksheet. The packet also did not document whether the resident’s blood thinner use was addressed with the provider or whether emergency transfer was considered. Staff stated that a resident interview had not been conducted and that the fall report could not be produced. For Resident 20, who was cognitively intact, the resident described slipping on the shower room floor, being unable to reach the call light cord, and using a wheelchair to push the door open because it was not fully shut. The resident also reported a prior fall earlier in the year that resulted in a dislocated shoulder and hospital transfer. The facility’s Accident and Incident Log did not contain an entry for this fall with injury and hospitalization. The fall packet lacked a resident interview, root cause documentation, a 5 Whys Worksheet, and evidence of interdisciplinary review or updated care planning. Staff confirmed that the resident should have been interviewed and that the fall should have been logged and fully investigated.
Insufficient nursing staff and delayed response to resident care needs
Penalty
Summary
The facility failed to ensure sufficient qualified nursing staff were available to provide care and services, including assistance with activities of daily living, restorative services, and staff documentation. Multiple residents reported long delays in staff response to call lights and requests for assistance, with several stating they waited 30 minutes to 3 hours for nurses or CNAs to respond. Residents also reported being left on the toilet for extended periods, sitting in feces while waiting for incontinence care, and having call lights turned off by staff who said they would return but did not come back for long periods. Residents described repeated problems across shifts, especially nights and evenings. One resident said staff were often rushed and forgot basic needs such as bringing water. Another resident reported medications scheduled for 8:00 PM were often not given until after midnight. A resident also said they were unable to get up and go to the dining room because there were not enough staff to help them out of bed, and said this made them feel "not important." Several residents stated that some CNAs told them they were not their CNA or not their resident and left without addressing the request, resulting in additional waits of 30 to 45 minutes. Staff interviews supported the residents’ reports of staffing limitations. CNAs stated delays occurred when staff were not on the floor or were busy. Restorative staff explained that their time was reduced by dining room duty, weekly weights, and other assigned tasks such as cleaning wheelchair cushions, checking refrigerators, and checking Roho cushions. Staff stated these extra duties took 2 to 3 hours per shift away from restorative services, and that this prevented them from providing residents’ restorative nursing programs six times per week. Administration acknowledged that call lights should be answered as soon as possible and stated that turning off a resident’s call light and not returning for an hour or more was not acceptable.
Missing Annual CNA Performance Reviews
Penalty
Summary
The facility failed to complete annual performance evaluation reviews for 3 of 3 sampled certified nursing assistants (CNAs), identified in the report as Staff W, Staff HH, and Staff JJ. Staff W was hired on 09/26/2016 and had a performance review completed on 04/17/2024. Staff HH was hired on 03/28/2023 and had a last performance review completed on 04/17/2024. Staff JJ was hired on 08/20/2021 and had a last performance review completed on 04/17/2024. During an interview on 07/28/2025 at 12:26 PM, the Administrator stated that all staff records provided were full and complete and that staff were reviewed annually, but when shown the last annual reviews for the listed staff, acknowledged that all staff should have had yearly performance reviews completed and documented.
Incomplete GDR Documentation for Psychotropic Medications
Penalty
Summary
The facility failed to ensure monthly pharmacist drug regimen review recommendations for gradual dose reductions (GDRs) were answered with accurate resident information and/or resident-specific rationales for three residents reviewed. The deficiency involved psychotropic medication GDR recommendations that were declined by the provider, but the documentation supporting the declinations was incomplete or not supported by the resident record. For one resident with diagnoses including depression, anxiety, and bipolar disorder, the provider declined a GDR because it was documented as clinically contraindicated due to weekly panic attacks and difficulty adjusting to the facility with repeated desire to return home. However, the electronic health record contained no documentation supporting weekly panic attacks, and no behavior monitors were in place for psychotropic medications to show they were being used to reduce panic attacks. During interview, the resident stated panic attacks occurred only occasionally, and staff later confirmed they were not aware of the panic attacks and they were not in the care plan. For a second resident with anxiety, depression, and an unspecified personality/behavior disorder, the GDR form dated 05/15/2025 showed the provider declined the GDR, but the section requiring a CMS patient-specific rationale was left blank. For a third resident with anxiety, bipolar disorder, neuropathy, and use of multiple psychotropic medications, the provider declined two separate pharmacist GDR recommendations and marked them clinically contraindicated, but provided no patient-specific rationale documentation for either declination. The Director of Nursing reviewed the records and confirmed the lack of resident-specific rationale documentation.
