Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rock Hill Health & Rehabilitation during CMS and state inspections, most recent first.
Failure to Protect Resident from Alleged Physical Abuse: A resident with moderate cognitive impairment and a prior sacral fracture alleged that an unidentified male entered the room, twisted the resident’s hand, and caused bruising, swelling, and pain to the left hand and pinky. The allegation was reported to nursing, the resident was assessed and treated for pain, and an x-ray showed OA with no fracture, but leadership could not explain how the abuse allegation was ruled out.
A resident reported that an unidentified male entered the room, tried to take the resident’s dog, and twisted the resident’s left hand, leaving bruising, swelling, and pain in the hand and finger. The facility’s investigation ruled out abuse and blamed hallucinations, even though staff and the resident described an injury of unknown origin and the record did not explain how the hand injury occurred. Staff later acknowledged the abuse allegation was not thoroughly investigated.
The facility failed to ensure the designated IP met the education qualifications for certification before taking on the role. The DON stated they were covering IP duties until the position was filled, did not have a copy of their IP certification, and confirmed no one else in the building had an IP certification. No confirmation of IP certification was provided.
A facility failed to keep resident rooms, shared bathrooms, hallways, the nurse’s station, and a visitor bathroom clean and orderly. Observations found soiled privacy curtains, sticky debris on floors, fecal matter on a toilet rim, urine/feces odor, dirty hallway flooring, debris and dried liquid on an overbed table, dead bugs and dust in a sanitizer tray, and damaged bathroom flooring and walls. Staff described housekeeping duties and noted deep cleaning of resident rooms only occurred when a resident moved or discharged.
A facility failed to make grievance information readily available and did not consistently resolve resident complaints. Staff were overheard dismissing a resident’s complaint about cold food, and another resident’s grievance about not receiving Valium before a dental visit could not be fully documented. During Resident Council, several residents said they did not know who handled grievances or where to find a form, and grievance forms and the locked grievance box were not easily accessible.
Failure to provide scheduled bathing assistance affected multiple residents who needed help with ADLs. Residents with stroke-related paralysis, dementia, MS, weakness, and other conditions were assessed as needing extensive or moderate assistance, but their bathing preferences were not consistently documented in the care plan or Kardex, and shower records showed repeated missed baths or showers, incomplete documentation, and no consistent refusal charting. Staff reported shower aides were often pulled to work the floor instead of bathing duties, and one resident was observed with greasy hair and body odor.
CNA competency records were not maintained or verified for three CNAs reviewed. The facility could not provide education, training, or competency documentation for an agency CNA, and the other two CNAs had competency evaluations that were last completed months earlier. The BOM/HR said the facility had changed ownership and the electronic files could no longer be accessed, and the DON was unaware the competencies were not completed.
Failure to complete annual staff performance reviews for multiple employees, including the DON, CNAs, and a PTA, was identified after the facility could not provide the most recent evaluations for 6 of 7 sampled staff. HR stated the records were unavailable due to a change of ownership and inaccessible electronic files. This was a repeat deficiency.
Expired probiotics and white petroleum were found in the Artist and Forest med rooms, and staff confirmed the items were past expiration. In the Forest med room, two bottles of TB solution lacked an open date even though the label said they were good for 30 days after opening. Vaccine refrigerator logs showed temperatures were checked only once daily with multiple missing entries, and the RN/RCM and DON/IP stated they were unaware of CDC guidance for twice-daily monitoring when required.
Meal service in the main dining room exceeded the 14-hour overnight interval, with dinner at 5:30 PM and breakfast at 8:00 AM. The Dietary Mgr believed the schedule was within the limit, but there was no routine substantial evening snack, no resident council approval, and the Administrator confirmed the posted times were accurate and had not been approved by the resident group.
Dishwasher temperatures in the kitchen did not meet required standards. A leased high-temp dishwasher had multiple logged wash cycles below 150 degrees F and rinse cycles below 180 degrees F, while the Dietary Mgr stated staff were told the dial read about 5 degrees off and to record the exact readings. The Admin was unaware of the low temps, and the most recent service note did not document the low readings or inaccurate dial issue.
Incomplete and inaccurate resident records were found for multiple residents. One resident’s chart lacked daily weights and proper sleep monitoring, and an allegation about a staff member was not fully documented or followed by alert charting. Another resident had no discharge note, and two residents had other residents’ documents scanned into their EHRs. Staff acknowledged missing documentation and mixed-up records.
The facility failed to ensure 5 of 5 CNA/NAC staff had the required 12 hours of annual in-service training. When training records were requested, none were provided. The BOM/HR said the facility had changed ownership and the education files were in electronic records that could no longer be accessed, and the DON stated they were unaware the required education had not been completed.
The facility failed to document advance directive information for multiple residents. One resident had a POLST but no documented AD discussion and said assistance had not been offered, another hospice resident with severe cognitive impairment had a POA listed but no legal paperwork in the EMR, and a third resident’s record and admission agreement contained no evidence that AD rights, options, or completion information were provided.
Failure to Provide Required Medicare Non-Coverage Notices: The facility did not provide required Medicare non-coverage notices for two residents receiving skilled services. One resident had no NOMNC or SNFABN documented, and another resident did not receive an SNFABN. The Social Services Director stated the residents should have received an SNFABN and could not locate a NOMNC or proof it was provided.
Unnecessary psychotropic medication use and inadequate documentation: Two residents received psychotropic meds without proper consent, behavior monitoring, or documented non-pharmacological interventions. One resident on hospice with dementia and other diagnoses was given an ABH gel containing lorazepam, diphenhydramine, and haloperidol multiple times despite no documented attempts at non-drug interventions and incomplete behavior tracking; the other resident was maintained on Abilify for unspecified depression and pseudobulbar affect, with minimal behavior documentation and no documented non-pharmacological interventions.
A facility failed to thoroughly investigate and timely report an allegation of verbal/mental abuse involving multiple residents. A resident reported that a former social services director used derogatory language and profanity toward another resident in conversation with a third resident, but the allegation lacked witness statements or detailed documentation, and the hotline report was delayed. Staff interviews showed the DON was informed, but the required report was not made immediately.
The facility failed to provide written bed-hold notice at the time of hospital transfer for multiple residents and did not ensure LTCO notification for one resident reviewed. For one resident, the EMR lacked the bed-hold document, a signed form was later found outside the EMR, and the form was incomplete; for another resident, there was no documentation that written bed-hold information was provided at transfer. Staff described the process as nursing offering the bed hold during transfer and documenting it in the EMR, but that did not occur as required.
PASRR referrals and Level II follow-up were not completed for multiple residents with MH diagnoses. One resident with depression and anxiety had a Level I PASRR showing a Level II referral was required, but no updated PASRR or Level II eval was documented. Another resident on hospice had an incorrect PASRR that initially said no Level II was needed despite positive SMI indicators, and a third resident with anxiety, depression, and PTSD remained in the facility past the expected stay while the Level II evaluator was only intermittently notified.
Care plans were not revised for several residents after changes in orders, assessments, and discharge planning. A resident on hospice had an as-needed antipsychotic gel ordered and active on the MAR, but the care plan was not updated for weeks. Another resident’s elopement risk status changed, yet the care plan was not revised, and a third resident had discharge planning documented without an active discharge care plan. A resident with PTSD also had a psychosocial care plan that lacked individualized bathing-related interventions and coping strategies.
Unsafe supervision and elopement monitoring failures: A resident with dementia, repeated falls, wandering, and agitation was observed entering other residents’ rooms, attempting to access restricted areas, and making unwanted contact with others, while incident documentation and follow-up were incomplete. Another resident with a history of elopement had inconsistent elopement risk documentation, missing wander guard monitoring records, and binder documentation that did not match the resident’s current status.
A resident was not given a prescribed pre-dental dose of Valium before a tooth extraction appointment, resulting in a significant med error. The grievance log, MAR, and dental note showed the resident reported never receiving the medication, while the RNCM said the dental office claimed it faxed the Rx but the facility never received it; the DON stated there was no communication between the dentist and the facility.
A resident admitted after a stroke had documented broken and missing teeth, poor dentition, and a dysphagia diet, but the care plan contained only generic dental interventions and no individualized monitoring for the resident’s current dental issues. The resident reported sore teeth and gums, and observation showed broken teeth with reddened, swollen gum tissue. The chart had no documentation of a dental follow-up visit or pending appointment, and an ordered PRN oral gel for tooth pain was administered only once.
The facility failed to implement its ASP for 3 residents receiving prophylactic antibiotics. One resident received Cephalexin for UTI prophylaxis, another received Macrodantin nightly for UTI prophylaxis, and a third received Fosfomycin every 10 days for UTI prophylaxis, all without clear stop dates or adequate documentation supporting continued use. Interviews confirmed the DON, Medical Director, and Administrator lacked consistent documentation and follow-through regarding the rationale for ongoing antibiotic prophylaxis.
Surveyors found that the facility’s use of a broad flex-time medication pass system led to multiple residents receiving APAP, levetiracetam, carvedilol, carbidopa-levodopa, and fosfomycin at times that did not comply with prescriber orders, manufacturer guidelines, or the facility’s own one-hour-before/after policy. One resident’s seizure and pain medications were repeatedly given late or at inconsistent intervals; another resident’s Parkinson’s medication was not coordinated with meals as ordered and APAP doses were given too close together; and a third resident’s APAP and carvedilol were scheduled and administered without regard to ordered meal timing, with some APAP doses only minutes apart and an antibiotic order left unclear between “evening” and “with breakfast.” Staff interviews showed reliance on wide flex-time windows, lack of clear documentation of exact administration times on the MAR, and inconsistent understanding of how to space BID and TID medications, contributing to the cited deficiency for pharmaceutical services.
Surveyors identified that the facility lacked an effective medication administration system, resulting in missed doses, poor adherence to provider orders, and failure to follow the facility’s stated ten rights of medication administration. One resident on prophylactic Fosfomycin Tromethamine for UTI prevention had a 20‑day gap between documented doses, with no evidence the scheduled intermediate dose was given. During observed med passes, an LPN did not check medication expiration dates, did not knock before entering rooms, failed to verify resident identity, misidentified or failed to identify medications when questioned by residents, and only told residents, “this is your medication.” Multiple nurses could not accurately state the ten rights of medication administration. MAR reviews for several residents showed no documentation that scheduled evening or HS medications, including psychotropics, cardiovascular agents, pain medications, bladder medications, glaucoma drops, antivirals, and blood sugar monitoring, were administered, while the DON who worked that shift believed the medications had been given.
