Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 Regency At The Park during CMS and state inspections, most recent first.
Failure to maintain resident dignity during mealtime: a resident with stroke history and dementia had confidential health concerns discussed in front of other residents in the dining room, and two other residents with dementia were addressed with pet names such as "honey" and "sweetheart" by staff during dining room interactions. The DON stated staff were expected not to discuss medical information in the dining room or use nicknames unless resident preferences were known.
A resident with diabetes, HF, and glaucoma was found with unlabeled meds and eye drops left at the bedside, including tablets the resident said were to be taken later and did not know what they were. The resident’s record had no self-medication assessment or provider order for self-administration, even though staff said the meds were left with the resident at the resident’s request and the DON confirmed meds should be observed rather than left at bedside.
Failure to Provide Requested Medical Record Copies: A resident with intact cognition and diagnoses including diabetes, muscular dystrophy, heart disease, and kidney disease was unable to obtain a paper copy of requested lab results and other medical records. Staff offered only to let the resident view the records on a computer and suggested the resident write the results down, while the resident stated they wanted a copy to review on their own. The Administrator and DON said there had been miscommunication between the RCM and the resident.
Failure to develop vision-specific care plans for two residents. One resident with CHF, dementia, and severe visual impairment and another resident with stroke and impaired cognition were observed with water cups and a call light placed out of reach or outside their visual field. Staff did not position items within reach, and the EHR contained no care plans or documented interventions to guide staff on environmental safety or accessibility related to the residents’ vision deficits.
Failure to provide adaptive eating equipment for a resident with severe vision impairment. The resident had dementia, CHF, and visual disturbance, required ADL assistance and set-up for eating, and stated it was hard to use the plastic utensils provided. Staff observed the resident eating with hands, spilling food, and using a standard spoon and regular plate with no adaptive equipment. The RD, DOR, and DON confirmed there was no OT evaluation or active order for adaptive eating equipment.
Missing Post-Dialysis Assessments: A resident with kidney failure, heart disease, depression, and dementia required dialysis 3 times weekly, but the facility did not consistently document post-dialysis assessments and vitals. The record showed multiple missed post-dialysis vital sign entries, and staff reported that after dialysis they would get the resident in bed, provide a meal, and do a quick change, with vitals not always obtained if the nurse was busy. The RCM also stated dialysis communication forms were not always completed by the dialysis center.
A resident receiving hospice care had no integrated hospice care plan in the EHR. The resident had CHF, CKD, and moderately impaired cognition with ADL assistance needs, while the RCM said hospice plans were not integrated and was unsure of the process; the hospice contact and DON both stated the hospice plan should be fully incorporated into the facility care plan.
Failure to Follow EBP, Hand Hygiene, and PPE During Resident Care: Staff did not consistently follow EBP requirements for a resident with stroke-related impairment, a resident with kidney disease and DM, and a resident with kidney failure and heart disease. A RN performed wound care without a gown, did not perform hand hygiene before donning gloves, and used the same gloves throughout dressing removal, wound cleansing, medication application, and linen care. In separate observations, NAs provided high-contact care in EBP rooms wearing gloves only and no gowns, despite signage indicating gowns were required.
Two residents experienced avoidable falls during mechanical lift transfers due to the facility's failure to follow care plan interventions and provide adequate supervision. One resident, with a recent amputation, fell when transferred by a single caregiver, reopening their surgical incision. Another resident, with hemiplegia, was left alone attached to a lift sling and slid to the floor. Staff acknowledged not following the required two-person assistance policy.
The facility did not support resident self-determination by limiting resident council meetings to 30 minutes, preventing residents from adequately discussing concerns such as food quality and call light response times. Residents reported dissatisfaction with the food and delays in call light responses, feeling their issues were not addressed.
The facility failed to provide a homelike dining environment as residents were served meals on delivery trays in two dining rooms. Staff admitted to feeling anxious and forgetting to remove trays, which led to the deficiency. A Registered Nurse confirmed the expectation for a homelike setting was not met.
A resident with a below the knee amputation experienced a fall resulting in a significant injury due to a staff member not following the care plan. The incident was not reported to the State Agency within the required timeframe, as the Director of Nursing believed logging it in the facility's logbook was sufficient.
