Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rockwood South Hill during CMS and state inspections, most recent first.
Surveyors found undated and expired food in dry storage and an uncovered, undated item in a refrigerator, along with a dishwasher final rinse temperature below the required level and repeated out-of-range temps in dining room refrigerators and freezers. During meal service, a CNA and a nursing assistant student failed to perform hand hygiene before handling food and assisting a resident, and staff interviews confirmed the required food safety and infection control practices.
The facility failed to maintain an effective infection prevention program. Policies were not reviewed annually, transmission-based precaution guidance was incomplete, and staff did not consistently follow PPE requirements for a resident with Human metapneumovirus. A maintenance worker entered the room without PPE, students used only surgical masks and no eye protection, and the facility lacked a compliant respiratory protection program with required documentation. Hand hygiene was missed during med pass, EBP was not used for residents with draining wounds, the water management plan was incomplete, and a hoyer lift was not sanitized between resident uses.
The facility failed to follow bowel protocols for 3 residents with constipation. One resident with COPD, malnutrition, HF, and cognitive impairment had several multi-day periods without a BM, but bowel meds were not given on the required schedule. Another resident with dementia, sciatica, and regular opioid use had no BM for 9 days, yet only MOM was documented and there were no bowel assessments or provider notifications. A third resident with dementia and malnutrition also had repeated gaps in BM documentation, but the required bowel assessment documentation was missing despite bowel meds being administered.
Controlled medication e-kits were not tracked or reconciled with sufficient detail for accurate accountability. The med fridge narcotic tracking book did not show routine shift counts, and the records for three Lorazepam e-kits did not match what was observed: one kit had a bottle removed without documentation, while two other kits were listed in the log but were not present in the refrigerator. Staff acknowledged the kits had not been counted or tracked since November and that the record did not reflect the actual status of the kits.
Delayed response to monthly pharmacy review recommendations. The facility did not timely address repeated pharmacist recommendations for several residents, including changes to medication indications and lab monitoring. Residents included one with GERD and mild cognitive impairment, one with glaucoma, one with anxiety, depression, and TIA, and one with heart failure receiving diuretics and a potassium supplement. The record showed repeated unsigned recommendations, incomplete provider responses, and missing CMPs for residents ordered to have lab monitoring.
A resident with a mental health disorder was admitted on a provider’s order for Seroquel 25 mg to be given once daily in the evening, but the order was incorrectly transcribed into the MAR as 25 mg once a day, give 0.5 mg in the evening. Based on this erroneous entry, the pharmacy dispensed 12.5 mg tablets (½ of a 25 mg tablet), and nursing staff administered 12.5 mg nightly over an extended period instead of the prescribed 25 mg dose. Interviews with the RCM and DON confirmed that the original order was for 25 mg every evening and that the resident received the wrong dose due to the transcription error.
A resident with repeat falls, depression, moderate cognitive impairment, and walker use had position change alarms added to the care plan for bed and chair use without informed consent from the resident or representative. The resident stated no consent was signed and the alarm appeared one day, while the RN confirmed the alarm was in use and the DON stated such alarms could be considered a restraint and required consent.
Two residents did not receive ADL assistance as care planned. One resident with Parkinsonism and cognitive impairment was repeatedly served meals without the planned adaptive utensils or Kennedy cup and had difficulty grasping and eating food, while staff acknowledged the resident needed help and that meal replacement practices were unclear. Another resident with dementia, glaucoma, and arthritis was observed multiple times with food residue around the mouth and dirt under the fingernails despite being dependent on staff for personal hygiene and oral care.
Failure to implement pressure ulcer interventions and notifications: A resident with Parkinsons disease, dementia, weakness, severe cognitive impairment, and fragile skin developed a facility-acquired stage II pressure ulcer on the right buttock while sitting up in a wheelchair most of the day. Staff observed the open area and the resident reported buttock pain, but the record had no new progress note, orders, or treatment interventions, and key disciplines such as the RD, OT, restorative, and DON were not notified as expected.
Oxygen care was deficient for two residents. One resident with HF and another with COPD and respiratory failure had oxygen concentrators with dust debris covering the vented/filter areas during repeated observations. One resident’s oxygen was also administered at 4L instead of the ordered 2-3L, while staff stated they were unsure how often the equipment was cleaned and acknowledged oxygen should be given as ordered.
The facility failed to protect resident rights in a mandatory binding arbitration agreement for two residents. The community residency contract embedded arbitration language that waived the right to court or a jury, but it did not document a 30-day rescission right or state that signing was not required for admission or continued care. One resident had dementia with moderate cognitive impairment and could not explain arbitration, while the other resident was cognitively intact but said staff did not review the paperwork and they would not have signed it. Staff were unsure who reviewed the contracts, and the arbitration agreement was used for SNF residents as part of the community residency agreement.
Nonfunctional Resident Call Light: A resident with Parkinson’s disease, dementia, weakness, and severe cognitive impairment had a call light that repeatedly did not work when activated or tested. Staff reported the problem had occurred before, tried unplugging and replugging the device without success, and noted the resident would have to yell for help if the call light failed.
Two residents who were wheelchair dependent had wheelchairs observed repeatedly in unclean condition, with food debris, splatter, and urine odor noted, and one wheelchair had a torn arm. The residents had severe cognitive impairment and diagnoses including Parkinson’s disease, dementia, arthritis, and glaucoma. Staff stated wheelchairs were cleaned mainly on night shift and were checked for needed repairs when used.
The facility failed to ensure proper hand hygiene and use of hair coverings during meal service, did not monitor food temperatures for all items, and had issues with food storage and labeling. Staff were observed not changing gloves between tasks, serving food without hairnets, and not checking temperatures for mechanical soft and pureed foods. Additionally, food items were found uncovered, unlabeled, and expired, and staff lacked competency in preparing thickened liquids.
The facility failed to maintain complete and accurate medical records for three residents regarding informed consents for psychotropic medications. The consents lacked drug class categories and symptoms for medications like Nuplazid, Trazodone, citalopram, buspirone, quetiapine, sertraline, and Valium. Staff acknowledged these omissions during interviews.
The facility failed to follow its Antibiotic Stewardship Program, as it did not document or evaluate antibiotic use according to the McGeer Criteria for several residents. This included residents prescribed antibiotics for pneumonia, UTIs, and thrush without proper symptom assessment, increasing the risk of unnecessary antibiotic use.
