Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Richmond Beach Rehab during CMS and state inspections, most recent first.
The facility failed to report an allegation of sexual abuse to the State Agency after a resident reported that another resident called her over, touched her face, told her she was pretty, and kissed her without consent, leading to increased anxiety and avoidance of activities. The cognitively intact resident disclosed the incident through a grievance and to social services, and staff, including the Activities Director, Social Services Coordinator, Administrator, and DON, became aware of the allegation. Facility policy defines sexual abuse as non-consensual sexual contact and requires mandated reporters to immediately report all alleged violations to the Administrator, state agency, and other required agencies, and the Administrator acknowledged that a non-consensual kiss meets the definition of sexual abuse. Despite this, the incident was not entered into the incident log or reported externally, with the Administrator stating they did not report it because the resident did not want the matter to go further.
Expired chlorine test strips were used to check a dishwasher’s chemical sanitization in the kitchen. A Culinary Aide used the strips to verify the ppm range for a low-temp dishwasher, but the strips were observed to be expired, and the aide said they had not been thrown away and replaced. The RD and Culinary Services Mgr stated staff were expected to check the expiration date before use, and the ADM stated expired strips should not be used.
Surveyors identified multiple infection control lapses, including a laundry aide transporting uncovered clean clothes and reusing a linen cover that had fallen to the floor, an LPN entering a droplet precaution room without required eye protection, and a nurse practitioner and an RN performing wound care without gowns despite Enhanced Barrier Precautions. An LPN also failed to properly disinfect a shared glucometer between residents and did not clean the rubber seal of a Liraglutide pen with alcohol before attaching a new needle, contrary to policy and manufacturer instructions. In addition, a urine-filled urinal was left on a bedside table next to a meal tray, which staff acknowledged should not have occurred.
Grievance Process Lacked Anonymous Filing System: A facility failed to ensure residents could file grievances anonymously. The grievance policy stated anonymous filing was allowed, but the posted procedures and grievance form did not show an anonymous submission system. Residents reported they had to identify themselves or hand forms directly to staff, and staff confirmed there was no locked box or other anonymous drop-off method.
A facility failed to properly store a CPAP mask when not in use, administer CPAP as ordered, and monitor O2 saturation for residents with OSA and other respiratory diagnoses. One resident’s CPAP mask was repeatedly left uncovered and later found hanging below the bed and touching the ground, another resident was observed asleep without CPAP despite an order for use during sleep, and a third resident with orders for O2 and saturation monitoring had multiple dates with no documented O2 sat checks. Staff stated CPAP should be stored in a bag when not in use and that CPAP and O2 sat monitoring were expected.
An LPN documented morning meds as given in the EMAR before actually administering them to four residents. The meds included multiple scheduled oral meds and a nasal spray for each resident, and the RCM and DON stated MARs were expected to be signed after the resident took the medications.
A resident who had previously received PPSV23 and PCV13 met CDC criteria for an additional pneumococcal vaccine dose and had signed consent to receive PCV20, but review of the EHR showed no documentation that PCV20 was ever administered. The facility’s policy required offering pneumococcal vaccines and following current CDC recommendations, and both the IP and DON acknowledged the expectation that the resident should have received the vaccine, yet the dose was not provided or recorded.
A resident received PRN lorazepam without clear documentation that informed consent explaining the risks and benefits had been completed before the medication was started. The chart showed conflicting and incomplete consent forms, and progress notes did not document that the resident or representative was informed and agreed to the psychotropic medication. Staff stated consent should be obtained before starting the medication and documented in the progress notes.
Unassessed Medication Self-Administration: Two residents were given oral meds in their rooms without documented self-administration evaluations or physician orders allowing bedside medication access. An LPN left multiple meds with one resident in medication cups and left another resident with meds to take independently, even though both records lacked self-med orders and the residents were not documented as being on a self-med program.
Dignity was not maintained when an LPN administered medications to two residents in the dining room while other residents were eating. One resident’s medication was mixed with yogurt and given in the dining room, and another resident also received medication there. Staff said this was part of the residents’ routine, but the care plans did not document a dining-room medication preference.
A resident enrolled in hospice, but the SCSA MDS was completed five days late. The RAI Manual required the assessment within 14 days of the hospice election date, and staff confirmed the assessment was not completed on time.
The facility failed to accurately code MDS assessments for three residents. One resident with ESRD and dialysis was not coded for dialysis, one resident’s MDS did not reflect antianxiety medication use despite MAR documentation of Buspirone, and one resident who continued to smoke and required supervision was incorrectly marked as not using tobacco on the MDS.
The facility failed to follow up on PASARR screening and Level II referrals for two residents with significant mental health diagnoses, including PTSD, schizophrenia, hallucinations, delusional disorders, anxiety, and MDD. Staff reported that a Level II referral had been emailed for one resident but no evaluation was received and no follow-up occurred, while the other resident’s PASARR record showed SMI and a Level II referral was needed, but the requested records were not documented as being sent and the case was later closed for missing medical records.
