Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Salmon Creek Post Acute & Rehabilitation during CMS and state inspections, most recent first.
Surveyors found that staff did not complete or individualize multiple care plan segments for four residents, leaving key areas such as communication impairment, fall risk, anticoagulant use, diuretic and opioid use, vision impairment, rehab needs, ADL assistance, and constipation risk without resident-specific causes or related diagnoses. These residents had conditions including spinal stenosis, osteoarthritis, an artificial knee joint, hypertension, chronic heart failure, type 2 DM with vision issues, moderate cognitive impairment with ambulation needs, and a traumatic subdural hemorrhage. The DON reported that unit managers are responsible for developing the comprehensive nursing care plans and acknowledged that these sections should have been fully completed.
Surveyors found recurring medication administration errors and omissions when several cognitively intact residents with complex conditions (including PTSD, CKD, COPD, chronic pain, DM2, psychotic disorder, and traumatic subdural hemorrhage) did not receive ordered medications and treatments as prescribed. MAR and TAR reviews showed omitted evening doses of inhalers, psychotropics, wound care treatments, anticoagulant monitoring, and multiple supplements, as well as numerous instances where analgesics, antihypertensives, diuretics, anticoagulants, psychotropics, insulin, thyroid medication, lipid-lowering agents, and laxatives were administered outside the accepted 2-hour nursing administration window. An RN leader confirmed that blank MAR/TAR entries reflected omissions and that many doses were given outside the permitted timeframe, and the issue was cited as a recurring deficiency under state regulation.
A resident with ESRD and severe cognitive impairment who depended on hemodialysis did not consistently receive ordered pre- and post-dialysis assessments or required documentation, and the care plan did not address these assessments or communication with the dialysis provider. EMR review showed multiple incomplete or blank pre/post HD assessments, and the MAR revealed that ordered Norco premedication before dialysis was not consistently documented or supported by progress notes. Dialysis staff reported the resident frequently arrived in pain, without the communication binder, and often without food, dentures, blanket, or appropriate clothing, and records showed the resident missed at least one scheduled dialysis treatment.
Expired and beyond-use-date meds were found in two med carts, including Torsemide, Hydralazine, and Ondansetron packs. In addition, a resident with visual field defects kept multiple OTC meds in a plastic basin on a shelf in his room, and staff noted they should have been stored in a lockbox accessible only to the resident and licensed staff.
Failure to Perform Hand Hygiene During Meal Tray Delivery: During the lunch meal pass in C-Wing, a NA delivered multiple meal trays to resident rooms and repeatedly left the rooms without washing or sanitizing her hands after placing trays on bedside tables and handling the tables. The NA stated she was supposed to perform hand hygiene after tray delivery and after touching unclean surfaces, and the IP/LPN confirmed staff were supposed to wash or sanitize their hands after delivering trays.
A resident with anxiety disorder and bipolar disorder was ordered Sertraline for MDD, but the EMR did not show a signed informed consent before the medication was administered. The DON/RN and regional nurse consultant/RN confirmed the consent was missing and stated their expectation that residents on psychotropic meds have signed consents before administration.
A facility failed to ensure that residents with personal fund accounts received accrued interest on their accounts. Quarterly statements for three residents showed account balances and $0.00 interest paid, and the BOM stated the interest from the interest-bearing accounts was not being dispersed properly and was not divided correctly to the residents.
A resident with severe cognitive impairment was readmitted and received a NOMNC informing the representative that Medicare Part A coverage would end, but the record did not show a SNF ABN was issued. The Social Services Director said staff were unclear which department was responsible for Medicare Part A services, and the DON stated social services was responsible for issuing the SNF ABN.
Unclean Resident Room Environment: A resident room in C Wing was observed with a hospital wristband and a tied-up plastic bag containing trash left on the floor near the bed and dresser across multiple observations. The HA stated she cleaned rooms daily and should sweep and pick up items around and under the bed, while the Housekeeping Supervisor Director stated trash should be picked up and floors dust mopped daily.
Missing AIMS Assessments for Residents Receiving Antipsychotic Medication: The facility failed to document AIMS assessments for two residents receiving quetiapine. One resident had a psychotic disorder and was alert and oriented, while the other had depression, dementia, and severe cognitive impairment. Both had active orders and EMAR documentation showing bedtime quetiapine administration, but the EHRs did not contain AIMS testing. Staff and the DON acknowledged the missing assessments.
A resident with moderate cognitive impairment was transferred to the hospital after the family requested evaluation for possible sepsis, but the facility did not provide a written transfer/discharge notice in a language and manner the resident or representative understood. The DON and Regional Nurse Consultant could not find a transfer notice form and confirmed no Hospital Transfer Form was completed, given in person, or mailed; they stated the notice was typically provided verbally and sent in writing the next business day.