Unlabeled and Unsecured Medications
Penalty
Summary
Medications and biologicals were not consistently labeled or stored in accordance with accepted professional principles. In the medication room, a multiuse vial of Tuberculin PPD had an open date of 06/23/2025, another had an open date of 06/25/2025, and a third vial was opened but not dated. The package insert indicated the vials were to be dated when opened and discarded after 30 days. The medication technician confirmed the two dated vials were expired, the undated vial was not properly labeled, and all three needed to be discarded. On the B Hall medication cart, a Spiriva Respimat inhaler for one resident was opened and undated, and a lispro insulin pen for another resident was opened and undated. The package inserts indicated both products were to be dated when opened and discarded after their specified timeframes. In addition, an A Hall treatment cart was observed unlocked and unattended with a bottom drawer pulled out and containing bio freeze cream, germicidal wipes, anti-fungal powder, and saline enemas, while the contents of the other drawers were unknown. Staff later stated carts were expected to be secured when left unattended. Two bottles of Nystatin powder were also observed on a resident’s bedside table, and the LPN and DON confirmed the medication should not have been left in the room or at bedside.
Kitchen sanitation and food preparation deficiencies
Penalty
Summary
The facility failed to prepare and serve food under sanitary conditions during kitchen observations and record review. On 07/16/2025, surveyors observed 10 loaves of bread that were both opened and unopened but undated, and a shop fan with visible debris blowing toward freshly baked uncovered rolls. On 07/18/2025, a non-staff member was observed sitting in the kitchen on a cellphone without a hair restraint, and the Dietary Manager was also observed in the kitchen without a hair restraint. A Dietary Aide was observed assisting with dishes while wearing a long unrestrained beard. Surveyors also observed food preparation that did not follow the facility recipe. A Dietary Assistant Director placed multiple slices of pork into a Black and Decker blender, added hot water from the coffee machine, and later added a scoop of powder and additional unmeasured water before blending the mixture again and placing it in the warmer. The Dietary Assistant Director stated the powder was thickener and said the facility had a recipe for puree meals, noting the industrial blender had been broken for over a week and a smaller blender was being used. The recipe reviewed called for 3 oz of meat, 3/4 teaspoon of food thickener, and 2 tablespoons of water or stock. The Dietary Manager and Administrator both stated that bread should have been dated, foods should have been covered after preparation, hair restraints were required in the kitchen, and dietary staff were expected to follow recipes.
Incomplete Antibiotic Stewardship Tracking and Monitoring
Penalty
Summary
The facility failed to ensure its antibiotic stewardship program tracked and monitored infections through complete monthly antibiotic line lists, reevaluation of residents for continued antibiotic use, and follow-up education regarding proper urine culture containers for April, May, and June 2025. Staff B, the DON, stated the facility used McGeer's criteria for screening residents for antibiotic use, but the April 2025 antibiotic line list did not include a column showing whether residents met criteria, and no line lists were provided for May or June 2025. For Resident 49, the April 2025 line list showed dysuria beginning on 03/30/2025 and antibiotics starting on 04/02/2025. Review of the resident's records showed the only symptom documented was painful urination, the urinalysis was negative, and the facility used conflicting screening forms referencing both Loeb's criteria and McGeer's criteria. The record did not show reevaluation after the negative urine results, and Staff B later stated the antibiotic should have been discussed with the provider for discontinuation because the symptoms had resolved and the use did not meet McGeer's criteria. For Resident 4, the April 2025 line list showed a positive UA and symptoms including painful urination and abdominal pain, but the urine culture was not completed because of improper specimen submittal. The record showed ciprofloxacin was started, and Staff B stated someone should have followed up with the provider when the culture was not performed. Staff B also stated staff should have received more education or reeducation regarding proper specimen containers, and confirmed there were no antibiotic line lists for May or June 2025.