The facility failed to accurately code the MDS for two residents regarding injectable anti-diabetic medications. One resident was incorrectly coded as receiving insulin, despite using Trulicity, a non-insulin medication. Another resident was similarly misclassified. The errors were acknowledged by the MDS Coordinator, who admitted to the incorrect coding.
A facility failed to maintain range of motion for a resident with a hand contracture after readmission from the hospital. The resident, with a history of stroke and hemiplegia, was not enrolled in a restorative program despite previous active ROM exercises. Staff interviews revealed a missed procedural step due to a transition in the therapy department.
A facility failed to coordinate a referral for denture services for a resident with heart failure and other conditions. The resident required assistance for daily activities and had moderately impaired cognition. Despite being interested in new dentures, there was no documentation of a completed referral. Interviews revealed a breakdown in the process for scheduling denture care appointments, with staff unable to confirm receipt of the referral form. The Regional Director acknowledged the lack of an effective system for dental referrals.
A resident with vascular dementia and other conditions experienced discomfort with dentures and requested a dental appointment. Although the appointment occurred, it was not documented in the medical record, revealing a lapse in communication and documentation among staff.
Two residents with impaired cognition were not properly educated or offered the COVID-19 vaccine, as required by facility policy. Despite documentation indicating refusal, neither resident nor their representatives were informed about the vaccine's risks and benefits. Staff interviews confirmed the failure to follow the correct process, placing residents at risk of uninformed health care decisions.
The facility's laundry room was found to be unsanitary due to leaks from washing machines four and five, causing water damage and sludge under the linoleum flooring. Staff acknowledged the issue, noting the potential for bacterial growth and the need for repairs to ensure a safe and cleanable environment.
The facility failed to complete annual performance reviews for 4 Nursing Assistants, with the last reviews for Staff B, C, and D conducted in 2020 and 2022, and no review for Staff E since their hire in 2023. This lapse was acknowledged by the Administrator and placed residents at risk for unmet care needs.
Failure to Maintain Resident Dignity During Mealtime
Penalty
Summary
The facility failed to promote resident dignity during mealtime in the dining room for 3 of 8 residents reviewed for dignity. Resident 70, who had diagnoses including a history of stroke with right hemiplegia and dementia and was dependent on staff for dressing, grooming, transfers, and mobility, was eating in the large dining room when a nursing assistant told the resident care manager that Resident 70 was not eating well and that staff were trying to get the resident to drink health shakes to replace refused meals. The resident care manager then discussed the possibility of a urinary tract infection and obtaining a urine sample to rule out a UTI, and this confidential health conversation occurred in front of eight other residents who were eating in the dining room. Resident 28, who had dementia and chronic kidney disease and required extensive assistance with dressing and mobility, was observed in the dining room while a nursing assistant conversed with the resident and referred to the resident as "honey" several times. Resident 74, who had dementia and hypertension and required moderate assistance with dressing and mobility, was observed in the dining room with two other residents when the director of therapy approached and said "Hello Sweetheart" while reminding the resident about working together later that day. The director of nursing stated staff were expected not to discuss medical information in the dining room or refer to residents by nicknames such as honey or sweetie unless resident preferences were known.
Failure to Assess and Order Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident was evaluated, assessed, and had physician orders in place for safe self-administration of medications. Resident 10 was admitted with diagnoses including diabetes, heart failure, and glaucoma, and the 11/02/2025 comprehensive assessment showed the resident was independent with ADLs except for supervision with bathing and had intact cognition. The facility policy stated bedside medications should not be provided without a physician order and approval by the Interdisciplinary Care Team and facility administration, and staff should not leave medications unattended or fail to observe the resident’s consumption of the medication. During observation and interview, Resident 10 was found with medications left on the bedside table, including two medications in an unlabeled clear cup and bottles of eye drops. The resident stated staff had placed the medications there after returning from an outing and that the eye drops would be given back to the nurse when finished. On another observation, the resident had two large white tablets in an unlabeled clear cup on the bedside table and stated they had taken some morning medications and left the remaining tablets to take after breakfast, without knowing what the medications were. Staff later confirmed the medications had been left with the resident at the resident’s request, but the medical record contained no self-medication assessment or physician’s order for self-administration.