Care plans were not revised to match current medication status for two residents. One resident’s behavior monitor care plan still listed antidepressants that had been discontinued, and another resident’s cognition/communication and vision care plans still listed medications no longer on the MAR. Staff acknowledged the care plans should have reflected the residents’ current orders and status.
A resident with a pressure ulcer did not receive prescribed wound care due to the unavailability of Dakin's solution. Despite the resident's report and staff awareness, the physician was not notified, and no alternative treatment was ordered. The resident's wound was treated with wet-to-dry dressing instead, contrary to the physician's order.
The facility failed to ensure accurate PASARR screenings for several residents, leading to missed Level II referrals for those with Serious Mental Illness (SMI) or Intellectual Disabilities (ID). This oversight involved incomplete or incorrect PASARR forms for residents with conditions such as anxiety, depression, and delusional disorders, placing them at risk of not receiving appropriate care.
The facility failed to accurately complete daily nurse staffing forms with actual hours worked for each shift over six days. Observations showed that the posted forms lacked the required information for nursing staff, including RNs, CNAs, and LPNs. The DON admitted to not filling out the actual hours due to previous training. The facility's policy required this information to be recorded, and the Administrator confirmed the need for accurate postings.
The facility failed to properly label and store medications, including insulin pens and a bronchodilator inhaler, and did not remove expired supplies. Additionally, the facility did not adhere to CDC guidelines for vaccine storage, as refrigerator temperatures were not checked twice daily despite storing RSV vaccines. Expired intravenous starter needles were also found in the medication room refrigerator.
A long-term care facility was found to have multiple infection control deficiencies, including improper disinfection of insulin pens, inadequate hand hygiene, and improper storage of personal care items and PPE. Additionally, hand hygiene supplies were lacking in medication rooms, and shared transfer lift equipment was not disinfected between uses, increasing the risk of infection.
A facility failed to notify the State LTC Ombudsman in writing about a resident's transfer to the hospital, as required by their policy. The Social Services Assistant responsible for sending the notice did not document the communication or retain a fax receipt. The Administrator confirmed the expectation for written notification and documentation of such communications.
A facility failed to accurately assess a resident's condition by not documenting oxygen use during the MDS assessment look-back period. The resident, admitted with asthma and respiratory failure, had received oxygen, as noted in the TAR, but this was not captured in the MDS. The Case Manager acknowledged the oversight, and the DON confirmed the expectation for accurate assessments per the RAI Manual.
The facility failed to provide baseline care plan summaries to two residents within 48 hours of admission, as required by policy. Reviews of the residents' EHRs showed no documentation of the summaries being provided, and interviews with staff confirmed the oversight. The residents did not receive the necessary written summaries outlining their care plans, which should have included goals, medication, dietary instructions, and services.
The facility failed to properly store oxygen tubing and cannulae for two residents, leading to a deficiency in respiratory care. One resident's tubing was found hanging on a wheelchair with nasal prongs touching the floor, while another's was on the floor beside their bed. Staff confirmed that the supplies should have been stored in a bag when not in use to prevent cross-contamination.
A facility failed to consistently evaluate and document a resident's dialysis care, despite a care plan requiring monitoring for infection at the access site. Staff interviews revealed a lack of awareness and adherence to the care plan, with some unaware of the access site's location and others acknowledging the order was not reinstated upon readmission. The DON confirmed the oversight, and the resident reported no consistent evaluations post-treatment.
Failure to Report Resident’s Allegation of Non-Consensual Sexual Contact
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse to the State Agency as required by its own policy and state regulations. The facility’s abuse policy, dated September 2022, states that all suspected, alleged, or actual cases of resident abuse, including sexual abuse defined as non-consensual sexual contact of any type with a resident, must be thoroughly investigated and reported to the Administrator, state agency, and all other required agencies when there is reasonable suspicion that abuse has occurred. A cognitively intact resident (Resident 1) reported via a grievance on 02/04/2026 that another resident (Resident 2) had called her over outside his room, put his hands on her face, told her she was pretty, and kissed her. Resident 1 stated this kiss was not wanted or consensual, that she felt scared, avoided the activities room because Resident 2 was there, and did not want to return to the facility after a hospital stay unless Resident 2 was removed. Staff interviews and documentation showed that Resident 1’s anxiety increased and she stopped attending activities after the incident. The incident was known to multiple staff members, including the Activities Director (Staff B), the Social Services Coordinator (Staff C), and the Administrator (Staff A) and DON, yet it was not reported to the State Agency. Staff B documented that Resident 2 continued to make inappropriate comments and behaviors and acknowledged hearing him say “you’re pretty” to residents, including Resident 1. Staff C reported that Resident 1 described Resident 2 telling her she was pretty, saying “he come here,” and kissing her, and that Staff C believed the kiss was not mutual and that Resident 1 was shocked. Staff C reported the allegation to the Administrator and DON. The Administrator (Staff A) acknowledged that a non-consensual kiss reported by a resident constitutes an allegation of sexual abuse that should be reported to the State Agency and stated that they usually report resident-to-resident incidents. However, Staff A admitted that the incident between Resident 1 and Resident 2 was not reported, explaining that Resident 1 did not want the matter to go further or be widely known and that they wanted to honor her wishes. Review of the incident logs for January, February, and March 2026 confirmed there was no documentation that this allegation of sexual abuse was reported to the State Agency.