A facility failed to notify a physician and a resident's POA of a change in condition for a resident with severe cognitive impairment and high blood pressure. Despite administering Hydralazine for elevated BP, the resident's condition remained concerning, with no documentation of notification to the physician or POA. The oversight was acknowledged by staff, highlighting a risk for delayed treatment decisions.
The facility failed to provide the required SNF Advanced Beneficiary Notice (ABN) to two residents, which is necessary for informing Medicare beneficiaries about their financial responsibilities when skilled services might not be covered by Medicare. One resident's Medicare Part A services ended, and they were discharged without receiving the SNF ABN, while another resident continued to reside in the facility without receiving the notice. The facility justified the lack of provision by stating that both residents used ten free contract days.
A facility failed to implement its policies on abuse and neglect prevention by not reporting or investigating multiple elopement incidents and a skin injury for a resident with severe cognitive impairment. Despite the resident's conditions, they managed to elope several times, and a skin tear was observed but not reported or investigated. The Director of Nursing acknowledged these failures.
The facility failed to document and communicate the transfer of two residents to the hospital, lacking physician orders and proper notification to the receiving hospital. This involved a resident with high blood pressure and heart failure, and another with sepsis and dementia, both experiencing acute symptoms requiring hospitalization.
The facility failed to notify the State LTC Ombudsman of hospital transfers for two residents. One resident, cognitively intact, was transferred due to symptoms like pain and low blood pressure, while another, with dementia, was transferred due to vomiting and low oxygen levels. Staff interviews confirmed the lack of notification documentation.
The facility failed to provide bed-hold notices to two residents during hospital transfers, as required. One resident, with high blood pressure and heart failure, was hospitalized twice without receiving a notice. Another resident, with sepsis and dementia, was also transferred without a notice. The DON confirmed that notices were only given upon admission, not during each hospital transfer.
The facility failed to create comprehensive care plans for four residents, neglecting to address specific medical needs such as high blood pressure, sleep disturbances, fragile skin, and hearing loss. This oversight led to inadequate management of conditions like hypertension, Alzheimer's, thrombocytopenia, and hearing impairment, as staff did not implement necessary interventions or document care strategies.
A facility failed to administer Hydralazine as needed for a resident with high blood pressure, despite multiple readings showing systolic BP above 160. The MAR indicated an as-needed order for the medication, but there was no documentation of its administration. The Resident Care Manager confirmed the oversight and acknowledged the need for order clarification.
A resident who was cognitively impaired and required assistance with ADLs was not consistently groomed, as evidenced by observations of facial hair over several days. Despite documentation of facial hair removal on certain dates, the resident was repeatedly seen with facial hair. Staff interviews indicated that shaving was done as needed, and the DON recognized the dignity issue of not removing facial hair during bathing.
A facility failed to update a resident's code status from CPR/Full treatment to Do Not Resuscitate/Selective Treatment as requested by the resident's POA. Despite a care conference and documentation of the change, the POLST form and electronic medical record still indicated full CPR, leading to potential risk of unwanted intervention.
The facility failed to implement the bowel protocol for three residents, leading to unmet needs and potential complications. A resident with neurogenic bladder and dementia did not receive prescribed laxatives, and another with a urinary tract infection and dementia experienced similar neglect. Additionally, a resident's bowel protocol was neglected, and the facility failed to monitor them after a fall and skin tear, with no documentation of the incidents or subsequent monitoring.
A facility failed to assess and implement restorative services for a resident with impaired range of motion in their lower extremities. Despite receiving physical therapy and having a history of neuromuscular impairments, the resident was not referred for restorative services to prevent further decline. Observations showed ongoing limitations, and staff interviews confirmed the resident was not on a restorative program, despite previous participation before hospitalization.
A resident with severe cognitive impairments and swallowing difficulties was not adequately supervised during meals, leading to multiple coughing episodes. Staff failed to document these incidents and did not promptly notify therapy and providers for a swallow evaluation, leaving the resident at risk for choking.
A facility failed to ensure timely coordination of controlled substances for a resident at the end of life due to a lack of effective after-hours physician availability. The resident, who required a change from morphine to Dilaudid, experienced delays as the primary physician was unreachable, and the covering NP could not manage controlled substance orders. The DON was unaware of the issue, and no process was in place to ensure prompt physician response.
A facility failed to monitor the effectiveness of sleep medication for a resident with dementia and weakness, who was prescribed Melatonin nightly. Despite receiving the medication, no sleep monitor was in place to assess its effectiveness, as confirmed by an LPN and the DON. This oversight posed a risk of adverse side effects.
The facility failed to consistently monitor refrigerator temperatures in the medication room, risking the efficacy of stored medications like Tubersol and RSV vaccines. Temperature logs were incomplete, and the room lacked a thermometer. The DON acknowledged the oversight and reported notifying maintenance about the issue.
The facility failed to ensure nursing staff had current Washington State Food Worker Cards, with three staff members either having expired cards or no information available. A Nursing Assistant was observed serving meals without a hair covering, and it was noted that nursing assistants served food when dietary staff were unavailable. This posed a potential risk for unsafe food handling practices.
A facility failed to ensure a resident received information and was offered the recommended pneumonia vaccinations. The facility's policy required pneumococcal vaccines to be offered upon admission, with documentation of consent or refusal in the EMR. However, the resident's records showed no documentation of vaccine assessment or offer, and the admission assessment questions about vaccination status were unanswered. This was confirmed by the Infection Preventionist.
Food Storage, Temperature Control, and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to date, cover, and discard expired food in the dry storage area and in one refrigerator. During an initial kitchen tour, surveyors found undated food items in dry storage, including 10-pound cans of beans, peaches, pineapples, and pears, cornbread mix, jalapeno peppers, a box of dry gravy mix, and an opened box of powdered potatoes. Surveyors also found expired marshmallow cream topping, a case of green peppercorns, scalloped potatoes, a bag of chopped peanuts, a bag of hazelnuts, and a bag of dry pasta. In refrigerator 1, two containers of lettuce were uncovered and undated. The Food Services Director discarded the undated and expired foods and stated that all food needed to be dated and expired food thrown away for food safety. The facility also failed to maintain required dishwasher and dining room refrigerator/freezer temperatures, and failed to complete hand hygiene when indicated during meal services. Observation of the dishwasher showed a final rinse temperature of 162 degrees, and review of logs showed 58 occasions when the final rinse temperature did not reach 180 degrees. Logs for the North and South Atrium Dining Room refrigerators and freezers showed 56 instances when refrigerator temperatures were above 40 degrees and 72 instances when freezer temperatures were above 0 degrees. During meal observations, a nursing assistant did not perform hand hygiene after putting on a hair net and before handling food, then used the same gloves while serving a resident and assisting with the meal; a nursing assistant student also put on gloves without hand hygiene before assisting a resident to eat. Staff interviews confirmed the expected hand hygiene and temperature requirements.