No Designated IP and Missing Infection Surveillance Documentation
Penalty
Summary
The facility failed to ensure it had a designated infection preventionist (IP) responsible for the infection prevention and control program. During the entrance conference, Staff A, the Administrator, provided one staff name for the IP role, then later emailed another staff name as the IP. In interviews, Staff K, an LPN, said infection control was being handled by the unit managers. Staff B, the DON, said they were the DNS and had infection control training, and also stated there had been an IP who traveled to all the facilities, but after the change in ownership all the nurses had been helping with infection control. Staff E, a regional RN, said Staff B was the designated IP because of certification and that the facility had lost the shared IP after ownership changed and was trying to recruit a replacement. Record review showed infection control surveillance documentation was provided only for January through April 2025. Staff A stated the facility had transitioned to a new management group and was using an infection control surveillance process integrated into the electronic health system. When asked for May and June 2025 antibiotic line listing records, Staff A said only records from January through April were available and reflected the work of the traveling IP nurse before the transition, and no additional facility-wide antibiotic line listing or infection surveillance reports were provided. Staff B confirmed that no infection control summary or organism map was available for May or June 2025, and said the facility was inputting information into the electronic health system, could print and analyze reports, and could create a map of organisms, but had not done so for those months.
Failure to Ensure COVID-19 Vaccination Offer, Documentation, and Administration
Penalty
Summary
The facility failed to ensure residents received COVID-19 vaccinations for 3 of 6 residents reviewed for vaccination status: Residents 4, 22, and 39. During review of the facility’s infection surveillance documentation from a February 2025 COVID-19 outbreak, 38 residents tested positive for COVID-19, and only 1 of those 38 residents was listed as up to date on vaccination status. The report also noted that the facility’s expectation was to offer the COVID-19 vaccine on admission and in the early fall, with documentation of consent or decline in the resident’s chart. Resident 4 had a prior COVID-19 vaccine documented in the Washington State Immunization Information System, but the facility had no record of administering a COVID-19 vaccine during the admission, and the resident later requested the vaccine. Resident 22 tested positive for COVID-19 and had only received one COVID-19 vaccine while at the facility, which occurred after the positive test. Resident 39 had a COVID-19 vaccine record showing one dose in August 2024, a consent for the vaccine in April 2025, and a progress note indicating eligibility and consent, but the resident was not given the vaccine after consenting and later tested positive for COVID-19.
Inoperable freezer and missing thermometer
Penalty
Summary
The facility failed to ensure kitchen equipment was maintained in a safe, functional, and working condition for 1 of 1 sampled freezer reviewed in the kitchen. During the initial tour on 07/16/2025, no thermometer was observed in the freezer. The freezer temperature log showed entries for 07/16/2025 and 07/17/2025 with documented temperatures of zero degrees, but the Dietary Manager stated they could not locate a thermometer for the freezer and did not know which staff member documented those temperatures. The Dietary Manager also stated staff were expected to take freezer temperatures every morning and afternoon and document them accurately. Later that day, Corporate Maintenance reported the walk-in freezer temperature was between 15-17 degrees and cleaned the coils while waiting to see if the temperature would drop. On 07/17/2025, the freezer was observed empty of all contents, and the Administrator stated the freezer was inoperable and the facility was waiting for an outside vendor to repair it.
Failure to Document Advance Directive Education and Choices
Penalty
Summary
The facility failed to ensure residents were informed and provided written information about their right to formulate an advance directive for 2 of 4 residents reviewed. One resident was admitted with a quarterly MDS showing cognitive intactness, and the resident’s AD care plan documented that the resident did not have an AD and declined to formulate one. However, the EHR contained no documentation that the resident was offered the opportunity to formulate an AD or that the resident accepted or declined to do so. The Social Services Director stated the facility offers ADs at care conferences but was unable to locate documentation supporting that the resident had been offered or had accepted or declined to formulate an AD. A second resident was admitted with a 5-day MDS documenting severe cognitive impairment. The resident’s AD care plan stated the resident did not have an AD formulated, was his own health care decision maker, and that the resident’s POA should be activated if warranted by MD evaluation. Review of the EHR found no POA document for the resident. The Social Services Director stated the resident’s son and wife did not want to formulate an AD at the time, but the documentation showing the family had been offered education regarding formulating an AD could not be located, and the care plan entry indicating a POA was documented in error.
Failure to Provide Privacy During Shower Care
Penalty
Summary
The facility failed to provide personal privacy during personal care for 1 of 1 sampled resident reviewed for privacy. Resident 45 was admitted to the facility and was documented on the Quarterly MDS dated 05/01/2025 as cognitively intact. On 07/16/2025, Resident 45 reported that Staff F, the Social Services Director, Staff Z, the Unit Manager, and an unidentified CNA took them to the shower room for a shower, and that Staff F used the shower hose with the spray nozzle to spray them with hard force while telling the CNA, "This is how you shower a resident." Resident 45 later told Staff N, a Certified Occupational Therapy Assistant, about the incident and said they did not want Staff N to say anything because they did not want retaliation. During interviews, Resident 45 stated they did not want Staff F in the shower room. Staff F confirmed they were a Certified Behavioral Health Tech and did not hold CNA, LPN, or RN credentials. Staff F stated Resident 45 had agreed to shower and that Staff AA and Staff BB, CNAs, assisted the resident to the shower room, after which Staff BB left and Staff F, Staff Z, and Staff AA remained in the room while the resident showered. Staff F acknowledged being present in the shower room and described the resident washing herself with multiple washcloths. Staff B and Staff A later stated Staff F should only have been in the shower room if Resident 45 allowed it, and both acknowledged Staff F should not have been in the shower room because Resident 45 did not want Staff F there.