Expired Chlorine Test Strips Used for Dishwasher Sanitization
Penalty
Summary
The facility failed to ensure chlorine test strips used to measure the concentration of free available chlorine in sanitizing solutions were not expired for 1 of 1 kitchen reviewed for dinnerware sanitization and storage. During a joint observation and interview, a Culinary Aide checked the dishwasher temperature and chemical sanitation ppm range using [Brand name] Chlorine Test Paper and stated the results should be between 50 ppm to 100 ppm. The observed test strip was expired on 01/01/2026, and the aide stated the strips were expired and had not been discarded and replaced. The facility used a low-temperature dishwasher with chemical sanitization. The Culinary Services Manager stated staff should check the expiration date of the chlorine test strips before use and had missed that. The Registered Dietitian stated kitchen staff would be expected to test dishwasher chemical sanitization before meals and to check the expiration date of the chlorine test strips before use, noting that expired strips could give a false reading and be inaccurate. The Administrator stated the chlorine test strips in the kitchen should not be used if expired.
Multiple Infection Control Lapses in Linen Handling, PPE Use, Wound Care, Glucometer Disinfection, Medication Technique, and Urinal Placement
Penalty
Summary
The deficiency involves multiple failures in the facility’s infection prevention and control practices by several staff members in different care processes. A laundry aide transported clean clothes on a rolling rack that was not fully covered, contrary to facility expectations and CDC guidance for linen transport. During transport, the linen cover fell to the floor, and the aide picked it up and placed it back on top of the rack containing clean clothes instead of treating it as soiled and sending it to dirty laundry. The laundry manager and the infection preventionist both stated that clean linens and clothes were expected to be fully covered during transport and that any linen that touched the floor was considered soiled and should be placed in dirty laundry. Another deficiency occurred in the use of PPE for a resident on droplet precautions. An LPN entered a droplet precaution room wearing a gown and gloves but only had prescription eyeglasses on and did not use required eye protection such as a face shield or goggles, despite signage outside the room indicating that eye protection was required. The LPN stated they were unsure if prescription eyeglasses counted as PPE. The infection preventionist and the DON both stated that prescription eyeglasses were not considered PPE and that staff were expected to wear appropriate eye protection when caring for residents on droplet precautions. Additional infection control failures were identified during wound care and medication-related procedures. A nurse practitioner and an RN performed wound care on a resident with a sacral pressure injury requiring dressing changes three times a week, wearing only gloves and no gowns, even though they acknowledged that wound care required Enhanced Barrier Precautions and that gowns should have been worn. For another resident with orders for blood glucose checks before meals and at bedtime, an LPN cleaned a shared glucometer with an alcohol wipe instead of disinfecting it with Sani-cloth or bleach-based wipes between uses, contrary to facility policy and infection control standards. The same LPN also prepared and administered a Liraglutide injection using a pen device without wiping the rubber stopper with an alcohol swab before attaching a new needle, despite manufacturer instructions requiring this step and facility expectations for antiseptic technique. A further deficiency involved improper handling of a resident’s personal care item in relation to food service. A resident’s urinal, filled with urine, was observed on the bedside table next to the resident’s meal tray. A CNA confirmed that the urinal should not have been on the table next to the meal tray and that it should have been emptied. The infection preventionist and the DON both stated they did not expect a urine-filled urinal to be placed next to a meal tray and that it should have been emptied and kept away from the bedside table.