Infection Prevention Program and Precaution Failures
Penalty
Summary
The facility failed to implement a comprehensive infection prevention and control program. Infection prevention and control policies were not reviewed annually, and Staff B, DNS, acknowledged there had been turnover in the Infection Prevention position and the policies had not been reviewed as required. The facility also did not provide a written policy for transmission-based precautions during the survey, despite using isolation signage and PPE carts for residents placed on precautions. Resident 40 had diagnoses including Alzheimer's dementia and pneumonia caused by Human metapneumovirus, and the care plan documented respiratory infection precautions. On observation, the resident's room had signs for droplet precautions and aerosol precautions, with a PPE cart outside the room containing gowns, gloves, eye protection, masks, and PAPR supplies. Three nursing assistant students entered the room wearing gowns, gloves, and surgical masks, but without eye protection or a higher-level respirator, and later moved the resident in full PPE while the resident did not have a surgical mask on. A maintenance staff member also entered the room to change a soap dispenser without wearing any PPE or respirator. The facility did not have a respiratory protection program developed according to OSHA requirements. Staff B stated the facility used CAPRs and PAPRs and did not fit test staff, and the facility did not provide a respiratory protection program or required medical screening documentation during the survey. PAPR hoods and components were observed stored in the hallway and on a walker seat, and it was unclear whether they had been disinfected after use. Staff interviews showed inconsistent understanding of when respirators were required and how PAPR equipment was to be handled. Additional infection control failures were observed during medication administration, when an RN did not perform hand hygiene before or after glove use while dispensing, crushing, and administering medications to two residents. Enhanced Barrier Precautions were not implemented for residents with draining wounds, including one resident with a reopened pressure ulcer and another resident with bloody drainage in a brief, and PPE was not available or worn during wound-related care. The facility's Water Management Plan lacked required elements and had not been reviewed annually, and the plan did not include infection prevention staff or written control measures for Legionella monitoring. A mechanical lift was also used for one resident and then another without being sanitized between uses.
Failure to Follow Bowel Protocols for Residents With Constipation
Penalty
Summary
The facility failed to implement its bowel protocols for 3 residents who had orders for constipation management. The facility policy required staff to check bowel records every shift and, if there was no bowel movement, to use Laxloaf as needed, give Milk of Magnesia on the evening shift of the second day, give a Dulcolax suppository on the night shift of the third day, and notify the provider if there was still no bowel movement by the fourth day. The policy also required bowel assessments, provider notification, and documentation of orders initiated. Resident 3 had chronic obstructive pulmonary disease, malnutrition, heart failure, moderate cognitive impairment, and needed supervision to touch assistance with toileting. The resident’s bowel record showed periods of no bowel movement for four days and three days, but the MAR showed Laxloaf and MOM were not given according to the bowel protocol timing. Resident 3 stated they had issues with constipation. Staff interviews confirmed bowel movements were monitored each shift, that small bowel movements did not count, and that the resident should have received bowel medications as ordered to help prevent impaction and bowel obstruction. Resident 4 had dementia, sciatica, moderate cognitive impairment, substantial ADL dependence, and regular opioid use. The resident had no bowel movement for nine days, yet the MAR showed MOM was given on three consecutive days and documented as ineffective, with no entries for Laxloaf, Dulcolax suppository, bowel assessments, or provider communication for the prolonged lack of bowel movements. Resident 13 had dementia, malnutrition, moderate cognitive impairment, was dependent for toileting, and had altered bowel elimination related to reduced mobility and medication use. The record showed multiple stretches of several days without a bowel movement, but the MAR contained bowel medications without the required bowel assessment documentation, including bowel tones, distention, and tenderness, as ordered.
Controlled Medication E-Kits Were Not Properly Tracked or Reconciled
Penalty
Summary
The facility failed to establish and maintain a system of records for the receipt and disposal of controlled drugs in sufficient detail to allow accurate reconciliation for 3 of 3 controlled medication emergency kits reviewed: e-kit 309, e-kit 314, and e-kit 315. The policy required controlled medications to be logged with specific identifying information and counted every shift, but the med fridge narcotic tracking book did not show routine counts since November 2025, and no documentation was found for December 2025, January 2026, February 2026, or March 2026. The November 2025 change-of-shift count signature pages showed counts were completed only 19 out of 31 days. During observation, the refrigerator contained e-kit 309 with two sealed 30 ml bottles of Lorazepam concentrate and two sealed vials of injectable Lorazepam, although the manifest showed the kit should contain three 30 ml bottles and two vials. Staff E stated one bottle had been removed the day before, but the narcotic tracking book showed e-kit 309 as full and sealed with no entry documenting access or removal. The tracking book also listed e-kit 315 and e-kit 314 with quantities and tag numbers, but those kits were not observed in the refrigerator, and there was no documentation showing they had been picked up by the pharmacy. Staff D and the DON acknowledged the kits had not been tracked or counted since November 2025 and that the record did not reflect the actual status of the kits.
Delayed Response to Monthly Pharmacy Review Recommendations
Penalty
Summary
The facility failed to ensure that monthly pharmacist medication regimen review recommendations were addressed within the required timeframe for 4 of 5 sampled residents reviewed for pharmacy monthly medication reviews. The facility policy stated the consultant pharmacist was to review each resident’s medication regimen at least monthly, communicate findings to the DON or designee and medical director, and have recommendations acted on within 30 calendar days, with provider acceptance or rejection documented in the medical record. For Resident 4, who had GERD and mild cognitive impairment, the provider ordered Protonix ER and sucralfate for GERD. The consultant pharmacist reviewed the regimen on 11/30/2025, 12/31/2025, and 01/31/2026 and repeatedly documented that sucralfate and Protonix were duplicate therapies and recommended discontinuing sucralfate because it was less effective and interfered with absorption of other medications. The recommendation was unsigned on each review until 02/10/2026, when an order was given to trial a decrease for 14 days and then discontinue the medication. For Resident 27, who had glaucoma, repeat falls, and depression, pharmacy consultation reports on 10/31/2025, 11/30/2025, 12/31/2025, and 1/31/2026 recommended changing the indication for an eye medication from eye health to glaucoma, with the physician response section not completed on the earlier reports. For Resident 17, who had anxiety, depression, and TIA, the pharmacist repeatedly recommended changing the aspirin indication from heart health to history of TIA and also recommended a CMP due to torsemide use; the recommendations were unsigned until 02/10/2026, when a handwritten response of yes-done was documented, but the CMP was not obtained as ordered and the aspirin indication remained heart health. For Resident 13, who had heart failure and was receiving blood thinners, diuretics, and a potassium supplement, the pharmacist repeatedly recommended a CMP because the last CMP on file was from November 2024, and the record showed no CMP had been obtained as recommended.