Surveyors found that a treatment cart on one unit was left unlocked while an LPN was away at another medication cart, with open Derma Fungal cream, an odor eliminator, and other treatments easily accessible in its drawers despite facility policy requiring carts to remain locked. On another unit, an open tube of Refresh eye drops was left in a medication cup on top of a medication cart while an RN was several feet away at a different cart, after a resident had refused the drops. The Administrator and DON later acknowledged that carts should not be left unlocked and medications should not be left unattended on top of carts.
Staff failed to consistently follow infection control practices, including hand hygiene, PPE use, and cleaning of resident care equipment. An LPN prepared and administered medications to a resident without performing hand hygiene before or after handling medication cups, then documented and moved on to another resident still without hand hygiene. For a resident on precautions, the same LPN checked blood glucose, left the room wearing PPE, handled a glucometer and medication cart in the hallway, removed PPE there, and continued care activities without performing hand hygiene or disinfecting the glucometer or vital sign cart. The glucometer was returned to its storage bag and cart drawer without cleaning, despite manufacturer instructions and facility handouts requiring cleaning and hand hygiene as part of standard infection prevention procedures.
The facility did not conduct comprehensive investigations into allegations of abuse and neglect involving two residents—one who reported delayed pain medication and verbal mistreatment by a nurse, and another who experienced a prolonged wait for incontinence care due to caregiver availability. Key investigative steps, such as interviewing involved staff and reviewing medical records, were omitted, and the needs of other residents with similar care preferences were not assessed.
The facility did not include agency staff hours in its PBJ submission, resulting in a significant underreporting of total staffing hours and failure to meet the required HPRD for the quarter. This led to inaccurate staffing data being reported to CMS.
Facility administration did not ensure timely payment to vendors, leading to the discontinuation of laboratory services and missed critical lab tests for several residents, including drug level monitoring and metabolic testing. Staff confirmed that unpaid bills caused the service disruption, and there was no alternative lab available for the required tests. The facility also experienced delayed payroll, affecting staff benefits and care continuity.
Multiple residents did not receive timely or complete laboratory testing as ordered, including missed urinalysis, Hemoglobin A1C, Depakote levels, CBC, and CMP tests. These failures were linked to a disruption in lab services caused by vendor non-payment, with staff interviews confirming missed draws and lack of follow-up or documentation.
A resident admitted with multiple pressure ulcers and at moderate risk for further skin breakdown did not receive a pressure offloading mattress in a timely manner. The care plan initially lacked pressure ulcer prevention interventions, and a low air loss mattress was not provided until about a month after the need was identified. This delay led to the development of a preventable stage 3 pressure ulcer on the coccyx, requiring advanced wound care and impacting the resident's rehabilitation.
The Governing Body did not ensure timely payment of vendor invoices, leading to discontinued lab services, missed essential lab tests for several residents, and threats of utility disconnection. Staff reported missed payroll and loss of benefits, while administration confirmed ongoing financial difficulties and delayed payments to vendors.
The facility did not conduct complete investigations into incidents involving falls, potential abuse or neglect, and medication errors. In several cases, investigations lacked necessary witness statements, omitted key details about the events, and failed to determine root causes or whether care plans were followed. For example, a resident with dementia was found with a head injury, but the investigation was missing staff statements and details about care provided prior to the fall. Another resident experienced multiple falls without thorough review of environmental factors or staff actions. Additionally, a medication error involving duplicate orders was not fully investigated, with missing verification from the pharmacy and no assessment of system failures.
The facility did not ensure timely and accurate completion of PASRR assessments for several residents with mental health diagnoses, including missing preadmission screenings, failure to update assessments when residents' conditions changed, and incomplete documentation of relevant psychiatric conditions. Staff responsible for PASRRs expressed uncertainty about the process, and required Level II evaluations were not initiated when indicated.
Nine CNAs worked with expired OBRA verifications, and the facility did not have a process to ensure active OBRA status prior to employment or scheduling. The Business Office Manager and Administrator confirmed that staff with expired verifications had been working and that OBRA documentation was not obtained for agency staff.
Surveyors found that the facility did not ensure complete and accurate medical records for several residents, with multiple omissions in MARs and TARs, including missing documentation of medication administration, monitoring, and assessments. In one case, a resident's record retained an incorrect mental health diagnosis despite a PASRR evaluator's correction, and staff were unaware of the error or lacked documentation audits.
A resident with cognitive impairment who required supervision for toileting was found on the floor with a significant head laceration after being left unsupervised, in violation of their care plan. The incident, which involved substantial injury and was not witnessed, was not reported to the state hotline as required by facility policy and state guidelines. Staff interviews confirmed the expectation to report such injuries, but the event was not documented as reported.
Two residents receiving psychotropic medications did not have their care plans revised to include current symptoms, resident goals, or non-pharmacological interventions. The care plans only addressed medication administration and monitoring for adverse effects, omitting key individualized information required for effective care planning.
Nursing staff administered cardiac medications to several residents despite physician orders to hold these medications for low blood pressure or heart rate. Medication administration records showed repeated instances where Amlodipine and Metoprolol were given when vital signs were below the specified parameters. Staff interviews confirmed awareness of the hold parameters, but the medications were still administered inappropriately.
A resident with severe cognitive impairment and a history of UTIs did not consistently receive adequate fluids, with daily intake falling short of the estimated requirement. Fluids were often not available or out of reach, and staff did not consistently assist or document hydration, despite the resident's need for extensive help and observed signs of dehydration.
A resident with mild cognitive impairment repeatedly reported significant pain, especially in the gluteal area, during daily care and repositioning. Staff did not consistently assess pain before or after administering scheduled pain medication, and pain assessments were only performed weekly. The provider was not notified of increased pain, and physical findings included red areas and an open wound. Staff interviews confirmed that pain complaints were not always followed by proper assessment or provider notification.
Annual staff performance reviews were not completed or properly documented for a nursing assistant certified, with missing signatures, dates, and incomplete evaluation forms. Only one page of a two-page evaluation was available, and no additional documentation was provided.
A resident with osteoporosis received duplicate weekly doses of Alendronate due to two active orders for the same medication on different days. Both doses were documented as administered over several weeks, and staff were unaware of the duplication until it was identified during review. The facility's medication error investigation did not fully clarify whether the pharmacy supplied extra medication or resolve inconsistencies in staff accounts.
A resident with osteoporosis received duplicate doses of Alendronate due to a duplicate order, and the error was not identified by the facility's medication management system or during monthly pharmacist reviews. Additionally, the resident's ongoing use of Enoxaparin lacked a documented stop date or treatment clarification, and these issues were not addressed in pharmacy reviews.
A NAC did not receive all required training in dementia care, abuse/neglect, communication, QAPI, and annual education. Review of training records showed only partial completion, and staff interviews revealed a lack of tracking for agency NAC training and unclear responsibilities for monitoring education requirements. This issue was previously cited.
A staff member worked as a NAC without an active certification after their credential expired. Employment and timecard records confirmed the individual continued to provide care while uncertified, and the lapse was not identified due to a missed follow-up in the facility's license audit process. Leadership confirmed that all NACs are expected to maintain current certification.
A resident with Alzheimer's disease eloped from the facility due to inadequate supervision and failure to follow the facility's wandering risk policy. The resident's assessments initially showed no elopement risk, and their care plan was resolved without proper documentation. Staff interviews revealed a lack of awareness and communication regarding the resident's risk status and procedures, contributing to the incident.
The facility failed to maintain a safe, sanitary, and homelike environment, with issues such as loose wallboard, broken ceiling tiles, and overgrown outdoor spaces. Additionally, hot water availability problems prevented residents from receiving showers, with water temperatures recorded as low as 61.9°F.
Failure to Protect Resident from Alleged Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by an unidentified male staff member. The resident, who had a diagnosis including a sacral fracture and moderate cognitive impairment on the admission MDS, alleged that a male entered the room during the night and twisted the resident’s left hand while trying to take the resident’s dog away. The resident later had bruising, swelling, and pain to the left pinky and outer left hand, including a 6 cm bruise to the left pinky finger, an 11 cm bruise to the side of the left hand, and a 3.5 cm by 5 cm bruise on the back of the hand below the thumb. Facility documentation and interviews showed the allegation was reported after the family member asked about the hand injury, and the primary nurse was notified. The resident was assessed, given oxycodone for pain, and an x-ray was obtained that showed osteoarthritis in the left hand with no fracture. The incident investigation documented the resident’s allegation of physical abuse from an unidentified male, but when asked how the abuse allegation was ruled out, the administrator, RN, and LPN/Resident Care Manager could not state how abuse was ruled out.
Failure to Thoroughly Investigate Abuse Allegation and Unexplained Hand Injury
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident who reported that an unidentified male came into the room during the night, attempted to take the resident’s dog, and twisted the resident’s left hand. The resident’s left hand was assessed and bruising, swelling, pain, and tenderness were documented on the left little finger, the left side of the hand, the back of the left hand, and below the left thumb. The facility’s investigation concluded that abuse and neglect were ruled out and attributed the event to hallucinations, despite the resident’s report of physical abuse and the observed injury. The resident’s statements were documented in multiple accounts, including that the unidentified male was white and in his late 40s to 50s, but the investigation summary did not identify how the injury of unknown origin occurred. Staff statements varied in what they observed and when they observed it, with some staff reporting no bruising, pain, or complaints during morning care, while later the resident and family raised the concern about the left hand injury. Witness statements from staff who worked the prior evening and night did not identify any concerns, and there were no additional witness statements to explain the injury. During interviews, the Administrator, DON, and other staff acknowledged that the abuse allegation was not thoroughly investigated. The record review showed the facility relied on the resident’s hallucinations as the explanation for the injury without documenting other factors that could account for the left-hand bruising and swelling. The report cited WAC 388-97-0640(6)(a)(b) in relation to the deficient investigation.