Failure to Provide Requested Medical Record Copies
Penalty
Summary
The facility failed to provide copies of a resident’s personal medical records as required. The facility policy titled Resident Rights stated that upon request, a resident has the right to receive records pertaining to care within 24 hours of request, and the policy review did not show that residents were required to submit a written request for their medical records. Resident 27 was admitted with diagnoses including diabetes, muscular dystrophy, heart disease, and kidney disease, and the comprehensive assessment showed the resident’s cognition was intact and the resident was independent with personal cares. During the Resident Council meeting, Resident 27 stated they were unable to obtain a copy of their medical records and were only offered the chance to view them on a computer. In a later interview, Resident 27 stated they wanted a paper copy of lab results from blood drawn in December and said their doctor had told them they could have a copy. Staff I, the RCM, stated they had explained that once medical records were in the chart, a written request might be needed, and said they offered to review the lab results with the resident on the computer and have the resident write them down. Staff I also stated they wanted to check the facility policy and that the discussion occurred on Monday before they became distracted. Resident 27 stated they did not want to write the results down and wanted a paper copy to review on their own. The Administrator and DON stated there had been miscommunication between Staff I and Resident 27.
Failure to Develop Vision-Specific Care Plans
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans to address vision impairments for 2 of 3 residents reviewed for care plan development, Resident 42 and Resident 76. Resident 42 had diagnoses including chronic congestive heart failure, dementia, and visual disturbance. The comprehensive assessment dated 11/27/2025 showed moderately impaired cognition, need for assistance from one staff member with ADLs, and severely impaired vision. During observation and interview on 01/06/2026, Resident 42 was lying in bed with a water cup placed on a bedside table that was out of reach, and the resident stated they could not see well, could not find the water cup, and sometimes put water on the floor so it could be found. On 01/07/2026, Staff O assisted the resident to bed but did not position the bedside table or water cup within reach. Record review on 01/09/2026 showed no care plan or documented interventions addressing the resident’s vision impairment or related environmental safety and accessibility needs. Resident 76 had diagnoses including stroke, and the comprehensive assessment dated 11/18/2025 showed moderately impaired cognition and need for assistance from one to two staff members with ADLs. During observation and interview on 01/07/2026, the bedside table was out of reach, the resident was attempting to reach water but could not do so, and stated they could not see the table or water because it was outside their visual field. The call light was clipped to the upper right-hand corner of the bed, out of the resident’s visual field and reach, and the resident stated they could not find the button. On 01/08/2026, the resident was again observed with the water cup out of reach and tipped it over while searching for it. Record review on 01/09/2026 showed no care plan or documented interventions addressing the resident’s vision impairment or related environmental safety and accessibility needs. Staff G stated they were aware of the vision deficits and that the facility’s process was to have a vision care plan in place, but they had overlooked doing so. Staff B stated the expectation was that vision-specific care plans be implemented for residents with visual impairments to provide staff direction.
Failure to Provide Adaptive Eating Equipment for Resident With Severe Vision Impairment
Penalty
Summary
The facility failed to provide necessary adaptive equipment for a resident with severely impaired vision to maintain the highest practicable level of independence with eating. The resident had diagnoses including chronic congestive heart failure, dementia, and visual disturbance. The comprehensive assessment dated 11/27/2025 showed the resident had moderately impaired cognition, required assistance from one staff member for ADLs, and needed set-up assistance for eating. The record also showed the resident's vision was severely impaired and that they were not receiving any specialized care with eating. During interview, the resident stated they had a hard time eating and wanted better forks and spoons because it was hard to get food onto the plastic utensils being used. Observations showed the resident using their hands to feel for food, eating with their hands throughout a meal, and having food on their shirt and spilled on the table while using plastic utensils and a regular plate with no adaptive equipment. At another meal, the resident was observed using a standard spoon, with food falling off the spoon onto the shirt and the resident using their hands to scoop food onto the spoon. Staff T, the RD, stated the facility's process was for OT to assess residents for adaptive equipment, but could not verify an OT assessment had occurred. Staff P, the DOR, stated the resident had not been evaluated by OT for eating or adaptive equipment needs, and Staff B, the DON, stated they expected the resident would have received a nursing evaluation and referral to OT for eating deficits related to severely impaired vision.