Incorrect Transcription and Dosing of Psychotropic Medication
Penalty
Summary
The deficiency involves the facility’s failure to correctly transcribe and administer a prescribed psychotropic medication for a resident admitted with a mental health disorder. On admission, the provider ordered Seroquel 25 mg to be given once daily in the evening. However, when the order was entered into the Medication Administration Record (MAR), it was incorrectly transcribed as Seroquel 25 mg once a day, give 0.5 mg in the evening. As a result of this incorrect transcription, the MAR reflected administration of only 12.5 mg (½ tablet of a 25 mg tablet) instead of the prescribed 25 mg dose. The MAR for January and February showed that the resident consistently received 12.5 mg of Seroquel every evening from early January through early February, rather than the intended 25 mg dose. A facility investigation documented that the pharmacy dispensed 12.5 mg (½ of a 25 mg tablet) based on the incorrect order, and this dose was administered throughout the period. Interviews with the Resident Care Manager and the DNS confirmed that the original provider order was for Seroquel 25 mg every evening and that the order had been transcribed incorrectly into the MAR, resulting in the resident receiving the wrong dose.
Failure to Obtain Consent for Position Change Alarms
Penalty
Summary
The facility failed to obtain informed consent for the use of position change alarms for one sampled resident. The resident’s care plan dated 08/08/2025 identified the resident as being at risk for falls and directed staff to keep the bed in the lowest position, place a fall mat at the bedside, ensure non-skid footwear was worn, and use position change alarms in the bed and chair. However, the medical record showed that before the alarms were used, no consent was obtained from the resident or the resident representative that included the potential risks versus benefits of the alarms. The resident’s quarterly assessment dated 02/02/2026 documented diagnoses including repeat falls and depression, two or more falls since admission, moderate cognitive impairment, and the need for a walker. During an observation on 03/16/2026, the resident was sitting in a chair with a position change alarm box on top of the chair and the sensor on the seat cushion. The resident stated they did not sign a consent for the alarm and that it had just appeared one day. Staff RN stated the resident was alert, had a position change alarm, and was instructed to use the call light when needing assistance. The DON stated position change alarms could be considered a restraint and required consent from the resident or resident representative, and if consents were not in the chart, they probably were not obtained.
Failure to Provide Planned ADL Assistance and Hygiene Care
Penalty
Summary
The facility failed to provide assistance with activities of daily living as care planned and needed for two residents. For one resident with Parkinsonism, moderate cognitive impairment, and a documented need for personal care assistance, the care plan called for set up and clean up at meals, foam handles on utensils, a Kennedy cup with a straw, finger foods, reminders to eat, and later 1:1 extensive meal assistance. During multiple meal observations, the resident was repeatedly served regular utensils and regular cups instead of the planned adaptive equipment, had difficulty grasping food and utensils, dropped food, and was not consistently assisted while eating. Staff acknowledged the resident needed help eating, that the resident could not state when hungry, and that the planned adaptive devices were not available in the dining room. During the meal observations, the resident was seen attempting to eat soup, sandwich, fruit, pancakes, eggs, bacon, and other items but was unable to effectively grasp or consume the food without assistance. Staff were observed cutting food or briefly placing food in the resident’s mouth, but the resident was not provided the planned Kennedy cup or foam-handled utensils. One staff member stated the resident ate 75%, although the observation showed only a small amount of food consumed. Staff also stated there was no facility process for offering a meal supplement or replacement when a resident ate 50% or less of a meal, and that shortbread cookies were available but were not equivalent to a meal. For the second resident, whose care plan documented dependence on staff for personal hygiene and oral care, observations showed repeated signs of inadequate hygiene. The resident was seen with brown matter around the mouth, eggs in and around the mouth after breakfast, and brown matter under the fingernails on multiple occasions. Staff interviews confirmed that the resident required assistance with personal hygiene, that oral care was expected in the morning and evening and when needed, and that hands, faces, and nails were to be cleaned when dirty. The resident’s diagnoses included dementia, glaucoma, and arthritis, and the resident had severe cognitive impairment and was dependent on staff for hygiene.
Failure to Implement Pressure Ulcer Interventions and Notifications
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met for a resident with Parkinsons disease, dementia, weakness, severe cognitive impairment, and dependence on staff for most ADLs. The resident had fragile skin and moisture associated skin damage documented on the care plan, along with interventions for frequent checks and changes, gentle handling, repositioning and transfers, laying the resident down after lunch until dinner, wound clinic and provider treatment orders, turning as tolerated, wound healing referrals, and a pressure relieving wheelchair cushion. A weekly skin issue evaluation documented that the resident had a facility acquired pressure ulcer. During an observation, the resident was sitting in a wheelchair eating lunch, stated they needed help, and said their buttocks hurt when asked if they were uncomfortable. Staff K told the resident they would be laid down after lunch. Shortly afterward, the resident was observed to have an open area on the right buttock about the size of a quarter with the top layers of skin gone. Staff K stated they were instructed to put cream on the area and said the resident was sitting up most of the day and laid in bed only at nighttime. Staff H, RN, stated the wound was a pressure ulcer and had opened that day, but the medical record showed no progress notes, orders, or interventions added for the new pressure ulcer. Staff H later stated the expected process was to photograph the wound, document it, place the resident on alert charting, notify the Resident Care Manager and providers, obtain treatment orders, and communicate with nursing assistants, and said they notified the Resident Care Manager and provider on the day the wound was found. However, the provider communication binder showed no notification, and Staff BB, the RD, Staff CC, the OT, and Staff L, Restorative Aide, all stated they were unaware of the pressure ulcer or had not been notified in the usual manner. Staff B, DON, stated the family and doctor should be notified and the care plan updated, but was unaware the resident had a pressure ulcer until the wound was shown during the observation.