Infection Preventionist Qualification Deficiency
Penalty
Summary
The facility failed to ensure the designated Infection Preventionist responsible for the Infection Control Program met the education qualifications for certification before assuming the role. Review of the undated facility policy titled, Infection Preventionist, documented that the IP had obtained specialized infection prevention and control training beyond initial professional training or education prior to assuming the role. During an interview on 05/28/2026 at 10:58 AM, the DON stated they were in charge of IP duties until someone was hired for the position, stated they did not have a copy of their IP certification but had completed it in 2022, and stated no one else in the building had an IP certification. The DON also stated they sent an email to obtain a copy of the certification but had not heard back, and no confirmation of IP certification was provided.
Unsanitary Environment in Resident Areas and Common Spaces
Penalty
Summary
The facility failed to ensure the environment was clean, sanitary, and orderly in resident rooms, shared bathrooms, hallways, the nurse’s station, and a visitor bathroom. In room [ROOM NUMBER], a privacy curtain between two beds had yellowish and white matter on the middle of the curtain at bed height, and red debris was observed on the floor near the window that was sticky when stepped on. An overbed table in another room had debris and dried brown liquid on the bottom portion and frame. Resident 14 stated they did not have housekeeping services every day. The shared bathroom between rooms 136 and 135 was observed on multiple occasions to have a dime-sized piece of fecal matter on the toilet rim and an odor of urine and feces. Hallway flooring had cracks, dried brown liquid, visible dirt between doors and frames, round brownish spill marks, and debris stuck to the floor. The main nurse’s station light fixtures contained debris and the outline of dead bugs, and the hand sanitizer dispenser tray had a dead bug and dust in a pool of hand sanitizer. The visitor bathroom in the dining room had cracked linoleum, black spots under the flooring, knicks and gouges, tears and rips in the drywall around the door frame, and brown matter on the wall below the light switch. Staff stated housekeeping duties included disinfecting high-touch areas, sweeping and mopping floors, disinfecting toilets, and taking out trash, while deep cleaning resident rooms only occurred when a resident moved or discharged.
Grievance Process Not Readily Accessible or Properly Resolved
Penalty
Summary
The facility failed to have a system in place to ensure information was readily available and posted in prominent places for residents on how to file grievances or complaints, and grievances were not addressed and resolved in response to residents’ concerns for 2 of 2 residents who voiced grievances. The facility policy stated residents and their representatives had the right to file grievances orally or in writing, and that staff would make prompt efforts to resolve grievances to the satisfaction of the resident or representative. For Resident 47, staff were overheard discussing a complaint that the resident’s food was cold, and a nurse’s aide responded that if the resident wanted hot food, they needed to go to the dining room. The social worker later stated they were in the process of completing a grievance form for this concern, and the Administrator stated a grievance should have been initiated when the resident complained. For Resident 7, the grievance log documented a complaint that the resident had not received Valium before a dental appointment, but social services could not locate the grievance form with the resolution. During Resident Council, multiple residents stated they did not know who the grievance official was or where to find a grievance form, and one resident said staff would fill it out for them. Observation showed grievance forms were placed at the employee time clock area and a locked grievance box in the reception area was obstructed and not readily accessible to residents.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
The facility failed to provide bathing assistance for residents who were unable to complete ADLs independently. Review of the facility policy showed qualified nursing staff were to provide at least two full baths or showers per week, document the date and time, and record refusals with notification to the licensed nurse. The deficiency involved Residents 3, 5, 7, and 50, all of whom had care needs requiring assistance with bathing and whose bathing preferences were not consistently included in their care documentation. Resident 3 had a stroke with right-sided paralysis and speech deficits and was assessed as needing extensive assistance with bathing. The care plan did not include bathing preferences. Resident 3 stated they were not receiving showers as scheduled, said they were supposed to have showers on Mondays and Thursdays, and reported they had not been asked about bathing preferences. Bathing records showed eight scheduled showers in May 2026 with four showers and two bed baths documented, no refusals, and April 2026 records showed eight scheduled showers with only one received and several entries marked N/A without explanation. March and February 2026 had no bathing documentation available. Resident 5 had diagnoses including cerebral infarction with hemiplegia, dementia, and multiple sclerosis and required extensive assistance with bathing; the Kardex did not include bathing or grooming guidance or preferences. Resident 5 was scheduled for two showers weekly in April 2026 but received six showers rather than eight. Resident 7 had depression, low back pain, muscle wasting, atrophy, and weakness, required moderate assistance with bathing, and had a history of nightmares related to being stuck in a bathtub prior to admission; this was not included in the Kardex. Resident 7’s April 2026 records showed six showers rather than eleven and May 2026 records showed eight showers rather than thirteen, and the resident was observed with greasy, uncombed hair and body odor. Resident 50 had depression, heart failure, and muscle weakness, required moderate assistance with bathing, and had bathing preferences omitted from the Kardex; records showed only one shower 13 days after admission, and staff interviews indicated shower aides were frequently pulled to work on the floor and that missed showers and refusals were not consistently documented.
CNA competency records were not maintained or verified
Penalty
Summary
The facility failed to implement a system to evaluate staff competencies in skills and techniques to ensure staff provided necessary care and responded to each resident's individualized needs for 3 of 5 CNAs reviewed for nursing services. The facility assessment stated that CNAs participated in annual skills assessments and were assessed annually for care competencies by qualified nurses in addition to training during all staff in-services, but the record review did not support that this process was completed for Staff G, Staff U, and Staff V. Staff V was an agency CNA hired on 10/01/2025, and the facility could not provide any competencies, training, or education for this staff member. Staff U was hired on 04/02/2024, and the last competency evaluation provided was completed on 04/30/2025. Staff G was hired on 05/02/2024, and the last competency evaluation provided was completed on 05/06/2025. The Business Office Manager/Human Resources stated the facility had recently gone through a change of ownership and the proof of education and training was in electronic files that could no longer be accessed. The DON stated they were unaware competencies were not completed and electronic access to staff education had been removed.
Failure to Complete Annual Staff Performance Reviews
Penalty
Summary
The facility failed to complete annual staff performance reviews and provide education based on the results for 6 of 7 sampled staff members: Staff B, G, H, T, U, and W. The staff list showed Staff B, the DON, was hired 04/25/2025; Staff G, a CNA, was hired 05/02/2025; Staff H, a CNA, was hired 06/19/2024; Staff T, a CNA, was hired 10/15/2018; Staff U, a CNA, was hired 04/02/2024; and Staff W, a Physical Therapist Assistant, was hired 03/03/2016. When the most recent performance evaluations for these staff were requested on 05/27/2026, none were provided. During an interview on 05/28/2026, the Business Office Manager/Human Resources stated the facility could not provide proof of performance evaluations because of a recent change of ownership and because the evaluations were in electronic files that could no longer be accessed. This was identified as a repeat deficiency from the Statement of Deficiencies dated 05/01/2025.
Expired Medications, Undated TB Solution, and Incomplete Vaccine Temperature Monitoring
Penalty
Summary
Expired medications were found in both the Artist Medication Room and the Forest Medication Room during observation and record review. In the Artist Medication Room, probiotics were observed in the medication refrigerator with an expiration date of 04/2026, and multiple individual packets of white petroleum were found in the cupboard with an expiration date of 11/2025. Staff confirmed the expiration dates and removed the items from the medication room for disposal. In the Forest Medication Room, probiotics were observed in the medication refrigerator and cupboard with expiration dates of 04/2026, and Staff confirmed those dates and removed the items for disposal. The Forest Medication Room refrigerator also contained two bottles of TB solution with a label stating it was good for 30 days after opening, but no open date was present. The refrigerator temperature logs showed temperatures were checked only once daily, with multiple missing temperature entries across January through May 2026 for both medication refrigerators. Staff stated they were unaware of CDC vaccine storage guidance requiring temperature checks and recording at least twice daily when the device does not provide minimum and maximum temperatures, and the DON/Infection Preventionist also stated they were unaware of the vaccine temperature guideline.
Meal Service Exceeded 14-Hour Overnight Interval Without Resident Approval
Penalty
Summary
The facility failed to ensure that the time between the evening meal and breakfast in the main resident dining room did not exceed 14 hours, and there was no approval from the resident group or provision of a substantial evening snack. The posted mealtime schedule showed dinner in the main dining room at 5:30 PM and breakfast at 8:00 AM, which was greater than 14 hours. The Dietary Manager stated the times had been adjusted and believed they were within 14 hours, but also confirmed there was no specific routine evening snack and that meal timing had not been discussed with the resident council because staff were not aware there was an issue. The Administrator confirmed the posted dining room times were accurate and acknowledged there had been no resident group approval and no substantial evening snack provided. The resident council also confirmed there had been no approval by the group for meal service between dinner and breakfast to exceed 14 hours.
Dishwasher Temperatures Did Not Meet Required Standards
Penalty
Summary
The facility failed to ensure that the dishwashing temperatures in the kitchen met required standards. The Washington State Retail Food code stated that high temperature dishwashers required a wash cycle temperature of 150 degrees Fahrenheit and a rinse cycle temperature of 180 degrees Fahrenheit. During observation and interview, the Dietary Manager stated the facility used a leased high temperature dishwasher. A High Temperature Dish Machine Log for May 2026 showed three temperature entries per day and documented 18 instances where the wash cycle did not reach the minimum 150 degrees Fahrenheit and 3 instances where the rinse cycle did not reach the minimum 180 degrees Fahrenheit. The Dietary Manager stated the dishwasher company reported the machine was functioning properly and reaching temperature, and that staff had been told the dial was reading about 5 degrees off and to record exactly what the dial showed. The Dietary Manager also stated they were not concerned because the company said the machine was functioning. The provided service note showed the most recent service was in March 2026 and did not include notes about low temperature readings at the facility or inaccurate dial readings. The Administrator stated they were not aware of the low dishwasher temperatures and said that if the dial was not reading correctly and temperatures were not reaching the minimums, the company needed to be contacted for repairs.