Grievance Process Lacked Anonymous Filing System
Penalty
Summary
The facility failed to develop a system that ensured residents had the right to file grievances anonymously for 5 of 8 residents reviewed for grievances. The facility’s policy titled, Grievance Policy, revised in January 2017, stated that grievances may be filed orally or in writing and with the right to file anonymously, but the undated Resident Grievance/Complaint Procedures and Grievance Communication Form did not show documentation of a system to file grievances anonymously. On 02/19/2026, observation and record review showed an undated Grievance/Complaint Procedures document posted in a glass bulletin board outside the administrator’s office, stating that grievance forms could be obtained from the wall mounted outside the administrator’s office. Further observation did not show a rack for grievance forms or a locked box to file a grievance form anonymously. During a Resident Council meeting, Residents 26, 37, 10, and 100 stated they were not able to file grievances anonymously. Resident 26 stated they had to write their name on the grievance form and give it directly to staff or slide it under the administrator’s office door, and that a rack previously outside the office was no longer available. Resident 37 stated they had to write their room number on the form and give it to staff. Resident 104 stated they were not sure about filing grievances anonymously. Staff H stated residents would hand in written grievances to staff or slide them under the office door and confirmed there was no locked box. Staff A stated grievance forms were handed directly to them or slid under their door, that the rack outside the office had been removed about a week or a week and a half earlier because residents were taking completed grievance forms from the open rack, and that there was no closed or locked box for completed grievance forms.
Respiratory Care Not Provided as Ordered
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for residents with orders related to CPAP and oxygen therapy. The report identified deficiencies involving improper storage of a CPAP mask when not in use, failure to administer CPAP as ordered, and failure to monitor oxygen saturation for three residents reviewed for respiratory care. The facility policy stated that CPAP/BiPAP support was intended to improve oxygen levels in residents with OSA and that the resident’s baseline oxygen saturation should be reviewed using a pulse oximeter. Resident 52 was admitted with OSA and had an order to clean the CPAP face mask and store it in a plastic bag every day shift. Observations showed the CPAP machine on the nightstand with the nasal mask uncovered and sitting on the machine on multiple occasions, and later the tubing and nasal mask were hanging below the bed and touching the ground. Staff stated that CPAP masks should be stored in a bag when not in use, and the DON stated that was the expectation. Resident 2 had OSA and an active order for CPAP for all sleep, but was observed asleep and not using the CPAP machine on multiple occasions. Resident 104 had diagnoses including respiratory failure with hypoxia and OSA, with orders for oxygen at 2 LPM to maintain saturation at or above 92 percent and oxygen at bedtime for severe nocturnal desaturation as needed. The care plan and cardiology note directed monitoring of oxygen saturation, but the record did not show oxygen saturation monitoring on multiple dates. Staff stated they expected CPAP to be administered to Resident 2 and oxygen saturation to be monitored for Resident 104 to assess respiratory status.
Medication Administration Documented Before Residents Received Medications
Penalty
Summary
Medication administration was not documented in accordance with professional standards for 4 of 6 residents reviewed for medication administration: Residents 46, 90, 29, and 93. The facility policy titled, Medication Administration, stated the person administering medications initials the resident’s MAR on the appropriate line after giving each medication and before administering the next ones. During observation on 02/23/2026, Staff K, an LPN, prepared morning medications for each of the four residents and documented them as given in the EMAR before taking the medications to the residents. For Resident 46, Staff K prepared cranberry, senna, lactulose, Excedrin, aripiprazole, lamotrigine, and oxycodone; for Resident 90, acetaminophen, fish oil, folic acid, ropinirole, and prednisone; for Resident 29, linzess, fluticasone nasal spray, metoprolol, senna, PreserVision, multivitamin, apixaban, torsemide, morphine, and allopurinol; and for Resident 93, aspirin, bupropion, fluoxetine, probiotic, and acetaminophen. In each instance, Staff K signed the EMAR as administered before entering the resident’s room and giving the medications. Staff K later stated they signed the MARs as given before administering the medications, and the RCM and DON stated they expected nurses to sign after the resident took the medications.
Failure to Administer Indicated Pneumococcal Vaccine per CDC Guidelines
Penalty
Summary
The facility failed to ensure that pneumococcal vaccination was up to date for one resident in accordance with its own policy and current CDC recommendations. The facility’s pneumococcal vaccine policy, dated October 2025, required that all residents be offered pneumococcal vaccines and that administration follow current CDC guidelines. CDC’s Adult Immunization Schedule Notes indicated that an adult who had previously received both PCV13 and PPSV23, but had not received PPSV23 at age 65 or older, should receive one dose of PCV20 or PCV21 at least five years after the last pneumococcal vaccine dose. Record review showed the resident had received PPSV23 on 02/14/2001 and PCV13 on 11/12/2018, meeting criteria for an additional pneumococcal vaccine dose. Further review of the resident’s records showed that on 03/10/2024 the resident had signed a Vaccination History and Consent form agreeing to receive Prevnar 20 (PCV20). However, review of the electronic health record did not show any documentation that Prevnar 20 was administered. During an interview and joint record review, the Infection Preventionist confirmed that the facility followed CDC guidelines, acknowledged the signed consent for Prevnar 20, and stated there was no documentation that the vaccine had been given. The DON also stated the expectation that the resident would have received the pneumococcal vaccination per CDC guidelines. This lack of administration and documentation for the agreed-upon and indicated pneumococcal vaccine constituted the deficiency.