Oxygen Equipment Not Kept Clean and Oxygen Not Given as Ordered
Penalty
Summary
Respiratory care was deficient for two residents because oxygen equipment was not maintained in a clean and sanitary manner, and one resident did not receive oxygen at the ordered flow rate. Resident 13 had heart failure, was dependent on supplemental oxygen, and had moderate cognitive impairment. The resident had an active order to receive oxygen to keep oxygen levels above 90% and a later order directing staff to rinse the oxygen concentrator filter and change, initial, and date the tubing weekly. During multiple observations, Resident 13 was wearing oxygen from a black concentrator with a thick layer of dust debris covering the slotted area in the back of the machine that housed the filter, and dust debris was also seen covering the compartment adjacent to the filter. Resident 30 had COPD, respiratory failure, and was dependent on oxygen. The resident’s care plan directed staff to administer 4L of oxygen at night and maintain oxygen saturation above 88% during waking hours, while a later provider order prescribed 2-3L of oxygen to keep saturation between 88-93%. The March 2026 MAR showed oxygen was given at 4L daily except for one evening shift, and observations showed the resident wearing oxygen at 4L instead of the ordered 2-3L. The oxygen concentrator repeatedly had dust debris over the vented area next to the filter. Staff stated they were unsure how often oxygen equipment was cleaned, that the vented area should be kept clean, and that oxygen should be administered as ordered.
Arbitration Agreement Lacked Required Resident Rights Information
Penalty
Summary
The facility failed to follow requirements intended to protect resident rights in an arbitration agreement for 2 of 4 sampled residents. The community residency agreement contained a mandatory binding arbitration section stating disputes would be settled exclusively by arbitration and that residents waived the right to have disputes decided in court by a judge or jury. The agreement did not document that the resident and/or representative had the right to rescind the agreement within 30 calendar days of signing, and it did not state that signing was not required as a condition of admission or continued care. The arbitration agreement was signed by both residents in 2017 as part of the community residency agreement. Resident 13 was admitted to the SNF with dementia and was documented on quarterly assessment as having moderate cognitive impairment with inattention and disorganized thinking. During interview, Resident 13 could not explain what arbitration was and referred the surveyor to their spouse. The record contained no documentation that the arbitration agreement embedded in the community residency agreement was explained in a form and manner understood by Resident 13 or their representative. Resident 14 was documented as cognitively intact and able to clearly verbalize needs. During interview, Resident 14 stated they reviewed and signed their own paperwork and their spouse's paperwork, explained arbitration as mediation instead of court, and said they did not recall staff reviewing the arbitration paperwork and were not aware it was included in the residency or admission paperwork. Resident 14 further stated they would not have signed or agreed to arbitration. The record contained no documentation that the arbitration agreement embedded in the community residency agreement was explained in a form and manner understood by Resident 14. Staff interviews showed uncertainty about who reviewed the residency contracts, and staff stated the community residency agreement with embedded arbitration was used for SNF residents.
Nonfunctional Resident Call Light
Penalty
Summary
The facility failed to maintain a resident call light system in a functional manner for Resident 25. Resident 25 had diagnoses including Parkinson’s disease, dementia, and weakness, required assistance with activities of daily living, and had severe cognitive impairment but was able to make needs known. The care plan identified the resident as at risk for falls related to Parkinson’s disease, poor balance, dementia, vision impairments, and a history of falls, and staff were instructed to keep the call light in reach at all times and remind the resident to use it for assistance. During observations, Resident 25’s call light was activated multiple times and did not light up outside the room or when tested by staff. Staff U stated the call light sometimes did not work and that they would pull it out of the wall and plug it back in, but that did not resolve the problem. Staff F and Staff K also observed the call light not working and stated there should be a secondary way to call for help like a bell, and Staff K stated the facility had a problem with call lights not working. Staff F reported the issue to the Health Care Services Director, and later the DON was notified that the call light was not working. Resident 25 stated that if the call light was not working, they would yell for help.
Unclean and Damaged Wheelchairs
Penalty
Summary
The facility failed to ensure wheelchairs were maintained in a clean manner for two residents who were dependent on staff for locomotion. Resident 25 had diagnoses including Parkinson’s disease, dementia, and weakness, with severe cognitive impairment and wheelchair dependence. During multiple observations, Resident 25’s wheelchair was unclean with food debris on the back, sides, side bars, and seat cushion, the right arm was torn, and there was a strong urine odor from the cushion with food underneath it. Resident 29 had diagnoses including dementia, arthritis, and glaucoma, with severe cognitive impairment and dependence on staff for all cares except eating. Resident 29 was wheelchair bound and dependent on staff for locomotion. During repeated observations, Resident 29’s wheelchair was unclean with food on the seat cushion and brown and white splatter on the wheels, spokes, and foot pedals. Staff stated wheelchairs were cleaned by nursing assistants, mainly on night shift, and that wheelchairs were assessed for needed repairs and wheelchair arms replaced when needed.
Deficiencies in Hand Hygiene, Food Safety, and Storage Practices
Penalty
Summary
The facility failed to ensure proper hand hygiene and the use of hair coverings during food preparation and meal service in both the North and South Dining Rooms. Observations revealed that staff members, including Nursing Assistants and Dietary Aides, did not change gloves or perform hand hygiene between tasks, such as serving food, touching residents, and handling utensils. Additionally, staff members were observed serving food without wearing hairnets, which is a requirement to prevent cross-contamination. The facility also failed to monitor and record the temperatures of all food items being served, particularly mechanical soft and pureed foods. Staff members were observed checking temperatures for regular textured food items but not for mechanical soft and pureed items, which is against the facility's policy. This oversight was acknowledged by the Food Services Director, who stated that all food items should have been checked to prevent illness. Furthermore, the facility did not adhere to proper food storage practices. Observations in the kitchen and nourishment areas revealed uncovered and unlabeled food items, as well as expired products. Staff members acknowledged these issues, noting the importance of labeling and covering food to prevent contamination and ensure food quality. Additionally, there was a lack of competency among staff in preparing thickened liquids, with staff unable to accurately determine the consistency required for residents' diets.