Incomplete and inaccurate resident medical records
Penalty
Summary
The facility failed to maintain complete, accurate, accessible, and systematically organized medical records for 6 of 6 residents reviewed for record accuracy and completeness. The record review found that Resident 50’s chart did not reflect daily weights on 05/18/2026 and 05/23/2026, and the sleep monitor was set up as a checkmark task rather than documenting the number of hours slept, resulting in no sleep monitoring for nursing to evaluate the resident’s sleep pattern. After Resident 50 made an allegation to surveyors about a staff member and reported waiting 3 to 4 hours for the call light to be answered, the progress note entered by the Administrator only documented that the resident said they waited 2 hours for the call light and did not include the concern about the staff member. The resident was not placed on alert for monitoring every shift for 3 days after the allegation, and there were no other progress notes about the allegation. The review also found that Resident 44’s discharge from the facility to a facility in Michigan had no discharge note in the progress record. In addition, Resident 4’s electronic record under miscellaneous records contained a hospice note that belonged to Resident 17, and Resident 23’s electronic record under miscellaneous records contained a pharmacy recommendation that belonged to Resident 30. Staff D stated the resident care managers had taken over the discharge process and that a discharge note should have been completed for Resident 44, while Staff A stated they were unaware that Resident 4 and Resident 23 had other residents’ records scanned into their charts. The report identified this as a repeat deficiency from a prior statement of deficiencies.
Nurse Aides Lacked Required In-Service Training
Penalty
Summary
The facility failed to ensure 5 of 5 nurse aides (Staff G, H, T, U, and V) had the required 12 hours of in-service training. Review of the staff roster showed Staff G, H, T, U, and V were CNA/NAC staff, including one agency aide used by the facility. When the required 12 hours of in-service training were requested, none were provided by the facility or staff. In interview, the Business Office Manager/Human Resources stated the facility had recently gone through a change of ownership and the proof of education and training was in electronic files that could no longer be accessed. The Business Office Manager also stated the prior staff development coordinator had completed competencies for staff before leaving. The DON later stated they were unaware the required education had not been completed and that electronic access to staff education had been removed.
Missing Advance Directive Documentation for Multiple Residents
Penalty
Summary
The facility failed to address required documentation for advance directives for 3 of 6 residents reviewed. The facility’s Advance Directives policy stated that upon admission, staff were to provide written information about the right to refuse or accept medical or surgical treatment and to formulate an advance directive, and that the Social Services Director or designee was to ask the resident, family member, or legal representative about any existing written advance directives. The policy also required that whether a resident had executed an advance directive be prominently displayed in the medical record, and that if no advance directive existed, staff offer assistance and document the resident’s decision to accept or decline that assistance. Resident 7 was admitted with a POLST in place that indicated no resuscitation and comfort-focused treatment, but the record contained no discussion of an advance directive and the resident stated they had not been offered assistance to formulate one. Resident 8 was admitted on hospice with cerebrovascular disease, dementia, and chronic kidney disease; assessments documented severe cognitive impairment and that the resident was rarely or never understood, and the EMR showed a POA had been making decisions since admission, but the legal POA paperwork was not in the record. Resident 4 was admitted with a left leg fracture and PTSD, and the EMR and admission agreement contained no documentation that the resident was notified verbally or in writing of the right to formulate an advance directive, the types available, or how to complete one.
Failure to Provide Required Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide required notices regarding anticipated Medicare non-coverage for 2 of 3 residents reviewed, Residents 38 and 51. Record review showed Resident 51 began receiving Medicare skilled services on 11/29/2025 and ended on 12/04/2025, and the facility documentation indicated that neither a Notice of Medicare Non-Coverage (NOMNC) nor a Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) was provided. Record review also showed Resident 38 began receiving Medicare skilled services on 09/03/2025 and ended on 09/18/2025, and the facility documentation indicated that an SNFABN was not provided. During interview on 05/26/2026 at 1:47 PM, the Social Services Director stated that Residents 51 and 38 should have received an SNFABN to explain potential costs of their care and stated they were unable to locate a NOMNC for Resident 51 or documentation that one was provided.
Unnecessary psychotropic medication use and inadequate documentation
Penalty
Summary
The facility failed to ensure two sampled residents were free from unnecessary psychotropic medications. The report states the facility did not obtain consent, did not monitor and document behaviors and symptoms, did not attempt and document non-pharmacological interventions before administration, and did not demonstrate adequate indication for use of the medications. The deficiency was cited under WAC 388-97-0620(1). Resident 8 was admitted on hospice with diagnoses including cerebrovascular disease, dementia, and chronic kidney disease. The resident’s quarterly MDS documented no hallucinations or delusions, but did note physical symptoms directed toward others on some days. On 02/13/2026, hospice ordered an as-needed compounded topical gel containing lorazepam, diphenhydramine, and haloperidol for use if the resident refused oral medications and for anxiety, restlessness, or agitation. The record showed consent for the antipsychotic gel was not obtained until 03/02/2026, and the POA documentation was not found in the EHR. The February, March, April, and May 2026 MARs documented multiple administrations of the gel, but the record did not show non-pharmacological interventions were attempted or documented before use, despite MAR instructions to offer interventions such as coffee, talking, walking, repositioning, massage, quiet setting, relaxation techniques, music, distraction, toileting, ambulation, food or drink, education, or one-on-one support. The record also showed a behavior monitor implemented on 05/01/2026 for antipsychotic use, but it was set up to document check marks and initials rather than the number of behaviors per shift. Progress notes and observations described the resident as hard to arouse, very drowsy, asleep in the hallway, and at times wandering, entering other residents’ rooms, grabbing staff, and attempting to leave areas without staff present. Staff interviews confirmed the resident was taking multiple psychoactive medications, that the ABH gel was applied when the resident refused pills, and that consent and non-pharmacological interventions should have been obtained and documented before administration. Resident 23 was admitted with anxiety disorder, unspecified depression, and pseudobulbar affect. The annual CAA documented Abilify for depression, with behaviors such that a gradual dose reduction was not warranted. The medication order summary showed Abilify 5 mg twice daily for unspecified depression, and the care plan listed target behaviors including excessive crying, verbal aggression toward staff, and refusing care and meals. The May 2026 MAR showed a behavior monitor for those behaviors, but only one instance of excessive crying was documented and no non-pharmacological interventions were documented. A progress note stated the provider was contacted to provide an appropriate diagnosis for the resident’s Abilify use, and staff interviews confirmed that unspecified depression was not an appropriate diagnosis for Abilify.
Delayed Investigation and Reporting of Alleged Verbal Abuse
Penalty
Summary
The facility failed to thoroughly investigate and timely report an allegation of verbal/mental abuse involving three residents. A resident reported that the social services director, who was no longer with the facility, had called another resident a derogatory name using profanity in conversation with a third resident. The incident report documented that the allegation was first reported to the social services director, but there was no specific description of what was said, and there was no documentation, interviews, or witness statements to determine what the alleged comments were. An investigation was not initiated until several days after the allegation was known, and the report to the state hotline was made five days after the facility became aware of the alleged verbal/mental abuse. Staff interviews showed the registered nurse/resident care manager was informed of the allegation, reported it to the DON either that day or the next day, and did not make a hotline report. The resident who was interviewed stated they had not made the allegation themselves but had previously heard the social services director use derogatory language and profanity, and also described prior inappropriate and demeaning comments by the other resident toward the resident involved.
Failure to Provide Bed-Hold Notice and Required Notifications During Hospital Transfers
Penalty
Summary
The facility failed to provide written bed-hold notice at the time of hospital transfer for 3 of 3 residents reviewed for hospitalization, including Residents 1, 4, and 42. The facility policy titled "Bed Hold Notice," dated 10/01/2021, stated that prior to transfers, residents or resident representatives would be informed in writing of the bed-hold and return policy. For Resident 42, who was discharged to the hospital while out at a medical appointment, the EMR did not contain an uploaded bed-hold document, although a progress note stated the representative was offered a bed hold and a notice was signed. Staff later provided a signed form from administrative documents, and Staff F stated it had not been uploaded into the EMR; Staff E stated the document had been uploaded into financial documents instead of the EMR. The signed form was incomplete and lacked the signature showing the bed-hold policy was provided to the resident or representative. For Resident 1, who was transferred to the hospital and later returned to the facility, the EMR contained no documentation that written bed-hold information was provided to the resident or responsible party at the time of discharge. During interviews, Staff D stated that when residents are transferred to the hospital, a bed hold should be provided at the time of transfer either to the resident if possible or to the resident's responsible party, and that it should be documented in a progress note or uploaded to the EMR. The report also states the facility failed to ensure notification to the Office of the State Long-Term Care Ombudsman occurred for 1 of 3 residents reviewed for hospitalization.
PASRR referrals and Level II follow-up were not completed for residents with mental health diagnoses
Penalty
Summary
The facility failed to ensure that Level I PASRR screenings were referred and followed up on for 3 of 5 residents reviewed for PASRR. Resident 1 was admitted with diagnoses including heart failure, depression, and anxiety. A Level I PASRR dated 05/20/2024 documented that a Level II evaluation referral was required for serious mental illness, with comments noting a history of depression and anxiety and use of an antidepressant medication. The resident’s record did not contain an updated PASRR, and the progress notes did not document a Level II evaluation. On 05/14/2026, the Social Services Director documented that they had requested an invalidation or a Level II PASRR from the PASRR coordinator and were awaiting a response. Resident 8 was admitted on hospice with diagnoses including cerebrovascular disease, dementia, and chronic kidney disease. A Level I PASRR dated 11/06/2025 documented positive indicators for serious mental illness, including mood disorder and anxiety, but also indicated that no Level II evaluation was needed because the person did not show indicators of SMI. The comments stated the resident was on hospice, nearing end of life, and that anxiety and depression were stable with current medications. The Social Services Director later stated the PASRR was incorrect and submitted a new PASRR on 05/26/2026, which documented that a Level II evaluation referral was required for SMI and noted the resident remained on hospice, had dementia, and was receiving antipsychotic, antianxiety, and antidepressant medications. Resident 4 was admitted with diagnoses including anxiety disorder, depression, and PTSD. Their PASRR dated 11/24/2025 documented known indicators of serious mental illness and an exemption from Level II evaluation because the resident was anticipated to stay less than 30 days. Progress notes showed the Level II evaluator was notified after the resident remained past 30 days and later indicated the evaluator was planning to complete the Level II evaluation, while the Social Services Director stated there was a backlog and that follow-up occurred every 30 days to six weeks.