Incomplete informed consent for psychotropic medication
Penalty
Summary
The facility failed to ensure informed consent explaining the risks and benefits of psychotropic medication was completed before lorazepam was administered to one resident. Review of the resident’s February 2025 MAR showed a PRN lorazepam order was given, but progress notes from January 2025 through February 14, 2025 did not show that the resident or the representative received informed consent regarding lorazepam or agreed to start the medication. The resident’s Consent for use of Psychotropic Medication Therapy, dated 01/09/2025, showed lorazepam was prescribed for generalized anxiety disorder, but the form stated the patient did not give consent to the medication and understood the risks of not accepting it, while also identifying the responsible party that was informed. Further review of the resident’s electronic health record showed no other informed consent was given to the resident or representative before lorazepam was received in February 2025. A later Anti-Anxiety Psychotropic Medication Disclosure and Consent dated 04/01/2025 did not show whether the resident and/or representative accepted or declined the medication. During interview, the Resident Care Manager stated consent should be obtained when a resident begins a psychotropic medication and that if the resident or representative disagreed, the medication would not be started and would be documented in the progress notes. The DON stated staff would be expected to obtain consent prior to starting a psychotropic medication and that the consent should inform the resident and/or representative about the medication, risks, and benefits.
Unassessed Medication Self-Administration
Penalty
Summary
The facility failed to ensure that residents were evaluated for self-administration of medications and/or had physician orders in place before medications were left at bedside or otherwise made available for self-administration. The deficiency involved two residents, both of whom were receiving multiple scheduled oral medications, including blood pressure medications and other routine treatments. The facility policy stated that residents may self-administer medications only if the attending physician, with the interdisciplinary care planning team, determined they had the decision-making capacity to do so safely. For one resident, the electronic record contained no documentation of a self-administration evaluation and no physician order for self-administration. During observation, the resident had eight and one-half tablets in one medication cup and two large tablets in another cup on the bedside table, and stated that staff had just brought them in and that they did not remember the names of the medications. The nurse later stated that the medications had been left in the resident’s room even though there were no orders to leave medications at bedside or to place the resident on a self-administration program. For the second resident, the record also showed no self-administration evaluation and no physician order for self-administration. The resident was observed taking oral medications from a medication cup in the room and stated they were taking medications for blood pressure, bladder, pain, and bipolar disorder. The nurse acknowledged leaving the medications with the resident and stated they should have watched the resident take the medications before leaving the room. The RCM and DON both stated that nurses should not leave medications at bedside for residents who are not on a self-medication program and should remain with the resident until all medications are taken.
Dignity Not Maintained During Medication Administration in Dining Room
Penalty
Summary
The facility failed to ensure dignity was maintained during dining observations for two residents when licensed nursing staff administered medications in the dining room while multiple residents were eating their meals. During an observation on 02/17/2026 at 12:54 PM, Staff K, an LPN, entered the dining room and mixed one resident’s medication with yogurt, and the resident took the medication in the dining room. A later observation on 02/19/2026 at 1:03 PM showed the same resident receiving medication in the dining room while others were eating. On 02/17/2026 at 1:04 PM, Staff K also administered medication to another resident in the dining room while multiple residents were present eating. During interview and record review, Staff K stated medication could be given in the dining room if it was necessary for the resident’s routine and said this should be reflected in the care plan. However, joint record review showed neither resident’s care plan documented a preference for receiving medication in the dining room as part of their routine. The RCM stated medication should not be administered during mealtimes in the dining room because residents were eating and for privacy, and that if a resident wanted medication there, the care plan should reflect it. The DON stated staff knew the residents and their routine and did not really expect care planning if a resident took medication in the dining room as part of their routine.
Late SCSA MDS After Hospice Enrollment
Penalty
Summary
The facility failed to ensure a Significant Change in Status Assessment (SCSA) MDS was completed timely for Resident 107 after the resident enrolled in hospice. The RAI Manual states that when a terminally ill resident enrolls in hospice or changes hospice providers and remains in the nursing home, an SCSA is required, with the ARD within 14 days of the effective date of hospice election and the assessment completed no later than 14 days after the determination date. A Certificate of Terminal Illness showed Resident 107 started hospice services on 12/14/2025. The resident’s SCSA MDS was completed on 01/02/2026, which was 19 days after hospice election and five days late. During interview and record review, the MDS Coordinator stated the hospice admission date was equivalent to the determination date and said they would consult with a supervisor about the completion timeframe. The Case Manager stated the assessment was five days late, and the DON stated MDS assessments were expected to be completed timely and accurately.