Incomplete Informed Consents for Psychotropic Medications
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents, specifically regarding informed consents for psychotropic medications. For Resident 15, the November 2024 Medication Administration Record (MAR) indicated the administration of Nuplazid, Trazodone, and citalopram. However, the consents dated 05/02/2023 for Trazodone and Nuplazid did not specify the drug class categories, and the consent for Nuplazid lacked the symptoms it was prescribed for, only mentioning 'psychosis.' Similarly, Resident 17's November 2024 MAR showed the administration of citalopram, Nuplazid, buspirone, and quetiapine, but the consents for citalopram and buspirone from 01/23/2024 did not identify the drug class categories. For Resident 19, the November 2024 MAR documented the administration of quetiapine, sertraline, Trazodone, and Valium, with consents from 11/22/2023 missing the drug class categories and symptoms for sertraline and quetiapine. Staff C and Staff D, Resident Care Managers, acknowledged the omissions in the consents during interviews, noting that the necessary information should have been included.
Failure to Follow Antibiotic Stewardship Program
Penalty
Summary
The facility failed to adhere to its established Antibiotic Stewardship Program (ASP) over a two-month period, as evidenced by a lack of documentation and evaluation of antibiotic use according to the McGeer Criteria. The policy required the facility to assess residents for infections using recognized standards and to reassess the appropriateness of empirically prescribed antibiotics. However, the facility did not document whether residents' signs and symptoms met the surveillance definitions for infections, nor did they evaluate the necessity of antibiotics prescribed upon admission or transfer. Several residents were affected by this deficiency. Resident 12 was prescribed Augmentin for pneumonia without documentation of whether the symptoms met the McGeer Criteria. Resident 28 was admitted with a prescription for Bactrim for cystitis, but there was no documentation of symptom evaluation. Similarly, Resident 17 was prescribed nitrofurantoin for a UTI based on symptoms that did not meet the McGeer Criteria. Resident 2 was given azithromycin and Levaquin for pneumonia without adequate evaluation of symptoms. Resident 29, Resident 7, and Resident 21 also received antibiotics without documented evaluation against the McGeer Criteria. The facility's failure to document and evaluate antibiotic use extended to Resident 24, who was treated for thrush and later a UTI without proper symptom assessment. The Infection Preventionist acknowledged the lack of documentation and evaluation for each resident's clinical signs and laboratory reports to determine if they met the McGeer Criteria for infection. This oversight increased the risk of unnecessary antibiotic use and potential adverse outcomes for residents.
Failure to Notify Physician and POA of Resident's Condition Change
Penalty
Summary
The facility failed to notify the physician and the resident's power of attorney (POA) of a change in condition for a resident with severe cognitive impairment and medically complex conditions, including high blood pressure and arrhythmia. The resident had an as-needed order for Hydralazine if their systolic blood pressure exceeded 160. On a particular day, after being showered, the resident exhibited signs of lethargy and a drooped lip, with a blood pressure reading of 194/95. Despite administering Hydralazine, the resident's blood pressure remained elevated, and there was no documentation of notification to the physician or the resident's representative about the ineffective medication or the continued high blood pressure. The staff documented the resident's condition and the administration of Hydralazine but failed to monitor the resident's status for adverse effects from the elevated blood pressure until 12 hours later. The lack of communication with the physician and the POA was acknowledged by a staff member, who stated that the nurse should have contacted the doctor and informed the POA about the interventions attempted. This oversight placed the resident at risk for delayed treatment decisions by the legal representative and the physician.
Failure to Provide Required Beneficiary Notices
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility (SNF) Advanced Beneficiary Notice (ABN) to two residents, which is necessary for informing Medicare beneficiaries about their financial responsibilities when skilled services might not be covered by Medicare. Resident 83's Medicare Part A services ended on August 22, 2024, and the resident was discharged on September 4, 2024, without receiving the SNF ABN. The facility justified the lack of provision by stating that the resident used ten free contract days before discharge. Similarly, Resident 1, whose Medicare Part A services ended on June 7, 2024, continued to reside in the facility without receiving the SNF ABN. The facility explained that Resident 1 also utilized ten free days under a contract agreement. The Director of Nursing, Staff B, confirmed that the SNF ABNs were not given due to the contract with the retirement community, which included ten free days, and asserted that the residents were aware of their costs. No additional information was provided.
Failure to Report and Investigate Elopement and Injury
Penalty
Summary
The facility failed to implement its Abuse and Neglect Prohibition Policies and Procedures, specifically in not reporting or investigating elopement episodes and a skin injury for one resident. The facility's policy required immediate investigation and reporting of any suspicion or actual abuse, neglect, or exploitation, with specific time frames for reporting to the Administrator and state agency. However, the facility did not document or report the elopement incidents or the skin injury of Resident 30, nor did it investigate the circumstances surrounding these events to determine if abuse or neglect contributed. Resident 30, who had a traumatic brain injury, restlessness, agitation, and Parkinson's disease, was assessed with severe cognitive impairment. Despite these conditions, the resident managed to elope multiple times, including reaching an independent living area and being found near a maintenance office. Additionally, a skin tear was observed on the resident's elbow, but the facility did not report or investigate this injury. The Director of Nursing acknowledged these failures when the findings were shared, but no further information was provided.
Failure to Document and Communicate Resident Transfers
Penalty
Summary
The facility failed to ensure proper documentation and communication during the transfer of two residents to the hospital, which resulted in a deficiency. Resident 24, who had diagnoses including high blood pressure, heart failure, and thrombocytopenia, was sent to the hospital on two occasions due to complaints of pain and low blood pressure. However, there was no documentation in the resident's medical record indicating that an order was obtained for the transfer or that the receiving hospital was informed of the resident's condition. Interviews with staff revealed that a transfer form should have been completed and that the hospital should have been notified, but this was not done. Similarly, Resident 22, who had diagnoses of sepsis and dementia, was sent to the hospital after experiencing vomiting and low oxygen levels. Again, there was no documentation of a physician's order for the transfer or communication with the receiving hospital. Staff interviews confirmed that a transfer form should have been sent with the resident, but there was no evidence that the hospital was informed of the resident's condition. These failures placed the residents at risk for delays in treatment and unmet care needs.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to ensure that the Office of the State Long-Term Care Ombudsman was notified in writing of hospital transfers for two residents, Resident 24 and Resident 22. Resident 24, who was cognitively intact and had diagnoses including heart failure, pneumonia, and thrombocytopenia, was transferred to the hospital on two occasions due to symptoms such as pain, lethargy, and low blood pressure. Despite these transfers, there was no documentation indicating that the Ombudsman was notified, as confirmed by interviews with staff members including the Medical Records staff, Resident Care Manager, and Director of Nursing. Similarly, Resident 22, who was not cognitively intact and had diagnoses of sepsis and dementia, was transferred to the hospital after experiencing vomiting, abdominal pain, and low oxygen levels. Again, there was no documentation of notification to the Ombudsman regarding this transfer. The lack of notification was acknowledged by staff during interviews, indicating a systemic issue in the facility's process for notifying the Ombudsman of resident transfers.