Care plans were not updated to reflect current assessments and resident needs
Penalty
Summary
The facility failed to ensure care plans were reviewed and revised by the interdisciplinary team for 4 of 5 residents reviewed for care planning. For Resident 8, who was admitted on hospice with cerebrovascular disease, dementia, and chronic kidney disease, a physician order dated 02/13/2026 directed use of an as-needed compounded topical antipsychotic gel for anxiety, restlessness, or agitation when oral medications were refused, and the order was active on the MAR by 02/16/2026. However, the care plan was not updated to include this medication until 04/18/2026. The DON confirmed in interview that the order had been in place in February and that the care plan was not updated until April, stating the care plan should have been updated more timely. For Resident 38, who had dementia, schizoaffective disorder, PTSD, and homelessness, progress notes documented elopements from the facility on 10/02/2025 and 10/13/2025, and the care plan dated 02/26/2026 identified the resident as an elopement risk with an air-tag intervention. An elopement risk assessment dated 05/26/2026 documented that the resident was not at risk for elopement, and the DON documented in a progress note that the resident was not at risk at that time, but the record did not show the interdisciplinary team reviewed or revised the care plan after that assessment. For Resident 44, the record showed discharge with family to an out-of-state facility on 04/03/2026, but the discharge care plan had been resolved as of 06/13/2025 and there was no active discharge care plan despite later notes documenting discharge planning. For Resident 7, who had schizoaffective disorder, PTSD, depression, and anxiety, the psychosocial well-being care plan addressed nightmares and difficulty sleeping related to a traumatic bathing experience, but it lacked individualized interventions for bathing, triggers, recovery goals, or coping strategies, and staff stated they were unaware of any specific bathing approaches.
Unsafe supervision and elopement monitoring failures
Penalty
Summary
The facility failed to maintain a safe resident environment free of accident hazards and failed to provide adequate supervision for residents identified as wandering or elopement risks. For Resident 8, who was admitted on hospice with diagnoses including cerebrovascular disease, dementia, and chronic kidney disease, the record showed severe cognitive impairment, impulsive unsafe self-transfers, repeated falls, wandering, grabbing staff and peers, and episodes of restlessness and agitation. The care plan identified the resident as a high fall risk and directed staff not to leave the resident alone in a wheelchair without supervision and to conduct frequent safety checks, yet the record documented 12 falls since admission and multiple observations of the resident moving about unsupervised. Resident 8 was observed entering other residents’ rooms, attempting to enter employee-only and therapy areas, trying to get into a locked utility room, and approaching residents and staff without adequate intervention to prevent unwanted touching. On one occasion, the resident self-propelled into a newly admitted resident and then into the surveyor while using a medication cart handle to move down the hall, and staff intervention did not prevent the contact. The incident log also showed an altercation with another resident, but the affected residents were not placed on alert charting and there were no progress notes about the altercation. The record further showed incidents of the resident crawling on the floor that were not entered in the incident log, and there was no assessment for injuries or incident investigation to determine the root cause. For Resident 38, the record showed prior elopement episodes and changing elopement risk assessments, including documentation that the resident was no longer an elopement risk despite a history of elopement and wandering. The physician order still documented a wander guard in place, but there was no supplemental documentation for nursing staff to check and document placement as required by facility policy. The elopement binder contained resident identification forms for some residents, but Resident 31, who was documented as an elopement risk with a wander guard in place, was not placed in the binder, and Resident 19 was documented as an elopement risk without a wander guard bracelet in place. Staff interviews confirmed that Resident 38 did not have a wander guard on at the time of observation and that the binder was not assigned to a specific person to update.
Missed Pre-Dental Valium Dose
Penalty
Summary
The facility failed to ensure a resident was free from a significant medication error when a prescribed pre-dental dose of Valium was not administered as ordered before a tooth extraction appointment. The grievance log documented that the resident reported never receiving Valium prior to the dental visit, and the medication administration record showed an order for the resident to attend the dentist with an escort because they were to be medicated with Valium beforehand. The resident’s record included a note that the facility nurse contacted the dental office and requested the Valium prescription be faxed to the facility, but there were no additional notes showing whether the prescription was received or processed. A dental visit note stated the resident did not take the medication as prescribed for the appointment. During interview, the resident stated they were supposed to receive a medication to help with sedation before the dental appointment and never got it, and staff later stated the dental office said it faxed the prescription but the facility never received it. The DON stated there was no communication between the dentist and the facility.
Dental care follow-up and pain management not ensured
Penalty
Summary
The facility failed to ensure the provision and follow-up of dental services for Resident 3, who was admitted following a stroke and had documented dental problems on the admission MDS and CAA. The MDS noted obvious and likely cavity or broken natural teeth, and the CAA documented some missing lower teeth in poor shape, an upcoming dental appointment, and a dysphagia diet. However, the care plan reviewed on 05/26/2026 contained only generic interventions to observe for complaints of pain or discomfort and refer to a dentist as indicated, with no individualized interventions or monitoring for the resident’s current dental problems or dental pain. During an interview and observation on 05/26/2026, Resident 3 stated they had sore teeth and gums, pointed to the right lower jaw area, and the mouth was observed to have missing and broken teeth with small white fragments visible, along with reddened and swollen gum tissue. The resident reported eating soft food and being careful brushing because the area was sore, and stated they had not seen anyone at the facility about the dental pain or dentition. Record review found no documentation of a dental visit since admission or any pending dental visit, although there was an order for topical mouth/throat gel for tooth pain and the MAR showed only one administration between 02/05/2026 and 05/28/2026. Staff Q stated the resident had gone to a dentist with their daughter about a week after admission, but the facility had no paperwork from that visit and did not know about any follow-up.
Antibiotic Stewardship Program Not Implemented for Residents on Prophylactic Antibiotics
Penalty
Summary
The facility failed to ensure its infection prevention and control Antibiotic Stewardship Program was implemented for 3 of 3 residents reviewed. The record review and interviews showed that the facility did not have adequate monitoring and tracking of antibiotic use for residents receiving prophylactic antibiotics, and there was no consistent documentation supporting why the antibiotics were continued. The facility policy referenced antibiotic stewardship requirements and noted concerns about unnecessary or inappropriate antibiotic use, but the residents’ records did not show the expected follow-through for stewardship oversight. Resident 5 was admitted with diagnoses including high blood pressure and a history of UTI. Physician orders directed staff to give Cephalexin 250 mg by mouth each morning for UTI prophylaxis, with no stop date. The clinical record did not show a trial discontinuation or physician documentation that prophylactic antibiotics were indicated. Resident 23 was readmitted with diagnoses including anxiety and depression. Physician orders directed staff to give Macrodantin 100 mg every evening for UTI prophylaxis beginning 09/26/2023, also without a stop date, and the record did not show a trial discontinuation or physician documentation supporting the prophylactic antibiotic. Resident 27 was readmitted with diagnoses including kidney disease and a history of UTI. Physician orders directed staff to give Fosfomycin 3 grams every 10 days for UTI prophylaxis beginning 04/11/2026, with no stop date. The record did not show physician documentation supporting prophylactic use until 05/29/2026, when documentation referenced a history of recurrent UTIs with current dysuria and burning reported on 05/28/2026, and a urology referral was ordered for frequent UTI symptoms. Interviews with the Medical Director, DON, RN/Resident Care Manager, and Administrator showed differing views about the residents’ prophylactic antibiotic use and confirmed that the facility lacked clear reasoning and documentation for continued use.
Failure to Administer Medications per Orders and Standards Under Flex-Time System
Penalty
Summary
The deficiency involves the facility’s failure to consistently provide pharmaceutical services that ensured medications were acquired, scheduled, and administered in accordance with prescriber orders, manufacturer guidelines, and the facility’s own policies. The facility’s “Medication and Flexible Pass Time” policy allowed broad administration windows (AM 6:00–11:00, noon 11:00–2:00, evening 2:00–7:00, HS 7:00–10:00) and defined routine medications as time-specific orders that could be given one hour before or after the scheduled time. Surveyors found that, in practice, medications were not administered within these parameters and were not consistently spaced according to general medication guidelines. Staff interviews showed that nurses relied on the flex-time windows and did not always know or document the exact administration times on the MAR, requiring separate reports to determine when doses were actually given. For one resident receiving acetaminophen (APAP) 1000 mg three times daily for pain and levetiracetam 1000 mg twice daily for seizures, the MAR showed APAP scheduled at AM flex pass, 11:00, and 8:00 p.m., and levetiracetam at AM flex pass and 4:00 p.m. The Medication Administration Audit Report (MAAR) documented multiple late or irregular doses. On several dates, the 11:00 APAP dose was given significantly late (e.g., at 1:41 p.m. and 1:34 p.m.), outside the one-hour window after the scheduled time. Levetiracetam doses were also given late or too close together, including a 4:00 p.m. dose administered at 8:46 p.m. and another day when the two daily doses were only five hours and 24 minutes apart, deviating from consistent interval guidelines. For a second resident receiving APAP three times daily and multiple daily doses of carbidopa-levodopa for Parkinson’s disease, the MAAR showed that carbidopa-levodopa was not administered in accordance with orders specifying dosing one hour before breakfast and one hour before or after meals. Morning doses ordered one hour before breakfast were given around 5:00 a.m., while breakfast was served between 7:50 and 8:00 a.m. Midday doses ordered one hour before or after lunch were administered approximately one hour before the scheduled lunch time, and an afternoon dose scheduled at 3:30 p.m. was set two hours before dinner, contrary to the order to give one hour before or after the meal. Evening doses ordered one hour before or after a meal were given at various times not clearly aligned with meal times. This resident’s APAP doses were also administered with very short intervals between the morning and 11:00 doses, sometimes less than three hours apart. For a third resident receiving APAP 1000 mg three times daily and carvedilol 6.25 mg twice daily ordered after meals, the MAR scheduled APAP at AM flex pass, 11:00, and 8:00 p.m., and carvedilol at AM flex pass and 4:00 p.m., without aligning carvedilol with meals as ordered. The MAAR showed instances where APAP doses were given late or too close together, including one day when the AM dose was given at 11:32 and the 11:00 dose at 11:59, resulting in 2000 mg of APAP administered 27 minutes apart. Carvedilol doses were also given late relative to the scheduled times. Additionally, this resident had an order for fosfomycin tromethamine “every 10 days in the evening…give with breakfast,” but the MAR scheduled it at 4:00 p.m., and there was no documentation in the EMR clarifying whether it should be given in the evening or with breakfast. During interview, the DON acknowledged the order was written in a confusing manner and would need clarification, and also recognized that the MAR did not show exact administration times, which could only be determined by running a separate report. Staff interviews further demonstrated inconsistent understanding and application of flex-time and dosing intervals. LPNs and an RN stated that AM flex time allowed administration between 6:00 and 11:00 a.m. and that for twice-daily or three-times-daily medications they would “spread out” doses as best they could, but they did not reference specific intervals or manufacturer guidelines. When asked how nurses would know the exact time a flex-time dose was given before administering the next scheduled dose, the DON initially stated it was documented on the MAR, then acknowledged that the MAR did not show exact times and that a separate report was needed. The survey report states that these failures to administer drugs and biologicals per physician orders and standards of nursing practice placed residents at risk for medication errors, unmet health care needs, and decreased quality of life.