Inaccurate MDS Coding for Dialysis, Medication, and Tobacco Use
Penalty
Summary
The facility failed to accurately complete MDS assessments for 3 of 24 residents reviewed, involving dialysis, medication, and smoking status. The report states that accurate assessment requires information from multiple sources, including the resident, direct care staff, and the medical record, and that the interdisciplinary team must validate the resident’s actual status during the look-back period. The cited deficiency was based on the facility’s failure to correctly code these items on the MDS for the residents reviewed. Resident 68 was admitted with diagnoses including end stage renal disease and dependence on renal dialysis, and a nursing progress note showed the resident was on dialysis during the assessment period. However, the admission MDS did not mark dialysis in Section O. Resident 13’s significant change MDS did not mark antianxiety medication in Section N0415, even though the January 2026 MAR showed Buspirone was administered during the 7-day look-back period. Resident 8’s annual MDS marked current tobacco use as No in Section J1300, despite a progress note stating the resident continued to smoke 1 cigarette daily and a smoking safety evaluation showing the resident required supervision with smoking.
PASARR Follow-Up and Referral Not Completed for Two Residents
Penalty
Summary
The facility failed to ensure that PASARR screening was followed up on or that a Level II PASARR referral was sent for 2 of 6 residents reviewed for PASARR screening. Staff H, Social Service Assistant, stated that a Level II PASARR referral would be sent for anyone with a diagnosis of mental illness and that medical records such as a face sheet, diagnoses, medications, and progress notes would be emailed, with follow-up expected within a month. Staff H also stated that it was important for a resident to be evaluated for a Level II PASARR to determine whether extra help or services were available to them. Resident 15 was admitted with diagnoses including PTSD, anxiety disorder, major depressive disorder, schizophrenia, paranoid personality disorder, visual hallucinations, adjustment disorder with mixed anxiety and depressed mood, and auditory hallucinations. Staff H stated that a Level II PASARR referral had been emailed on 11/05/2025 but no evaluation had been received, and that no follow-up had been done since then. Resident 12 was admitted with diagnoses including anxiety disorder, auditory hallucinations, visual hallucinations, delusional disorders, and MDD. Their PASARR form dated 12/11/2024 showed SMI and that a Level II PASARR referral was needed, and an email dated 12/10/2024 showed Staff H requested a Level II review, but the response asked for the completed PASRR Level I and there was no further documentation that the requested information was provided. The Level II PASRR Invalidation Assessment dated 11/22/2025 listed the referral date as 12/11/2024 and noted that medical records were not received and the case was closed due to records not being received.
Care plans not updated after medication discontinuation
Penalty
Summary
The facility failed to revise care plans to accurately reflect discontinued medications for two residents. For Resident 13, the Behavior Monitor care plan still listed Venlafaxine and Mirtazapine, even though the December 2025 MAR showed both medications were discontinued on 12/07/2025 and 12/08/2025. The Order Summary Report printed on 02/18/2026 did not show active orders for either medication. During a joint record review, the RCM stated the behavior monitor care plan had not been updated and acknowledged that both medications had been discontinued in December 2025. For Resident 12, the alteration in cognition and communication care plan and the alteration in vision care plan still referenced Rivastigmine, Prednisone, and carboxymethylcellulose, although the February 2026 MAR did not show active orders for those medications. Staff stated they would expect the care plan to be updated to reflect current medications, and the RCM confirmed the resident had discontinued medications and that the care plan should have been revised to reflect that. Staff also stated that care plans were to be revised quarterly and as needed when there were changes in condition or medication.
Failure to Provide Prescribed Wound Care for Resident
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with a pressure ulcer, consistent with professional standards of practice. The resident, who had an unstageable pressure ulcer related to a deep tissue injury, reported not receiving wound treatment according to their physician's order due to the unavailability of the prescribed wound cleaning solution, Dakin's solution. Despite having an order to apply moistened gauze with Dakin's solution, the solution was not available from 12/23/2024 to 01/03/2025, and there was no documentation that the resident's physician or wound consultant was notified about this issue. Staff interviews revealed that the resident's wound was being treated with wet-to-dry dressing instead, without notifying the physician or obtaining a new wound care order. The Resident Care Manager acknowledged that the pharmacy and the resident's physician should have been notified when the prescribed solution was unavailable, and the Director of Nursing confirmed that an alternative wound treatment order should have been obtained. The lack of communication and failure to follow protocol placed the resident at risk for deterioration of their pressure ulcer and a diminished quality of life.