Failure to Provide Bed-Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to provide a bed-hold notice to residents or their representatives at the time of discharge or within 24 hours of transfer to the hospital, as required by regulations. This deficiency was identified for two residents who were hospitalized. Resident 24, who was cognitively intact and had diagnoses including high blood pressure and heart failure, was sent to the hospital on two occasions due to pain, lethargy, and low blood pressure. However, there was no documentation indicating that a bed-hold notice was provided to the resident during these hospitalizations. Similarly, Resident 22, who had diagnoses including sepsis and dementia, was sent to the hospital after experiencing vomiting, abdominal pain, and low oxygen levels. Again, there was no documentation of a bed-hold notice being provided. During an interview, the Director of Nursing acknowledged that bed-hold notices were only offered upon admission and not each time a resident was transferred to the hospital, which is contrary to the requirements.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for four residents, leading to deficiencies in addressing their specific medical needs. Resident 15, who was admitted with high blood pressure and arrhythmia, had multiple instances of elevated systolic blood pressure readings, yet there was no care plan developed to manage these conditions. Staff acknowledged the absence of a care plan for these active diagnoses, which should have been in place to guide the management of the resident's health issues. Resident 19, diagnosed with Alzheimer's disease and severe cognitive impairment, was receiving Melatonin as a sleep aid. However, the resident's care plan did not include any interventions or considerations for sleep disturbances, despite the ongoing administration of the medication. Staff confirmed that a care plan addressing the resident's sleep needs should have been developed to ensure appropriate care. Resident 24, with diagnoses including high blood pressure, heart failure, and thrombocytopenia, exhibited significant bruising on their arms due to low platelet count. Despite the high risk for bruising and bleeding, there were no care plan interventions in place to protect the resident's fragile skin. Staff interviews revealed that protective measures such as sleeves and gentle care should have been documented in the care plan. Additionally, Resident 8, with Alzheimer's disease and bilateral hearing loss, had no care plan addressing their hearing aids, which were essential for communication. Observations showed the resident often without their hearing aids, and staff did not assist in managing them, impacting the resident's ability to communicate effectively.
Failure to Administer As-Needed Medication for Elevated Blood Pressure
Penalty
Summary
The facility failed to implement a physician's order for the treatment of elevated blood pressures for Resident 15, who was admitted with medically complex conditions including high blood pressure and arrhythmia. The November 2024 Medication Administration Record (MAR) indicated an as-needed order for Hydralazine every six hours if the resident's systolic blood pressure exceeded 160. However, multiple readings showed the resident's systolic blood pressure was above 160 on several occasions, yet there was no documentation that the staff administered the Hydralazine as ordered. Staff C, the Resident Care Manager, confirmed the lack of documentation and acknowledged that the order required clarification, as there were no instructions to cue the staff on administering the medication when needed.
Failure to Consistently Provide Grooming for a Resident
Penalty
Summary
The facility failed to consistently provide grooming for a resident, identified as Resident 25, who was cognitively impaired and required partial to moderate assistance with activities of daily living, including personal hygiene. According to the resident's care plan, assistance with personal hygiene was necessary. However, observations from December 3 to December 6, 2024, noted that Resident 25 had facial hair approximately a centimeter long, indicating a lack of grooming. Despite documentation showing facial hair removal on specific dates in November and December, the resident was observed with facial hair on multiple occasions. Interviews with staff revealed that shaving was performed as needed, and the Director of Nursing acknowledged that not removing facial hair during bathing was a dignity issue.
Failure to Update Resident's Code Status
Penalty
Summary
The facility failed to follow up on a resident's request to change their code status, which is the level of intervention a resident chooses if their heart or breathing stops. This failure involved Resident 17, who was admitted with medically complex conditions and severe cognitive impairment. During a care conference, the resident's Power of Attorney (POA) requested a change in the code status from CPR/Full treatment to Do Not Resuscitate/Selective Treatment. The facility documented this change and faxed the POLST form to the provider for signature. However, the POLST form in the electronic medical record still indicated full CPR and full treatment, contrary to the POA's decision. Staff M, a Registered Nurse, was unable to confirm the correct code status for Resident 17, as the resident roster did not display code statuses, and the CPR book and electronic medical record both directed staff to initiate CPR. This discrepancy was acknowledged by Staff C, the Resident Care Manager, who confirmed that the electronic medical record and POLST did not reflect the POA's choice. This oversight placed Resident 17 at risk of receiving CPR against the legal representative's wishes.
Failure to Implement Bowel Protocol and Monitor Post-Incident
Penalty
Summary
The facility failed to implement the bowel protocol for the management of constipation for three residents, leading to unmet needs and potential complications. Resident 14, diagnosed with neurogenic bladder and dementia, did not receive the prescribed laxatives as per the bowel protocol during specific periods in November 2024, despite having no bowel movements for several days. The Resident Care Manager confirmed the protocol was not followed, which was necessary to prevent constipation and related complications. Resident 28, with diagnoses including a urinary tract infection and dementia, also did not receive the prescribed laxatives according to the bowel protocol. The resident experienced multiple periods of no bowel movements from November to December 2024, yet there was no documentation of laxative administration during these times. The Resident Care Manager acknowledged the oversight and emphasized the importance of following the protocol to avoid constipation and further medical issues. Resident 30's bowel protocol was similarly neglected, with no documentation of laxative administration despite the absence of bowel movements over several days. Additionally, the facility failed to monitor Resident 30 after a fall and a skin tear, with no documentation of the fall's occurrence, the abrasion's details, or subsequent monitoring. The Director of Nursing confirmed the lack of documentation and expected monitoring for at least 72 hours post-incident.