Missing Post-Dialysis Assessments
Penalty
Summary
The facility failed to consistently document post-dialysis assessments for a resident who required dialysis services. The facility policy titled Dialysis Policy, revised March 2024, required a licensed nurse to complete pre- and post-dialysis assessments with each dialysis visit. Resident 6 was admitted with diagnoses including kidney failure, heart disease, depression, and dementia, and the comprehensive assessment showed the resident’s cognition was intact and that the resident was dependent on two staff members for care and transfers. Physician orders required dialysis every Tuesday, Thursday, and Saturday, and staff were to follow the dialysis flow sheet protocol for pre- and post-dialysis care and check the pressure dressing after dialysis and remove it after two to three hours. The medical record showed missing post-dialysis vital signs for Resident 6 on 12/16/2025 and 12/23/2025, and also on 11/04/2025, 11/11/2025, and 11/22/2025. During interview, the resident stated they were unaware of communication between dialysis and the facility when sent out or returned, and stated staff were not consistently checking on them after dialysis. A nursing assistant stated the process after dialysis was to get the resident in bed, provide a meal, and do a quick change, and that vitals were not always obtained if the nurse was too busy. The resident care manager stated the dialysis communication forms were not always completed by the dialysis center and that staff were expected to follow the dialysis protocol for post-dialysis care.
Missing Integrated Hospice Care Plan
Penalty
Summary
The facility failed to develop and maintain a current hospice care plan in collaboration with contracted hospice services for one resident receiving hospice care. The hospice contract dated 01/05/2026 required a coordinated care plan that was responsive to the resident’s needs, consistent with hospice philosophy, and that identified specific hospice services, including pain management and symptom relief, the scope and frequency of those services, measurable anticipated outcomes, and the provider responsible for each function, including drugs, treatments, medical supplies, and appliances. The resident had diagnoses including chronic congestive heart failure and chronic kidney disease, and the 12/03/2025 comprehensive assessment showed moderately impaired cognition and the need for assistance from one staff member with ADLs. Review of the EHR on 01/06/2026 showed the resident had no hospice care plan. During interviews, the Resident Case Manager stated hospice care plans were not integrated with the facility care plan and that they were unsure of the process, while the hospice contact stated the hospice care plan should be fully integrated with the facility’s comprehensive care plan. The DON stated nursing staff were expected to incorporate the hospice care plan into the facility’s comprehensive care plan, and that this was not followed for the resident.
Failure to Follow EBP, Hand Hygiene, and PPE During Resident Care
Penalty
Summary
The facility failed to ensure staff followed Enhanced Barrier Precautions and proper hand hygiene during resident care and wound care for three residents. The report states that staff did not consistently use required PPE, including gowns, during high-contact care activities in rooms identified for EBP, and that hand hygiene was not always performed before or during resident care tasks. For Resident 76, the medical record showed a history of stroke, moderately impaired cognition, and a need for assistance with activities of daily living. During wound care, a RN entered the room without a gown or gloves, did not place a barrier on the bedside table before setting out wound supplies, and after re-entering the room donned gloves without performing hand hygiene. The RN removed the soiled dressing from the left lower leg wound and continued using the same gloves to clean the wound, handle clean gauze, apply Iodosorb with a tongue depressor, apply the new dressing, replace the resident’s sock, and adjust the bed linens. During a separate observation, two NAs assisted Resident 76 into bed while wearing only gloves and not gowns, despite the EBP signage indicating gowns were required for high-contact care activities such as transferring and repositioning. For Resident 31, the medical record showed diagnoses including kidney disease and diabetes, with cognition intact. During a dressing change, the RN entered the room with an EBP sign and wore gloves but no gown, removed the resident’s sock, removed and replaced gloves multiple times, sanitized hands, placed barriers on the table and under the heel, cleansed the left heel wound with saline, used a Q-tip to remove film from the wound, and applied Santyl and a bordered gauze dressing. For Resident 6, the medical record showed kidney failure, heart disease, depression, intact cognition, and dependence on two staff members for care and transfers. In an EBP room, an NA repositioned the resident and cleaned spilled water from the floor while wearing gloves only and was unable to state what the EBP sign directed; after reviewing the sign, the NA stated a gown should have been worn. The Infection Preventionist stated staff had failed to use proper PPE while delivering care to residents in EBP rooms and that staff needed to follow the signs placed for protection.