Failure to Ensure Accurate PASARR Screening
Penalty
Summary
The facility failed to ensure the accuracy and completion of the Preadmission Screening and Resident Review (PASARR) forms for several residents, which is crucial for identifying individuals with Serious Mental Illness (SMI) or Intellectual Disabilities (ID) who may be inappropriately placed in nursing homes. The report highlights that the PASARR forms for five residents were either incomplete or incorrect, leading to a lack of necessary Level II PASARR referrals. This oversight placed the residents at risk of not receiving appropriate care and services tailored to their specific needs. For Resident 41, the PASARR form was marked for a mood disorder but failed to include the resident's anxiety disorder, and no Level II referral was made. Similarly, Resident 67's PASARR form included anxiety disorder but omitted the depressive disorder, and no Level II referral was completed. Resident 36's form marked mood and anxiety disorders but did not include delusional disorder, and a Level II referral was not sent. Resident 46's form included PTSD and anxiety but omitted major depressive disorder, and no Level II evaluation was indicated. Lastly, Resident 20's form did not mark major depressive disorder, and no Level II referral was completed. Interviews with staff revealed a lack of understanding and adherence to the updated PASARR regulations, which require a Level II referral for any SMI indicators. Staff members acknowledged the discrepancies and admitted to missing necessary corrections and referrals. The facility's social services department was responsible for reviewing PASARR documents for accuracy, but the oversight in these cases indicates a failure to comply with the regulatory requirements, as outlined in the Washington Administrative Code (WAC) 388-97-1915.
Failure to Accurately Complete Daily Nurse Staffing Forms
Penalty
Summary
The facility failed to ensure the daily nurse staffing form was accurately completed with actual hours worked for each shift over a period of six days. Observations on multiple days revealed that the posted daily nursing staffing forms did not include the actual hours worked for each shift by the nursing staff, which included Registered Nurses, Certified Nursing Assistants, and Licensed Practical Nurses. This omission was confirmed during an interview with the Director of Nursing Services, who stated that they had not been filling out the actual total hours due to training received from a previous staffing coordinator. The facility's policy required that shift staffing information must be recorded on a form for each shift, including the actual hours worked during that shift for each category and type of nursing staff. The Administrator acknowledged that daily nurse staff postings need to be visible and available with the actual hours filled out.
Deficiencies in Medication Labeling, Storage, and Expired Supplies Management
Penalty
Summary
The facility failed to ensure proper labeling and storage of drugs and biologicals, as well as the removal of expired supplies, in accordance with professional standards. During an observation, a Licensed Practical Nurse (LPN) did not date two newly opened insulin pens before storing them in the medication cart. Additionally, a prescription bronchodilator inhaler was found with an incomplete label that did not come from the pharmacy, lacking the necessary prescription or pharmacy label. The facility also did not adhere to the Centers for Disease Control and Prevention (CDC) guidelines for vaccine storage. The Cascade medication room refrigerator's temperature was only checked once a day, despite the presence of a Respiratory Syncytial Virus (RSV) vaccine, which requires twice-daily temperature checks. Similarly, the [NAME] medication room refrigerator had missing temperature records and was also checked only once daily, despite storing an RSV vaccine. Expired medical supplies were found in the Baker medication room refrigerator, including intravenous starter needles with an expired date. The facility's Director of Nursing Services and other staff acknowledged these deficiencies, stating that the facility followed CDC guidelines and that expired supplies should have been discarded.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices, as evidenced by multiple deficiencies observed during the survey. One significant issue involved the improper disinfection of insulin pens and inadequate hand hygiene practices during medication administration for a resident. A Licensed Practical Nurse (LPN) was observed administering insulin doses without performing hand hygiene after removing gloves and before donning new ones. Additionally, the insulin pens were placed on a sink counter and stored in the medication cart without being cleaned, contrary to the facility's policy and CDC guidelines. Another deficiency was noted in the storage of personal care items and Personal Protective Equipment (PPE). Personal hygiene items were found unbagged and placed directly on the bathroom floor, which is against the facility's policy that requires such items to be bagged and stored properly. Furthermore, isolation carts for Enhanced Barrier Precautions (EBP) were improperly stocked, with non-PPE items like chips, cups, and linens stored alongside PPE. Some carts lacked essential PPE such as gowns, and staff were unaware of the correct PPE to be stored, indicating a lack of adherence to CDC guidelines and facility expectations. The facility also failed to provide adequate hand hygiene supplies in medication rooms and did not ensure the disinfection of shared transfer lift equipment between resident uses. Observations revealed that handwashing stations lacked necessary supplies like paper towels and hand sanitizer. Additionally, a Hoyer lift used for transferring residents was not disinfected between uses, increasing the risk of cross-contamination. Staff interviews confirmed these lapses, with some staff unaware of the need to disinfect equipment after each use, despite the facility's policy and OSHA standards requiring such practices.
Failure to Notify State LTC Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to properly notify the Office of the State Long Term Care (LTC) Ombudsman in writing regarding the transfer of a resident to the hospital. This deficiency was identified during a review of the facility's policy and resident records. The policy, revised in March 2021, mandates that a copy of the transfer or discharge notice be sent to the State LTC Ombudsman at the same time it is provided to the resident and their representative. However, a review of Resident 36's nursing progress notes from September 30, 2024, to November 25, 2024, revealed no documentation indicating that the notice of transfer was sent to the Ombudsman office. Interviews with facility staff further highlighted the deficiency. Staff I, a Social Services Assistant, acknowledged their responsibility for completing and faxing the transfer notice form to the State LTC Ombudsman office. However, they admitted there was no documentation or fax receipt confirming that the notice had been sent. Additionally, Staff A, the Administrator, confirmed the expectation that the Ombudsman office should have been notified in writing about the resident's hospital transfer and that such communications should have been documented.