Widespread Medication Administration Errors and Omissions
Penalty
Summary
The deficiency involves the facility’s failure to maintain a functioning medication administration system that ensured medications were given according to provider orders, not omitted, and administered in accordance with the facility’s stated ten rights of medication administration. The facility’s policy on medication pass required all morning medications to be administered between 6:00 AM and 11:00 AM and referenced ten rights to medication administration, but did not define what those ten rights were. The facility’s policy on medication incidents and errors defined an omission as any dose of medication not delivered to the resident. For one resident receiving Fosfomycin Tromethamine 10 grams every 10 days for UTI prophylaxis, the MAR showed doses given on 02/10/2026 and 03/02/2026, with a code on 02/20/2026 directing staff to see the nurse’s notes. The nurse’s note documented a call to the pharmacy about the medication and that the pharmacy would send as much as insurance allowed, but there was no evidence the 02/20/2026 dose was administered, resulting in a 20‑day gap between doses. The administrator and DON were not aware of this omitted dose. During a continuous medication pass observation, an LPN prepared six morning medications for another resident, including duloxetine, Tylenol, thyroid medication, a stimulant laxative, a gout medication, and a medication for an autoimmune disease. The LPN separated the duloxetine into one cup and the remaining medications into another, did not check expiration dates, entered the resident’s room without knocking, did not verify the resident’s identity, and addressed the resident only by first name. When the resident asked what the first cup of medications contained, the LPN first stated it was duloxetine and Tylenol, then, after the resident did not understand and asked again, stated it was Tylenol; the resident then took the two pills. When handing the second cup, the LPN again told the resident it was Tylenol when asked what the medications were. In a subsequent observation with a different resident, the same LPN took an acidophilus capsule from a house‑supply bottle without checking the expiration date, admitted they did not check expiration dates because the cart was filled at the beginning of the year, and then prepared additional medications. The LPN entered the resident’s room without knocking, did not verify the resident’s name, administered medications one by one with a spoon, and each time only stated, “this is your medication,” without identifying the medication name or purpose. Interviews with multiple nursing staff showed they could not correctly state the facility’s ten rights of medication administration, each listing only five or six rights, and the DON stated they would have to follow up on what the ten rights were. Review of MARs for several residents showed no documentation that scheduled 8:00 PM or HS medications were administered on 03/15/2026. One resident had no documentation of receiving a cholesterol‑lowering medication, a pain medication, and a probiotic; another had no documentation of an anti‑anxiety medication and an overactive bladder medication; another had no documentation of a cholesterol‑lowering medication, stimulant laxative, antipsychotic, and blood pressure medication; another had no documentation of an antiviral, glaucoma eye drops, a cholesterol‑lowering medication, and a nerve pain medication; and another had no documentation of an overactive bladder medication or blood sugar monitoring. When interviewed, the administrator and DON initially stated there had been no medication errors since surveyors arrived, and the DON, who passed medications on the PM shift on 03/15/2026, believed they had administered the HS and/or 8:00 PM medications. They were informed that the sampled residents’ MARs showed omitted medications and that only a small sample of residents on that hallway had been reviewed.
Unlocked Treatment Cart and Unattended Medications on Medication Cart
Penalty
Summary
The deficiency involves failure to keep medication and treatment carts locked and medications properly stored and labeled as required by facility policy and professional standards. The facility’s policy titled “Medication and Flexible Pass Time,” dated 10/27/2023, required that medication carts be locked at all times. On the morning of 03/16/2026, surveyors observed the [NAME] Lane treatment cart unlocked on two separate occasions while the responsible nurse, an LPN identified as Staff D, was down the hallway at a different medication cart. During this time, unidentified staff were seen walking past the unlocked cart on their way to the dining room. When informed, Staff D acknowledged responsibility for the cart and confirmed it should have been locked, stating that the prior shift, which ended at 6:00 AM, must not have locked it. Upon inspection of the unlocked [NAME] Lane treatment cart with Staff D, surveyors found an open tube of Derma Fungal cream and a bottle of simple odor eliminator in the top drawer, both labeled under their warning sections to be kept out of reach of children, along with other drawers containing various treatments, ointments, and creams that could be easily removed. Additionally, on the Artist Lane medication cart, surveyors observed a small open tube of Refresh eye drops placed in a plastic medication cup on top of the cart while the assigned RN (Staff C) was approximately 10 feet away at another medication cart preparing medications. Staff B later acknowledged that the eye drops should not have been left there and that the resident had refused the drops. In separate interviews, the Administrator (Staff A) and the DON/RN (Staff B) both stated that treatment and medication carts should not be left unlocked and that medications should not be left unattended on top of the cart.
Failure to Follow Hand Hygiene, PPE, and Glucometer/Vital Sign Equipment Cleaning Protocols
Penalty
Summary
The deficiency involves the facility’s failure to follow standard infection prevention and control practices, including hand hygiene, PPE use, and cleaning of resident care equipment such as vital sign (VS) equipment and a glucometer. Facility handouts from the Infection Prevention Manual for Long Term Care, revised 02/2018, directed staff to perform hand hygiene as part of donning PPE and to remove PPE at the doorway before leaving a resident’s room, followed immediately by hand hygiene. Despite these written procedures, staff actions during medication administration and resident care did not align with these guidelines. During continuous observation, one LPN prepared medications for a resident without performing hand hygiene, placing multiple pills into small plastic medication cups and handling the cups in the palm of unclean hands before entering the resident’s room. After the resident ingested the medications, the LPN discarded the cups, exited the room, returned to the medication cart, documented medication administration, and proceeded to another resident’s room without performing hand hygiene. Later, the same LPN was observed to perform hand hygiene before entering another resident’s room, but then inconsistently applied hand hygiene practices before and after subsequent resident care tasks. For a resident on precautions requiring gown and gloves for high-contact care, the LPN performed a blood glucose check, exited the room wearing PPE, walked down the hall, discarded an item in the sharps container, placed the glucometer on top of the medication cart, removed gown and gloves in the hallway, and returned to the cart without performing hand hygiene. The LPN then re-gowned and re-gloved without hand hygiene, entered the resident’s room with the VS cart, and later exited with PPE still on, parked the VS cart by the medication cart, removed PPE at a hallway trash can, and began preparing the resident’s medications without hand hygiene or sanitizing the VS cart or its components. The glucometer, which manufacturer guidelines required to be cleaned with soap and water or 70–80% isopropyl alcohol after use, was placed on the medication cart, then returned to its storage bag and cart drawer without being cleaned. The LPN acknowledged they were supposed to clean the glucometer with an alcohol pad after use but did not do so. Additionally, the administrator noted the lack of trash cans inside rooms of residents on precautions and stated this was unusual.
Failure to Conduct Thorough Abuse and Neglect Investigations
Penalty
Summary
The facility failed to conduct thorough investigations into allegations of abuse and neglect for two residents. For one resident with multiple sclerosis and anxiety, who was cognitively intact and experienced constant pain, the facility did not fully investigate an allegation that a nurse withheld pain medication and made derogatory comments. The investigation did not include a review of the resident's medical record to confirm medication administration times, nor did it include an interview with the nurse involved or with other residents regarding their experiences with medication administration or verbal abuse. The investigation summary instead focused on the resident's history of making allegations and ruled out abuse and neglect without substantiating the facts. For another resident with demyelination of the central nervous system, anxiety, and depression, who was dependent on staff for toileting and preferred female caregivers, the facility did not thoroughly investigate an allegation of neglect after the resident waited over an hour and a half for incontinence care. The investigation acknowledged the delay but did not identify it as potential neglect, nor did it assess whether other residents with similar care preferences were at risk. The investigation also failed to interview another resident who preferred female caregivers to determine if their needs were unmet. Interviews with facility leadership revealed a lack of awareness regarding key documentation and investigative steps, such as not reviewing relevant progress notes or interviewing involved staff. The Director of Nursing confirmed that essential investigative actions were omitted, including not checking medication administration times and not interviewing other potentially affected residents. The facility's investigations did not meet the minimum requirements outlined in their own abuse prevention policy, which mandates interviews with alleged perpetrators and thorough record reviews.
Failure to Accurately Report Staffing Hours in PBJ Submission
Penalty
Summary
The facility failed to ensure accurate submission of Payroll Based Journal (PBJ) data to CMS for Fiscal Year Quarter 4, 2024. The PBJ report submitted included only hours worked by facility-employed staff and omitted hours worked by agency or contracted staff, resulting in 28,907.80 hours unaccounted for in the report. This omission led to the facility not meeting the minimum required 3.4 Hours Per Resident Day (HPRD) and being short by 920 hours. The process for PBJ reporting involved the corporate office preparing the report, sending it to the administrator for review and approval, and then submitting it, but the failure to include agency staff hours was confirmed by the Chief Operating Officer. The inaccurate data submitted to CMS affected the reported staffing levels for the entire facility.
Failure to Maintain Financial Obligations Resulting in Disruption of Essential Resident Services
Penalty
Summary
Facility administration failed to maintain effective financial management, resulting in overdue payments to multiple vendors, including laboratory services, utilities, staffing agencies, and medical supply companies. The administration was aware of the outstanding balances and received multiple demand notices and service discontinuation warnings from vendors. Despite this awareness, the facility did not ensure timely payment, leading to a disruption in essential services. On a specific date, the laboratory services provider placed the facility on a non-payment hold, which resulted in the discontinuation of laboratory services. As a direct consequence, four residents did not receive critical laboratory tests as ordered. These included Depakote levels for two residents, which are necessary to monitor therapeutic drug levels and prevent toxicity, a Comprehensive Metabolic Panel and Complete Blood Count for another resident, and a Hemoglobin A1C test for a fourth resident. Staff interviews confirmed that the missed laboratory services were due to the vendor not coming to the facility because of unpaid bills, and there was no alternative laboratory available for these tests. Additionally, staff reported that the facility had experienced a delayed payroll, resulting in a temporary loss of staff benefits and out-of-pocket expenses for medical needs. The business office manager and administrator both indicated that invoices were forwarded to the corporate office for payment, but payments were not made in a timely manner. The failure to pay vendors on time directly impacted the facility's ability to provide necessary care and services to all residents, as evidenced by the missed laboratory tests and the risk of further service interruptions.