Failure to Implement Care Plan Interventions During Mechanical Lift Transfers
Penalty
Summary
The facility failed to implement care plan interventions and provide adequate supervision during mechanical lift transfers, resulting in avoidable accidents for two residents. Resident 30, who had a recent below-the-knee amputation, fell from a Sara Steady lift when transferred by a single caregiver instead of the required two. This fall caused the surgical incision on their stump to reopen, necessitating emergency surgery and a hospital stay. The resident had been making progress towards rehabilitation and discharge, but the fall significantly set back their recovery. Resident 7, who had a stroke with hemiplegia and was dependent on two staff members for transfers, was left alone in their wheelchair with a mechanical lift sling attached. A nursing assistant attached the sling and left to find another staff member but forgot about the resident, who subsequently slid to the floor. The mechanical lift's brakes were not engaged, and the resident was found on the floor, indicating a lack of supervision and adherence to safety protocols. Interviews with staff revealed that both incidents were due to deviations from established procedures for mechanical lift transfers. Staff involved acknowledged their mistakes, and the facility's Director of Nursing Services confirmed that the required two-person assistance was not provided in both cases. The facility's policy mandates two caregivers for all mechanical lift transfers, which was not followed, leading to these preventable accidents.
Failure to Support Resident Self-Determination in Council Meetings
Penalty
Summary
The facility failed to honor the residents' right to self-determination by not allowing them to hold resident council meetings at times of their choosing and to discuss topics important to them. Six residents expressed concerns during a council meeting that they were not given adequate time to voice their issues, as meetings were scheduled by the activities department for only 30 minutes before lunch, limiting their ability to discuss concerns thoroughly. Residents reported consistent issues with the quality of food and call light response times. They noted that the food was often not what was listed on the menu, served cold, and lacked appeal. Additionally, residents expressed frustration with the slow response to call lights, with some waiting over an hour for assistance. These issues were repeatedly brought up in council meetings, but residents felt their concerns were not being addressed. The residents' dissatisfaction with the council meetings and the facility's response to their concerns highlights a failure to support resident choice and self-determination. The lack of adequate time for meetings and the unaddressed issues regarding food quality and call light response times contributed to a diminished quality of life for the residents involved.
Failure to Provide Homelike Dining Environment
Penalty
Summary
The facility failed to provide a comfortable and homelike dining environment for residents in two dining rooms, as observed by surveyors. Residents were served and ate their meals with plates still on the delivery trays, which is not in line with creating a homelike atmosphere. In the subacute dining room, several residents, including Resident 2, Resident 7, Resident 18, Resident 22, and Resident 36, were observed eating their lunch meals directly from trays. Similarly, in the 900-unit dining room, Staff J, a Nursing Assistant, served meals to residents and left the plates on the trays, failing to create a homelike dining setup. Interviews with staff revealed that the failure to remove plates from trays was due to staff feeling anxious and nervous during observations, leading to lapses in following the expected procedure. Staff M, a Nursing Assistant, admitted to feeling anxious and forgetting the sequence of actions, while Staff J stated they were nervous being watched, which led to forgetting to remove the trays. Staff K, a Registered Nurse, confirmed that the expectation was for staff to provide a clean, comfortable, and homelike environment for residents, which was not met in this instance.