Failure to Maintain Ordered Pressure Redistribution and Weekly Wound Monitoring
Penalty
Summary
The facility failed to ensure pressure injuries were consistently assessed and that ordered pressure redistribution equipment was in place and functional for a resident with an unstageable left heel pressure injury. The resident was cognitively intact, at risk for pressure injury development, and had an unstageable pressure injury that was not present on admission. Orders in the electronic health record included treatment for the left heel wound, a heel protector with placement checks each shift, mupirocin ointment with a bordered gauze dressing, and a low air loss mattress for pressure redistribution. Surveyors observed the resident in bed on multiple occasions lying on a standard pressure reduction mattress rather than the ordered low air loss mattress, and the Unit Manager confirmed the low air loss mattress was not in place. The care plan directed staff to assess, record, and monitor the wound weekly, including measurements and wound characteristics, but the record showed no wound assessments, measurements, or monitoring documented for five consecutive weeks. A wound consult documented that the left heel pressure injury had progressed from unstageable to stage III, and the Unit Manager acknowledged the expectation that pressure injuries be assessed weekly with wound description and measurements.
Indwelling Catheter Lacked Clinical Justification and Securement
Penalty
Summary
The facility failed to ensure appropriate care for a resident with an indwelling urinary catheter by not documenting a valid clinical justification for continued catheter use, not assessing the ongoing need for removal in a timely manner, and not providing catheter care in accordance with professional standards of practice. The resident was admitted with a diagnosis of obstructive uropathy and was cognitively intact on the quarterly MDS. The care plan for altered urinary elimination related to the indwelling catheter, revised in April 2025, did not include a supporting diagnosis or clinical justification for the catheter. The resident stated that the catheter was in place so he would not sit in wet diapers and reported that a wound that had been debrided had healed. The resident also stated that the catheter was not secured with a leg strap, and observation confirmed there was no securement device in place. A unit manager followed the catheter to the insertion site and also stated that no securement device was present. A prior urology consultation documented a history of prostate cancer, prostatectomy, radiation complicated by bulbar urethral stricture and bladder neck contracture, and noted the resident had requested to keep the Foley catheter in place because it helped avoid wetness around healing inguinal and scrotal wounds. When asked about the current diagnosis or wounds, staff stated there was no diagnosis of obstructive uropathy or ongoing inguinal/scrotal wounds and that there was no clinical justification for the catheter.
Pain management not consistently assessed, documented, or monitored
Penalty
Summary
The facility failed to ensure pain was appropriately addressed, monitored, and recorded for two residents receiving pain management services. For one resident with chronic pain, the quarterly MDS showed the resident was cognitively intact and receiving restorative nursing programs, including active range of motion and walking. The MAR showed scheduled acetaminophen three times daily and scheduled oxycodone every six hours, yet multiple pain scores documented with those medications were recorded as 0/10 even though the EHR banner stated, "Record ACCURATE pain scale. 0/10 is not accurate for this resident." The resident’s pain care plan did not include that information. The same resident’s restorative nursing log showed repeated refusals of restorative services over several days, with notes indicating the refusals were due to pain. A wound consult on the coccyx identified a stage 3 pressure ulcer, and a pain evaluation documented chronic stabbing and aching right hip pain and sacral ulcer pain, with pain rated 7/10 during the assessment and ranging from 5/10 to 10/10. During interviews, the resident reported significant ongoing pain and said the facility was not doing enough to address it. Staff interviews showed the LPN, restorative aide, unit manager, and DNS were not aware of the refusals being related to pain or were not notified of the refusals, and the DNS stated staff should have documented the resident’s reported pain and completed a change of condition form with provider notification. For the second resident, the record showed an order for hydromorphone five times daily for severe pain and a separate order for staff to provide NPIs to reduce pain and document effectiveness as needed. The EHR contained no side effect monitoring order and no documentation of NPIs for the hydromorphone. During interview, the DNS stated she did not see side effect monitoring in place, expected it to be present, and confirmed staff were not documenting NPIs. She also stated staff should have been trying NPIs and documenting them, and that the order should have been a standard order rather than as needed.