Removal Plan
- Ensured resident lab testing had been completed.
- Ensured an active laboratory services vendor was in place.
- Provided evidence of vendor contract payments to ensure continuity of essential services.
- Audited resident laboratory orders.
- Obtained ordered laboratory testing for affected residents.
Failure to Provide Timely Laboratory Services Due to Vendor Non-Payment
Penalty
Summary
The facility failed to provide timely laboratory services for five residents, resulting in missed or delayed lab tests as ordered by physicians. For one resident, a urinalysis was ordered to rule out a urinary tract infection due to new delusions and hallucinations, but the sample was not collected, and there was no documentation of follow-up or physician notification regarding the missed test. Another resident did not have a Hemoglobin A1C test completed as ordered, with no documentation in the medical record or treatment administration record indicating the lab was drawn or any result received. Two residents receiving Depakote for mood and behavioral management did not have their Depakote levels drawn as ordered. The orders specified that the Depakote level should be drawn on the night shift, but the tests were not completed on the specified dates. In one case, the Depakote level was eventually obtained two days after the order, and the result was reported as low. Additionally, a complete metabolic panel (CMP) was ordered for one of these residents but was not documented as completed. Another resident with a history of diabetes had an order for a Hemoglobin A1C, but there was no evidence the test was performed or results obtained. A further resident with a recent toe amputation and gangrenous tissue was to have a CBC and CMP drawn for ongoing monitoring, but these labs were not collected as ordered. Instead, a basic metabolic panel (BMP) was drawn several days after the order, and there was no documentation that the correct labs were obtained. Staff interviews confirmed that the facility experienced issues with laboratory services due to vendor non-payment, resulting in missed lab draws and lack of follow-up or documentation regarding the missed tests.
Failure to Timely Provide Pressure Offloading Mattress Resulting in Stage 3 Pressure Ulcer
Penalty
Summary
A facility failed to ensure timely ordering and implementation of a pressure offloading mattress for a resident who was at moderate risk for pressure ulcer (PU) development and admitted with existing wounds. Upon admission, the resident had stage 2 PUs on the right and left buttocks and an unstageable PU on the left foot, but no skin breakdown on the coccyx. The initial care plan did not address existing pressure ulcers or include prevention interventions, and there was no documentation of a higher-level mattress being provided at admission. Despite the resident's risk factors and care needs, the care plan was not updated to include pressure ulcer prevention interventions until a week after admission, when a slit was first noted on the coccyx. The resident developed a stage 3 PU on the coccyx, which progressed to require wound vacuum treatment. Documentation showed inconsistent wound assessments and delayed implementation of a low air loss (LAL) mattress, which was not provided until approximately 30 days after the need was identified and the RCM was notified. Interviews with staff confirmed that there was no standard protocol for pressure ulcer prevention interventions upon admission, and staff were unclear about the process for ordering specialty mattresses. The delay in providing appropriate pressure relief measures contributed to the development and worsening of the resident's coccyx wound, which impacted the resident's rehabilitation and discharge potential.
Governing Body Failed to Maintain Financial Oversight, Resulting in Discontinued Lab Services and Missed Resident Care
Penalty
Summary
The facility's Governing Body failed to maintain oversight of the facility's finances, resulting in significant unpaid balances to multiple vendors, including laboratory services, utilities, staffing agencies, and medical supply companies. The Governing Body was aware of overdue payments and notices for discontinuation of services but did not ensure that these financial obligations were met. As a result, the laboratory services provider discontinued services due to non-payment, and other vendors issued urgent notices threatening to cease services or disconnect utilities. Due to the discontinuation of laboratory services, necessary lab tests for several residents were not obtained as ordered. Specifically, residents who required Depakote levels, comprehensive metabolic panels, complete blood counts, and hemoglobin A1C tests did not receive these services. Staff confirmed that the laboratory did not come to the facility as scheduled, and there was no documentation explaining the missed lab draws. Additionally, staff were not aware if providers had been notified about the missed labs, and alternative laboratory options were limited. Interviews with facility staff and administration revealed that invoices were processed and sent to the corporate office for payment, but payments were delayed or not made, leading to daily calls from vendors regarding overdue balances. Payroll was also delayed on one occasion, resulting in staff temporarily losing benefits and having to pay out of pocket for medical expenses. The facility was also behind on required Safety Net Assessment payments, which had been referred for collection, further impacting cash flow and the ability to pay vendors.
Failure to Conduct Thorough Investigations of Incidents and Medication Errors
Penalty
Summary
The facility failed to conduct thorough investigations into incidents involving accidents, potential abuse, neglect, and medication errors for several residents. In multiple cases, investigations lacked comprehensive documentation, including missing or incomplete witness statements, insufficient details about the circumstances of the incidents, and failure to determine the root cause or contributing factors. For example, after a resident with Alzheimer's dementia was found on the floor with a head injury, the investigation did not include statements from the assigned nursing assistant, lacked information on the resident's care prior to the fall, and omitted a summary of the incident's cause or necessary corrective actions. Additionally, post-fall monitoring was incomplete, and the incident was reported late to the state. Another resident with multiple sclerosis and severe cognitive impairment experienced multiple falls, yet investigations did not include statements from all relevant staff, failed to assess environmental or equipment factors, and did not address whether care plan interventions were implemented. In one case, a resident was found on the floor after their wheelchair rolled back during a haircut, but the investigation did not review the wheelchair's condition or the environment. In another, a resident with significant cognitive impairment was found on the floor in the dining room, but the investigation did not address positioning or follow-up care. The facility also failed to thoroughly investigate a medication error involving duplicate orders for Alendronate, resulting in the resident potentially receiving double doses. The investigation did not verify the number of tablets dispensed by the pharmacy, nor did it determine how the duplicate order was entered without system or pharmacy alerts. Across all incidents, there was a consistent lack of comprehensive review, failure to identify involved staff, and absence of summaries detailing the who, what, where, when, and how of each event, as well as missing documentation of whether care plans were followed.
Failure to Complete and Update PASRR Assessments as Required
Penalty
Summary
The facility failed to ensure that Pre-Admission Screening and Resident Review (PASRR) assessments were accurately completed prior to or upon admission, or updated when residents' conditions changed, for four out of five residents reviewed. Specifically, two residents were admitted without a Level I PASRR completed preadmission, with the assessments being performed only after admission. Another resident's PASRR did not accurately reflect all relevant diagnoses, such as psychotic or delusional disorders, and was not revised upon admission. Additionally, a resident who began experiencing hallucinations and delusions did not have their PASRR updated to reflect these significant changes in condition. Record reviews and staff interviews revealed that the social worker responsible for PASRR completion and accuracy was uncertain about the process and acknowledged errors in the documentation. One resident's PASRR indicated depression but did not trigger a required Level II evaluation, contrary to PASRR instructions. The administrator confirmed awareness of the requirement for preadmission Level I PASRRs but was unsure why they were not completed as required. These deficiencies were identified through observation, interview, and record review, and were in violation of the facility's own policy and state regulations.
Failure to Verify Active OBRA Status for CNAs
Penalty
Summary
The facility failed to ensure that nine Certified Nursing Assistants (CNAs) had active Omnibus Budget Reconciliation Act (OBRA) verifications at the time of their employment and while working in the facility. Employment records showed that one CNA was hired and worked with an expired OBRA verification, and a review of all facility staff revealed a total of nine staff members with expired OBRA verifications. The Business Office Manager acknowledged awareness of the expired OBRA status for at least one CNA and provided documentation showing the expiration. The manager also stated that OBRA verifications were only being updated as they expired and that there was no plan in place to update expired verifications prior to employment. Additionally, the facility did not have OBRA documentation for any agency staff. Interviews with facility staff confirmed that the identified CNAs with expired OBRA verifications had been scheduled and working in the facility. The Business Office Manager expressed uncertainty about how to address the expired verifications and indicated that staff would need to be removed from the schedule until their OBRA status could be verified as active. The Administrator confirmed that there had been a period when OBRA verifications were not processed in a timely manner, resulting in staff being taken off the schedule. The Administrator also stated that agency staff should have OBRA verifications and that CNAs without current OBRA documentation should not work until the issue is resolved.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete, accurate, and systematically organized medical records for several residents, as required by policy and regulatory standards. For three residents reviewed, there were multiple omissions in Medication Administration Records (MAR) and Treatment Administration Records (TAR), including missing documentation of medication administration, behavior and side effect monitoring, anti-coagulant bleeding monitoring, hours of sleep, weekly skin checks, and pain assessments. These omissions were noted across several months and shifts, making it unclear whether prescribed care and monitoring were provided as ordered by physicians. Additionally, for one resident, the facility did not follow up on a PASRR evaluator's identification of an erroneous diagnosis of bipolar disorder, which originated from a hospital record. The incorrect diagnosis remained in the resident's medical record, MAR, and care plan, despite the evaluator's findings. Interviews with staff revealed a lack of awareness regarding the documentation errors and the absence of ongoing documentation audits at the time of the survey.
Failure to Immediately Report Potential Neglect and Substantial Injury
Penalty
Summary
The facility failed to immediately report a potential case of neglect involving a resident with significant cognitive impairment who required supervision for toileting. The resident was found on the floor with a 2-inch laceration on the forehead, labored breathing, and signs of distress after being left unsupervised on the toilet, contrary to their care plan. The incident was unwitnessed, and the assigned nursing assistant did not provide the required supervision. The facility's investigation identified contributing factors such as poor lighting, confusion, drowsiness, impaired memory, and gait imbalance. The injury was substantial, occurring in an area not generally vulnerable to trauma. Despite facility policy and state guidelines requiring immediate reporting of suspected abuse, neglect, or substantial injuries to the state hotline, the incident was not documented as reported. Staff interviews confirmed the expectation to report such injuries, but the state reporting log did not reflect that the incident was reported as required. The failure to report the potential neglect and injury was identified during the survey and cited as a deficiency.