Failure to Report Fall with Significant Injury
Penalty
Summary
The facility failed to report an incident involving a fall with significant injury for a resident to the State Survey Agency as required. The resident, who had a below the knee amputation of the right leg, was involved in a fall on January 31, 2025, which resulted in a deep dehiscence of the surgical incision, necessitating immediate surgical intervention. The incident was investigated as potential abuse and/or neglect because a nursing assistant did not follow the resident's care plan, which required assistance from two caregivers and a manual mechanical lift for transfers. Despite the investigation, the incident was not reported to the State Agency within the required 24-hour timeframe as per the Washington State Department of Social and Health Services Nursing Home Guidelines. The Director of Nursing Services stated that the incident was not reported because they believed that logging the incident in the facility's incident and reporting logbook within five days was sufficient, given that the cause of the injury was known. This oversight resulted in the failure to recognize patterns of potential abuse and/or neglect with incidents of significant injury.
Inaccurate MDS Coding for Injectable Medications
Penalty
Summary
The facility failed to ensure the accuracy of the residents' comprehensive assessments regarding injectable anti-diabetic medications for two residents. Resident 32, who was admitted with diagnoses including diabetes, chronic obstructive pulmonary disease, and depression, was incorrectly coded as receiving insulin injections on their Minimum Data Set (MDS). However, during an interview, Resident 32 stated they did not use insulin. Staff C, the Registered Nurse/MDS Coordinator, admitted to entering the code for insulin use based on the resident's use of Trulicity, a non-insulin medication, and acknowledged the error in coding. Similarly, Resident 49, who was admitted with diagnoses including diabetes and depression, was also incorrectly coded on their MDS as using insulin. Staff C confirmed that Resident 49 received Trulicity, not insulin, and recognized the need to correct the MDS. The Regional Director of Clinical Services, Staff D, mentioned that there was a process in place to ensure the accuracy of the MDS for skilled nursing, but the errors in coding for these residents were not caught, leading to inaccurate assessments.
Failure to Maintain Range of Motion for Resident with Hand Contracture
Penalty
Summary
The facility failed to provide necessary treatment and services to maintain or prevent a further decrease in range of motion for a resident with a hand contracture. The resident, who had a history of stroke with hemiplegia affecting the left side, heart failure, and anxiety, was readmitted to the facility after a hospital discharge. Upon readmission, the resident was not enrolled in a restorative program, despite having previously received active range of motion exercises. The resident expressed an inability to move their left hand and mentioned that they used to have a splint or brace to assist with their condition. Interviews with facility staff revealed that the resident was not currently on a restorative program, and a procedural lapse occurred when the resident was readmitted. The Director of Rehab stated that the facility's process for readmitted residents included evaluations by physical, occupational, and speech therapy, but the resident was not enrolled in an occupational therapy program. A form that should have been completed to restart the resident's previous restorative services was missed due to a transition in the therapy department from contracted services to facility staff.
Failure to Coordinate Denture Services for a Resident
Penalty
Summary
The facility failed to coordinate a referral for denture services for Resident 7, who was reviewed for dental services. Resident 7 was admitted with diagnoses including heart failure, gastro-esophageal reflux disease without esophagitis, and Barrett's Esophagus. The comprehensive assessment indicated that Resident 7 required assistance for activities of daily living and had moderately impaired cognition but was able to communicate needs. The care plan noted that Resident 7 had full upper dentures and partial lower dentures. However, during an observation and interview, Resident 7 mentioned they were supposed to get new dentures, but there was no documentation in the medical record that the referral had been completed. Interviews with facility staff revealed a breakdown in the process for scheduling denture care appointments. Staff G, the Patient Care Coordinator/RN, stated that dental referrals were to be forwarded to Staff H, the Social Services Director, who would then schedule the appointments. However, Staff G did not see the referral form from Resident 7's dental appointment. Staff H explained that they would complete a scheduling form and give it to Staff I, the Activities Driver, to arrange the appointment and transport. Staff I, responsible for scheduling outside appointments, did not recall receiving a referral form for Resident 7. The Regional Director of Clinical Services acknowledged the concerns and noted that there was not a good system in place for completing dental referrals.