Failure to Honor Resident Food Preferences and Allergies
Penalty
Summary
The facility failed to provide food in accordance with resident preferences for Resident 20, who was able to make needs known. During lunch observation, Resident 20’s tray card listed allergies/dislikes of cheese, dairy, pork, and processed meats, yet the resident was served a salad, a baked potato with sour cream, cheese, and green onions, chocolate pudding with whipped topping, and beef. During interview, the resident stated they no longer made a big deal about it because staff had given them things they had said they did not like over and over. Staff D, the Dietetic Technician, stated the sour cream, cheese, and pudding with whipped topping were not appropriate based on the resident’s allergies/preferences. Staff C, the Dietary Manager, stated the resident’s preferences should have been honored, and Staff A, the Administrator, stated the expectation was that staff followed resident preferences and allergies.
Therapeutic Diets Not Followed for Residents on CCHO Diets
Penalty
Summary
The facility failed to ensure therapeutic diets were provided as ordered by the physician for 2 of 10 residents reviewed for dining, Residents 1 and 47. The deficiency involved the lunch meal service on 07/18/2025, when the primary lunch meal consisted of bratwurst, oven browned potatoes, sauerkraut, lemon chiffon pie, and a dinner roll, while the Consistent Carbohydrate Diet menu indicated residents on that diet should receive wheat bread instead of the dinner roll. Staff OO, the Cook, was observed plating the meal with assistance from Staff C, the Dietary Manager, during the tray line from 12:06 PM to 1:30 PM. Resident 1 was admitted with diabetes and the 5-Day MDS dated 06/30/2025 documented severe cognitive impairment. During the lunch meal service at 12:06 PM, Staff OO prepared Resident 1's tray and provided the primary lunch meal, and the tray card showed the resident was on a CCHO diet and should have received wheat bread. Resident 47 was admitted with diabetes, and during the lunch meal service at 12:10 PM, Staff OO prepared Resident 47's tray and provided the primary lunch meal; the tray card also showed a CCHO diet with wheat bread ordered. During interview at 12:20 PM, Staff C confirmed residents on the CCHO diet should have been provided wheat bread and stated it did not meet expectations that no wheat bread was prepped for the lunch meal.
Failure to Complete Comprehensive Skin Assessments and Documentation
Penalty
Summary
The facility failed to ensure comprehensive skin assessments were completed for three residents who required services meeting professional standards. For one resident with multiple chronic wounds on admission, there was no documentation of wound measurements or characteristics on weekly skin evaluations after the initial assessment, and no skin evaluations were completed following hospitalizations for cellulitis and skin tears. Staff interviews confirmed that nurses were expected to document wound location, measurements, characteristics, and notify providers of changes, but this was not consistently done. Another resident with skin conditions in the abdominal folds, groin, and under the breasts reported that prescribed treatments were not administered as ordered, and documentation lacked details about a coccyx wound and the characteristics of skin conditions. The DON was unaware of the coccyx wound and acknowledged possible incomplete documentation of care and treatment refusals. A third resident had a wound care order, but skin evaluations did not document the wound or its characteristics, and a new skin tear was not measured or described until the wound management company became involved. Staff interviews revealed confusion about proper documentation and incomplete use of skin evaluation forms.
Significant Medication Error Due to Unordered Aspirin Administration
Penalty
Summary
A facility failed to ensure that a resident was free from significant medication errors when an agency LPN administered multiple doses of 81mg chewable aspirin without a provider's order. The resident, who had a history of myocardial infarction and heart disease and was assessed as mildly cognitively impaired, began experiencing chest pain late in the evening. The LPN gave a total of 324mg of aspirin in 81mg increments every five minutes while simultaneously calling 911, despite the resident already having received their prescribed daily dose of 81mg aspirin that morning. There were no standing or emergency orders in place for additional aspirin administration for chest pain. The LPN stated that their agency training directed them to begin an aspirin protocol for chest pain, but acknowledged that no physician order was obtained prior to administering the medication. Facility leadership, including the Administrator and DON, confirmed that there was no facility protocol authorizing this action and that a physician should have been contacted before administering any additional medication. The incident was documented in the nursing progress notes and confirmed through staff interviews and record review.