Failure to Assess and Implement Restorative Services for Resident
Penalty
Summary
The facility failed to assess the need for restorative services for a resident with impaired range of motion in their lower extremities. The resident, who had diagnoses including dementia and abnormalities of gait and mobility, required substantial to total assistance with activities of daily living and had received physical and occupational therapy. Despite a physical therapy evaluation identifying new or worsened neuromuscular impairments and high tone in the resident's bilateral lower extremities, there was no assessment or referral for restorative services to prevent further decline. The resident's care plan lacked interventions related to their lower extremity limitations or directions for range of motion or restorative exercises. Observations of the resident showed their legs stretched out and foot pointing upward while sitting in a wheelchair, indicating ongoing limitations. Interviews with staff revealed that the resident was not on a restorative program, despite having been on one prior to a hospitalization. Staff acknowledged the oversight, noting that the resident should have been placed back on a restorative program after therapy completion to prevent contractures and maintain their current level of functioning.
Inadequate Supervision During Resident's Coughing Episodes
Penalty
Summary
The facility failed to provide adequate supervision during a coughing episode for a resident with severe cognitive impairments and a history of dementia and stroke. The resident required total assistance with eating and was on a mechanical soft diet with nectar thick liquids due to swallowing difficulties. Despite these needs, the resident was observed coughing during meals on multiple occasions without immediate intervention or documentation of the episodes. Staff left the resident alone after a coughing episode, and there was a delay in notifying the appropriate personnel for a swallow evaluation. The resident's care plan required one-to-one feeding assistance and specific instructions for safe swallowing, which were not consistently followed. Staff failed to document the coughing episodes and did not promptly communicate the resident's condition to therapy and providers. The lack of immediate assessment and documentation of the resident's condition after the coughing episodes contributed to the deficiency, as it placed the resident at risk for choking and compromised their quality of life.
Delayed Physician Response for End-of-Life Medication
Penalty
Summary
The facility failed to ensure the timely coordination of controlled substances for a resident at the end of life, due to a lack of an effective system for physician availability after hours. Resident 31, who was readmitted to the facility for comfort care following a rapid health decline, was described as alert but confused and incoherent. The resident was administered morphine to manage symptoms of anxiety and agitation, but the medication was not effective, and a change to Dilaudid was needed. However, the facility's staff encountered delays in obtaining the necessary physician orders for the medication change. Staff F, a registered nurse, attempted to contact the resident's primary physician, Staff I, who was also the facility's Medical Director, but was unable to reach them promptly. Despite leaving messages with the physician's answering service, the nurse was informed that a nurse practitioner was covering for the physician, who could not manage orders for controlled substances. This led to further delays, as Staff I was not able to call in the order to the pharmacy immediately. The Director of Nursing, Staff B, was unaware of the issue and stated that no process was in place to ensure prompt physician response, highlighting a gap in the facility's emergency procedures for medication management at the end of life.
Failure to Monitor Sleep Medication Effectiveness
Penalty
Summary
The facility failed to ensure that sleep medications were consistently monitored for a resident, identified as Resident 183, who was reviewed for unnecessary medications. Resident 183 had diagnoses including dementia and weakness and was prescribed Melatonin for sleep, to be administered every night at bedtime. The medication administration records for November and December 2024 confirmed that the resident received Melatonin nightly. However, interviews with Staff K, an LPN, and Staff B, the Director of Nursing, revealed that a sleep monitor should have been in place to assess the effectiveness of the Melatonin, which was not done. This oversight placed the resident at risk for potential adverse side effects and medical conditions.
Improper Medication Storage Due to Inconsistent Temperature Monitoring
Penalty
Summary
The facility failed to maintain proper storage conditions for medications, as observed during a survey. On December 6, 2024, a Registered Nurse and surveyors found that the refrigerator in the medication room contained a vial of Tubersol and respiratory syncytial virus vaccines. However, the temperature logs for the refrigerator were inconsistently monitored, with only 14 days recorded in September, 16 days in October, and 16 days in November 2024. Additionally, the medication room lacked a thermometer to monitor the storage temperature of medications. During an interview, the Director of Nursing acknowledged that the refrigerator's temperature should have been monitored to ensure medication efficacy and mentioned that maintenance had been notified about the need for a temperature gauge in the medication room. This deficiency placed residents at risk of receiving compromised or ineffective medications.
Deficiency in Food Worker Card Compliance
Penalty
Summary
The facility failed to ensure that nursing staff had the required qualifications, specifically current Washington State Food Worker Cards, for three nursing staff members. This deficiency was identified through observation, interview, and record review. During an observation, a Nursing Assistant, Staff G, was seen serving meals from the steam table without wearing a hair covering. In an interview, a Cook, Staff Z, stated that nursing assistants served food from the steam table when dietary staff were unavailable. Upon request, the facility was unable to provide current Food Worker Cards for the dietary and nursing staff. A review of the dietary cards revealed that Staff N and Staff BB had expired cards, and there was no information available for Staff CC. This lack of proper qualifications posed a potential risk for unsafe food handling practices, which could lead to foodborne illness among residents.
Failure to Offer Pneumonia Vaccination to Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 183, received information on and was offered the recommended pneumonia vaccinations as per the Centers for Disease Control and Prevention guidelines. The facility's policy, dated 10/19/2022, required that pneumococcal vaccines be offered to all residents upon admission unless medically contraindicated. The policy also mandated that staff assess residents for vaccine eligibility upon admission and annually, counsel them on the benefits and adverse effects, and document consent or refusal in the electronic medical record (EMR). However, upon review of Resident 183's records, there was no documentation indicating that the resident was assessed for vaccine eligibility or offered the pneumonia vaccine. The comprehensive admission assessment for Resident 183, dated 11/26/2024, included questions about the resident's pneumococcal vaccination status, but these were left unanswered. Additionally, the Immunizations section of the EMR and the Miscellaneous section for uploaded files showed no evidence that the staff assessed the resident's eligibility or offered the vaccine. This oversight was confirmed during an interview with the Infection Preventionist, Staff E, on 12/09/2024, who was unable to provide further information.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 149 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Spokane
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Spokane Health & Rehabilitation | 1.6 mi | ★★★★★ | 1 | 0 |
| Emerson Health & Rehabilitation | 1.6 mi | ★★★★★ | 0 | 0 |
| Spokane Falls Care | 1.9 mi | ★★★★★ | 34 | 0 |
| Spokane Veterans Home | 2.3 mi | ★★★★★ | 1 | 0 |
| South Hill Rehabilitation And Care Center | 2.5 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Rockwood South Hill.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.