Inaccurate Medical Record for Dental Services
Penalty
Summary
The facility failed to ensure the medical record related to dental services was accurate for Resident 18, who was admitted with diagnoses including a stroke, vascular dementia with psychotic disturbance, and depression. A nursing progress note indicated that Resident 18 experienced discomfort with their dentures due to a sore spot and requested to see their denturist. Although the resident was taken to a dental appointment on December 12, 2024, there was no documentation in the medical record confirming this visit. Interviews with facility staff revealed a breakdown in communication and documentation processes. Staff G, a Patient Care Coordinator/RN, reported the dental issue to Staff H, the Social Services Director, who then forwarded the appointment request to Staff I, the Activities Driver, for scheduling. Staff I confirmed the appointment took place but did not ensure the visit was documented in the resident's medical record. The Director of Nursing Services later confirmed with the resident's son that the appointment occurred, highlighting the expectation that a nursing progress note should have been entered following the visit.
Failure to Educate and Offer COVID-19 Vaccine to Residents
Penalty
Summary
The facility failed to ensure that residents and their representatives were properly educated and offered the COVID-19 vaccine, as required by the Department of Social and Health Services guidance. Specifically, two residents, identified as Resident 26 and Resident 42, were not provided with adequate education or documentation regarding their COVID-19 vaccination status. Resident 26, who had a severely impaired cognition, was recorded as having refused the vaccine without any documentation of an immunization assessment or a signed consent/declination form. The resident's representative confirmed that they were not offered or educated about the vaccine. Similarly, Resident 42, who had moderately impaired cognition, was noted to have refused the vaccine without proper documentation of education or consent. The resident and their representative both stated that they were not offered or educated about the vaccine, despite the resident's previous vaccination history and willingness to receive the current vaccine. Interviews with facility staff, including the Registered Nurse for Resident 26, the Infection Preventionist, and the Director of Nursing Services, revealed that the correct process for offering and educating residents and their representatives about the COVID-19 vaccine was not followed. Staff acknowledged that residents with impaired cognition should have their representatives educated and offered the vaccine, but this did not occur for Residents 26 and 42. The failure to follow the proper procedure placed these residents at risk of making uninformed decisions regarding their health care, as noted in the report.
Unsanitary Conditions in Laundry Room Due to Leaking Washing Machines
Penalty
Summary
The facility failed to maintain a safe, functional, and sanitary environment in the laundry room, specifically concerning washing machines number four and five. During an observation and interview, it was noted that washing machine number five had caused water damage to the linoleum floor beneath it, with water currently leaking and seeping under the flooring. This leak had spread to a four-foot by three-foot section under the machine. Staff R, the Housekeeping/Laundry Director, acknowledged awareness of the leak and mentioned that a new washing machine was being ordered. Additionally, when the surveyor walked between washing machines four and five, the floor squished, and a grayish sludge oozed out from between the laminate flooring, indicating further water damage and potential contamination. Staff Q, the Infection Preventionist, and Staff S, the Maintenance Director, confirmed the unsanitary conditions during a concurrent interview and observation. They observed the water leak and sludge oozing through the linoleum flooring, acknowledging that the floor was not a safe or cleanable surface. Staff Q noted the potential for bacterial growth due to the sludge, and both staff members agreed that the floor needed to be fixed. The report highlights the risk of cross-contamination of diseases due to the inability to disinfect the area properly.
Failure to Conduct Annual Performance Reviews for Nursing Assistants
Penalty
Summary
The facility failed to complete a performance review at least once every 12 months for 4 of 4 Nursing Assistants (NAs) reviewed for performance reviews. Specifically, Staff B's last performance review was conducted in 2020, Staff C's in 2022, Staff D's in 2022, and Staff E had no performance review completed since their hire in 2023. This deficiency was identified through interviews and record reviews, and the Administrator acknowledged the lapse in timely performance reviews. The failure to conduct these reviews placed residents at risk for unmet care needs from potentially unqualified staff.
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Illustrative
What surveyors actually found near you
We read the 47 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near College Place
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Park Manor Rehabilitation Ctr | 1 mi | ★★★★★ | 12 | 0 |
| Washington Odd Fellows Home | 2.7 mi | ★★★★★ | 1 | 0 |
| Washington State Walla Walla Veterans Home | 3.4 mi | ★★★★★ | 28 | 0 |
| Milton Freewater Health And Rehabilitation | 7.4 mi | ★★★★★ | 6 | 0 |
| Willowbrook Post Acute | 34.5 mi | ★★★★★ | 18 | 0 |
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