Failure to Provide Required Equipment and Restorative Services for Mobility
Penalty
Summary
A resident with paraplegia, who was dependent on staff for transfers and required a Hoyer lift, was not provided with the necessary equipment to maintain or improve mobility. The resident had been requesting access to a standing frame for several months, but the device had been loaned to a sister facility and was not returned in a timely manner. Despite communication between nursing and therapy staff regarding the resident's need for the standing frame to assist with mobility, the equipment remained unavailable for an extended period. The resident expressed ongoing frustration about the lack of access to the standing frame, and observations confirmed that the device was not present or set up for use during multiple visits. Additionally, the resident's care plan did not include specific interventions, exercises, or therapy to maintain or improve mobility, nor did it reflect the resident's preference for a restorative program utilizing the standing frame. The lack of appropriate equipment and individualized care planning resulted in the resident not receiving restorative services necessary to maintain or improve range of motion and mobility.
Failure to Enforce Smoking Safety Policies and Interventions
Penalty
Summary
The facility failed to ensure that residents who smoked were properly assessed and that safety interventions were followed, as required by their own smoking policy. Two residents, both moderately cognitively impaired and with significant physical or cognitive limitations, were not managed according to their Smoking Evaluations. One resident, who required a smoking apron, was observed smoking without it, and another resident, who had been deemed not safe to smoke, was also observed smoking. Additionally, residents were not restricted to the designated smoking area, with several observed smoking along the sidewalks outside the designated structure. Observations revealed that residents were flicking ashes onto the ground and pocketing cigarette butts, and that cigarette smoke was drifting into rooms with open windows, affecting other residents. Staff interviews confirmed that required interventions based on Smoking Evaluations were not being followed, and that facility leadership was unaware of these lapses. The facility's policy required quarterly smoking evaluations and adherence to safety interventions, but these were not consistently implemented or monitored.
Failure to Secure Medications at Bedside Without Assessment
Penalty
Summary
A deficiency was identified when a resident, who was cognitively intact and had a history of gastric ulcers, type 2 diabetes, and anemia, was found to have a variety of pills stored in a garlic seasoning bottle inside a Kleenex box at their bedside. The resident stated they only wanted to take their weekly Mounjaro injection and did not want to take the other medications, which included omeprazole, a probiotic, a multivitamin, Vitamin D, and iron. The medication administration record confirmed these medications were prescribed, and the care plan documented the resident's refusal to take any medication other than Mounjaro. Despite the resident's refusal, there was no assessment found that allowed for medications to be left at the bedside, as required by facility policy and professional standards. Both the LPN Unit Manager and the DON confirmed that medications should not be left at the bedside unless an assessment had been completed. The lack of an assessment and the presence of unsecured medications at the resident's bedside constituted a failure to store medications appropriately, as required by regulation.
Failure to Maintain Mechanical Beds in Safe Working Condition
Penalty
Summary
The facility failed to maintain mechanical beds in a fully functional and safe condition for four out of four beds reviewed. One resident reported that their bed collapsed while they were sitting on the edge, resulting in a significant drop. Staff attempted to identify the issue at the time but were unable to resolve it, and the resident was moved to another bed. Maintenance was notified of the broken bed through the TELS system, and a part was ordered for repair. However, staff interviews revealed that other beds were also malfunctioning, including beds that would not raise or lower, beds with non-functioning remotes, and beds where the head section would not operate, requiring staff to physically support residents during transfers. Observations confirmed that several beds were not operating as intended, with issues such as motors making loud grinding noises and remotes being jammed. Staff reported that the bed frames were old and prone to frequent breakdowns, with two frames breaking in the previous week. Maintenance staff indicated that there was no routine audit of mechanical beds to ensure proper functioning, and communication about bed issues was inconsistent, with some staff using the TELS system and others only mentioning problems informally, leading to unresolved maintenance needs.
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 1,096 citations issued within 25 miles in the last 12 months — including the 1 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 Bremerton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Belmont Terrace | 1.9 mi | ★★★★★ | 22 | 0 |
| Bremerton Trails Post Acute | 2 mi | ★★★★★ | 55 | 0 |
| Washington Veteran Home-retsil | 2.6 mi | ★★★★★ | 19 | 0 |
| Life Care Center Of Port Orchard | 3.2 mi | ★★★★★ | 20 | 0 |
| Avamere Rehabilitation At Ridgemont | 3.2 mi | ★★★★★ | 16 | 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 July 2026) and official state health department websites.