Failure to Accurately Assess Resident's Oxygen Use
Penalty
Summary
The facility failed to accurately assess a resident's condition by not capturing the use of oxygen during the Minimum Data Set (MDS) assessment look-back period. The resident, who was admitted with asthma and respiratory failure, had received oxygen during the look-back period, as documented in the Treatment Administration Record (TAR). However, this was not reflected in the MDS assessment, which is a critical tool for evaluating the resident's care needs. The oversight was identified during an interview and joint record review with the Case Manager, who acknowledged that the MDS should have included the oxygen use. The Director of Nursing Services confirmed that the expectation was for staff to adhere to the Resident Assessment Instrument (RAI) Manual and complete MDS assessments accurately. This failure to document the resident's oxygen use placed the resident at risk for unidentified and/or unmet care needs, potentially affecting their quality of life.
Failure to Provide Baseline Care Plan Summaries
Penalty
Summary
The facility failed to develop baseline care plans and provide a written summary of these plans to two residents, identified as Residents 40 and 151, within 48 hours of their admission. This deficiency was identified through interviews and record reviews. The facility's policy, revised in March 2022, mandates that a written summary of the baseline care plan, including goals, medication, dietary instructions, and services, be provided to residents or their representatives. However, reviews of the Electronic Health Records (EHR) for both residents showed no documentation that such summaries were provided. Resident 40's EHR lacked any evidence of a written summary being given, while Resident 151, who had intact cognition, confirmed not receiving the summary. Staff interviews revealed that the baseline care plan was supposed to be developed upon admission, with the summary provided by social service personnel. However, both the Resident Care Manager and the Social Services Director acknowledged the absence of documentation indicating that the summaries were given. The Director of Nursing Services also confirmed the expectation that these plans should be developed and provided within the specified timeframe.
Improper Storage of Oxygen Tubing and Cannulae
Penalty
Summary
The facility failed to ensure proper storage of oxygen tubing and cannulae for two residents, leading to a deficiency in respiratory care. Resident 17, who was admitted with diagnoses including congestive heart failure and asthma, had a physician's order for oxygen via nasal cannula as needed for shortness of breath. Observations on two separate occasions revealed that Resident 17's oxygen tubing and cannula were not stored properly when not in use, with the nasal prongs touching the floor. Staff K, an LPN, confirmed that the tubing and cannula should have been stored in a bag when not in use. Similarly, Resident 46, who was admitted with diagnoses including congestive heart failure, asthma, and chronic respiratory failure with hypoxia, had a physician's order for supplemental oxygen. An observation showed that Resident 46's oxygen tubing and cannula were found on the floor beside their bed instead of being stored properly. Staff N, an LPN, acknowledged that the tubing should have been bagged when not in use and stated that it should be discarded. Both the Resident Care Manager and the Director of Nursing Services confirmed the expectation that oxygen therapy supplies should be stored in a bag when not in use to prevent cross-contamination.
Failure to Consistently Evaluate Dialysis Care
Penalty
Summary
The facility failed to consistently evaluate and document the dialysis care for a resident who required such services. The resident, who was cognitively intact and received dialysis three times a week at an offsite center, had a care plan directing staff to monitor and report any signs of infection at the dialysis access site. However, the facility's records showed no consistent evaluation or documentation of the resident's condition after dialysis treatments. Interviews with staff revealed a lack of awareness and adherence to the care plan, with some staff unaware of the location of the dialysis access site and others acknowledging that the order to check the site was not reinstated upon the resident's readmission. The Director of Nursing Services confirmed that the order to check the dialysis access site was not placed back when the resident was readmitted, and there was an expectation for staff to evaluate and document the resident's condition after each dialysis treatment. The resident also reported that the facility never checked the dialysis access site or evaluated them consistently after treatments. This oversight placed the resident at risk for unmet care needs and potential deterioration of their chronic condition.
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.
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What surveyors actually found near you
We read the 1,087 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Shoreline
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bridges To Home | 1.9 mi | ★★★★★ | 9 | 0 |
| The Broadview Center | 3.2 mi | ★★★★★ | 16 | 1 |
| Pine Ridge Post Acute | 3.3 mi | ★★★★★ | 18 | 0 |
| Edmonds Post Acute | 3.4 mi | ★★★★★ | 60 | 0 |
| Avamere Rehabilitation Of Shoreline | 4 mi | ★★★★★ | 12 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.