Failure to Revise Care Plans for Residents on Psychotropic Medications
Penalty
Summary
The facility failed to ensure that care plans were revised as required for two residents who were receiving psychotropic medications. For one resident with moderate dementia, depression, and anxiety, the care plan did not include the symptoms the resident was experiencing, resident goals, or non-pharmacological interventions, despite the use of anti-anxiety and antidepressant medications. The care plan only listed administering medication as ordered and monitoring for adverse effects. Similarly, another resident with major depressive disorder, who was experiencing hallucinations and delusions and was being treated with multiple antidepressants and an antipsychotic, had care plans that also lacked documentation of symptoms, resident goals, and non-pharmacological interventions. The deficiency was identified through interviews and record reviews, which showed that the care plans for both residents were not updated to reflect their current symptoms or needs, as required by the Resident Assessment Instrument (RAI) manual. The administrator acknowledged awareness of care planning issues and stated that work had begun to address them. The lack of comprehensive and updated care plans was found to have the potential to impact staff knowledge of resident needs.
Failure to Hold Cardiac Medications per Physician Orders
Penalty
Summary
The facility failed to follow physician orders and professional standards of care for medication management in three out of five residents reviewed. Specifically, nursing staff administered cardiac medications, including Amlodipine and Metoprolol, to residents despite physician orders to hold these medications if certain blood pressure (BP) or heart rate (HR) parameters were not met. For example, one resident with a history of atherosclerosis, prosthetic heart valve, hypertension, and hyperlipidemia received these medications on multiple occasions when their HR or diastolic BP was below the ordered threshold. Another resident with congestive heart failure, atherosclerotic heart disease, and a cardiac pacemaker was given Amlodipine when their systolic BP was below the ordered limit. A third resident with hypertension also received Amlodipine when their BP or HR was below the specified parameters. Interviews with nursing staff confirmed that they were aware of the need to check vital signs and hold medications per parameters, yet the medication administration records (MARs) showed repeated instances where medications were given despite abnormal vital signs. The administrator also confirmed the expectation that medications should be held according to the parameters set by the physician orders. These findings were based on record reviews and staff interviews, and reference was made to WAC: 388-97-1060 (1).
Failure to Ensure Adequate Hydration for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that a resident with severe vascular dementia and a history of UTIs consistently received adequate fluids to meet their daily estimated needs of 1900 cc. Despite the resident's significant cognitive impairment and need for extensive assistance with eating, multiple observations over several days revealed that fluids were not consistently available at the bedside, and when present, were often out of reach. Documentation showed that the resident's daily fluid intake ranged from 336 cc to 1056 cc, never meeting the required amount. Family members expressed concern about the lack of fluids at the bedside during visits, and staff interviews confirmed that the resident rarely initiated drinking independently and required cues and hand-held assistance. Clinical records and care plans lacked specific documentation or interventions regarding hydration, aside from general encouragement for good nutrition and hydration. There were no recent laboratory assessments to monitor hydration status, and staff were not aware of any hydration concerns. Observations also noted physical signs of dehydration, such as a dry tongue. The administrator stated that the expectation was for nursing to provide water regularly and for dietary to supplement fluids as needed, but these practices were not consistently implemented or documented for this resident.
Failure to Provide Effective Pain Management and Timely Assessment
Penalty
Summary
A deficiency occurred when staff failed to adequately reassess, report, or provide effective pain management for a long-term resident who was mildly cognitively impaired. The facility's policy required staff to identify situations that increase pain, understand the rationale for pain medication, and document pain levels when pain increases. Despite this, the resident repeatedly expressed significant pain, particularly in the gluteal region, during routine activities such as repositioning and peri-care. Observations showed the resident attempting to reposition themselves, vocalizing pain, and reporting high pain scores, yet staff did not consistently assess or respond to these complaints as required. Interviews with staff revealed that pain assessments were only being conducted weekly rather than before and after medication administration, contrary to facility policy. The medical provider was not informed of the resident's increased pain, and pain assessments were not documented following administration of scheduled pain medication. Physical observations later revealed red areas and an open wound on the resident's buttocks, indicating ongoing discomfort and lack of effective pain management. Staff acknowledged that complaints of pain were not always followed by appropriate assessment or notification to the provider.
Failure to Complete and Document Annual Staff Performance Reviews
Penalty
Summary
The facility failed to complete annual staff performance reviews as required and did not provide education based on the outcomes of these reviews for one of five sampled staff members. Specifically, a nursing assistant certified (NAC) hired in December 2022 had an annual performance evaluation that was not dated or signed by either the evaluator or the staff member, and only one page of a two-page evaluation was available. No additional documentation was provided for this staff member's performance evaluation. During an interview, the administrator confirmed that evaluations had only recently been updated and were now being conducted on staff anniversary dates, but no further information was provided.
Duplicate Medication Orders and Administration Error
Penalty
Summary
The facility failed to ensure accurate pharmaceutical services for a resident with osteoporosis by allowing duplicate orders for Alendronate 70mg to be entered and administered. The resident had an original physician's order for Alendronate 70mg once weekly on Mondays at 5:00 AM, but a second, duplicate order was later entered for the same medication and dose to be given on Sundays at 7:00 AM. Medication Administration Records showed that both doses were signed as given on multiple consecutive weeks. Staff responsible for resident care were unaware of the duplicate order until it was brought to their attention, and there was an expectation that the system or pharmacy would catch such duplications. Additionally, the facility's medication error report did not thoroughly investigate whether the pharmacy supplied extra tablets or reconcile discrepancies in staff statements regarding the administration of the duplicate medication.
Failure to Prevent Duplicate Medication Orders and Ensure Accurate Pharmaceutical Review
Penalty
Summary
The facility failed to ensure that pharmaceutical services were provided in accordance with established procedures to guarantee accurate order entry, dispensing, and administration of medications for a resident with osteoporosis. Specifically, a duplicate order for Alendronate 70mg was entered, resulting in the resident receiving the medication twice weekly instead of once, as intended. Medication Administration Records confirmed that both doses were administered on consecutive Sundays and Mondays. This duplication error was not identified or addressed by the facility's medication management system or during the monthly consultant pharmacist review. Additionally, the resident had an active order for Enoxaparin, an injectable blood thinner, with no documented stop date or clarification of the treatment course. The consultant pharmacist's review did not address the duplicate Alendronate order or clarify the ongoing use of Enoxaparin, despite reviewing the resident's regimen monthly. Interviews with facility staff and the consultant pharmacist revealed an overreliance on the system to flag duplications and a lack of proactive review to identify and resolve medication order issues.
Failure to Ensure Required Training for Nursing Assistant Certified Staff
Penalty
Summary
The facility failed to ensure that one of five nursing assistant certified (NAC) staff received the required training in dementia care, abuse and neglect, communication, quality assurance performance improvement (QAPI), and the mandated 12-hour annual training. Review of the staff member's training record showed only a few completed documents related to abuse/neglect and care of the cognitively impaired, with no evidence of other required trainings. Interviews with facility staff revealed that there was no system in place to track the 12-hour education requirement for agency NACs, and responsibilities for tracking and providing training were unclear among staff. This deficiency was previously cited in a prior statement of deficiencies.
Failure to Ensure Nursing Assistant Maintained Active Certification
Penalty
Summary
The facility failed to ensure that a staff member working as a Nursing Assistant Certified (NAC) maintained an active professional certification. Review of the staff member's employment and certification records showed that their NAC certification had expired, yet they continued to work on multiple dates without a valid certification. The staff roster and timecard confirmed the staff member was scheduled and worked as an NAC during the period their certification was expired. The Business Office Manager acknowledged that although the staff member was hired with an active certification, there was a failure to follow up and verify the renewal of the certification, and the monthly license audit process had not been completed prior to discovering the lapse. The Interim Director of Nursing Services stated that all NACs are expected to have current certification.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide necessary supervision and services for a resident, resulting in an elopement incident. The resident, who had diagnoses including peripheral vascular disease, heart disease, and Alzheimer's disease, was found outside the facility by a neighbor. The facility's policy required residents to be assessed for wandering risk at admission, with specific interventions for those at increased risk. However, the resident's assessments initially determined they were not at risk for elopement, and their care plan for elopement risk was resolved without proper documentation or follow-up. Interviews with staff revealed a lack of awareness and communication regarding the resident's elopement risk and the facility's procedures. Staff members were unaware of the wander risk book and the resident's care plan updates. The Director of Nursing Services and the Clinical Regional Nurse did not ensure the resident had a wander guard, and there was confusion about the resident's risk status. This deficiency was a repeat issue from a previous survey, indicating ongoing problems with the facility's supervision and risk management processes.
Failure to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, sanitary, and homelike environment in both resident units and the outdoor space. Observations revealed multiple issues including loose wallboard, broken ceiling tiles, mismatched paint, large dark stains on floors, and gouges in the drywall in various rooms. Additionally, the courtyard was overgrown with grass and weeds, and cluttered with gardening supplies, which was visible from resident rooms. Interviews with residents confirmed their dissatisfaction with the state of the courtyard, and the administrator acknowledged the absence of a maintenance person and a gardener, indicating ongoing issues with facility upkeep. Furthermore, the facility experienced problems with hot water availability, impacting residents' ability to receive showers. One resident reported not receiving a shower due to the lack of hot water, and a nursing assistant confirmed that showers were not being provided at the time. Water temperature measurements in the facility kitchen showed significantly low temperatures, ranging from 61.9 to 97 degrees Fahrenheit. The administrator admitted that the hot water issue was still being addressed. This deficiency was noted as a repeat citation from a previous survey.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 191 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bellingham
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avalon Healthcare Bellingham | 1.6 mi | ★★★★★ | 15 | 0 |
| Alderwood Park Health And Rehab Of Cascadia | 2.5 mi | ★★★★★ | 14 | 0 |
| Mt Baker Care Center | 2.6 mi | ★★★★★ | 2 | 0 |
| Highland Health And Rehabilitation Of Cascadia | 2.8 mi | ★★★★★ | 5 | 0 |
| North Cascades Health And Rehabilitation | 4.5 mi | ★★★★★ | 47 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.