Inaccurate MDS Coding for Dialysis and Hospice Services: The facility failed to accurately complete the MDS for two residents. One resident with CKD and ESRD had dialysis orders, care plan documentation, and treatment records showing community dialysis, but the Quarterly MDS did not capture dialysis. Another resident with Alzheimer’s disease was receiving hospice services per orders and the care plan, but the Annual MDS did not code hospice. MDS nurses acknowledged the omissions during interview.
A resident with moderate cognitive impairment was placed on comfort care, but the care plan was not updated until a month later. The DON/RN stated the expectation was that the care plan would be updated when the resident’s level of care changed to comfort care.
Failure to assist a resident with shaving. A resident with visual field defects and an inability to shave himself was repeatedly observed with unkempt facial hair and stated staff did not help him shave. A CNA said staff were to assist with shaving, and the DON stated staff were expected to assist residents with shaving.
Failure to Document Bowel Interventions and Ordered Weights: A resident with PRN laxative orders had more than five days between documented BMs, and the MAR did not show the bowel protocol was initiated during that time. Another resident with renal insufficiency and dialysis had an order for daily weights, but multiple weights were missing from the MAR and dialysis communication log, and an LPN noted several weights were not completed.
A resident on hospice was observed receiving continuous oxygen via nasal cannula, but the EHR contained no physician order for oxygen after readmission. The care plan and progress notes documented oxygen use, and the UM/LPN and DON both stated that an order was expected for residents using oxygen.
Failure to Post Daily Nursing Staffing Information: The facility did not accurately post resident census and nursing hours on the Daily Nursing Staffing Information postings for all days reviewed. The postings did not include resident census, and staffing changes related to call-outs and illness were updated the next day instead of on the actual shift when they occurred. The DON/RN stated the expectation was for staffing changes to be adjusted every shift and the resident census to be updated daily.
Failure to Use PPE for Contact Precautions: A CNA entered a resident room on contact precautions with a lunch tray without donning gloves or a gown, placed the tray on the bedside table, spoke with the resident, then exited without hand hygiene before returning the tray to the food cart. The room had a posted sign requiring staff to clean hands and don gloves and a gown before entry and remove them before exit, and the IP/LPN and DON/RN stated staff were expected to follow those directions.
The facility did not follow its own policy to provide at least two baths or showers per week for residents dependent on staff for ADLs. One resident with ESRD, incontinence, and moderate cognitive impairment missed multiple scheduled showers because bathing was routinely scheduled at the same times the resident was out of the facility for dialysis, and the TAR showed many of these showers were not provided. Another resident with cancer, severe cognitive impairment, and reduced mobility missed a scheduled shower with no explanation documented in the progress notes, despite the DON’s expectation that missed baths be documented.
Surveyors found that staff failed to follow prescriber orders and facility policy for two residents when multiple medications and treatments were omitted and not documented on the MAR/TAR. For one resident with metastatic cancer, chronic respiratory failure, and severe cognitive impairment, catheter care, urinary output documentation, bladder scans with straight catheterization, weekly skin observations, barrier cream applications, and heel boot use were not carried out or recorded as ordered. For another resident with metabolic encephalopathy, a UTI, and severely impaired cognition, ordered doses of levothyroxine and acetaminophen, orthostatic BP checks, weekly weights, barrier cream to the coccyx, and elevation of the head of the bed for SOB prevention were also missed or undocumented. The RN Director of Resident Services confirmed that blank MAR/TAR entries meant the interventions were not done or not documented.
A resident with moderate cognitive impairment and a history of rhabdomyolysis was discharged with medications that did not match the reconciled list in the discharge summary. The resident later discovered, with a case worker, that one of the four medications they were taking at home had another person’s name on the container, even though the MAR showed only three medications were ordered to be sent home. The DON confirmed that an incorrect medication belonging to another resident had been provided at discharge, indicating a failure to ensure accurate medication reconciliation and prescriptions at discharge.
A resident with diabetes and peripheral vascular disease, who had multiple open wounds, did not receive prescribed wound care treatments on several occasions. The MAR and TAR lacked documentation for these missed treatments, and progress notes did not explain the omissions, except for one instance where care was provided by an outside provider but not recorded. Facility policy required treatments to be administered and documented as ordered, but this was not followed.
A resident with acute kidney failure and pancreatitis experienced a significant episode of hypotension, but there was no documented notification to the physician about this change. Facility policy required such notification, and the DON confirmed that nurses are expected to inform the doctor of new or concerning symptoms, which did not occur in this case.
A resident with multiple acute medical conditions did not receive scheduled bathing assistance as required by facility policy, with documentation showing missed bathing opportunities and staff confirming that showers were not consistently provided according to the established schedule.
A resident with multiple medical conditions had an open coccyx wound documented on admission, but subsequent weekly skin assessments and progress notes failed to consistently address or document the wound's status. Despite facility policy requiring weekly documentation by a licensed nurse, several entries indicated no skin concerns, and there was no record of the wound's healing. The DON confirmed that ongoing documentation should have occurred.
A resident with multiple medical conditions did not receive several prescribed medications and treatments as ordered, including missed doses of psychiatric, cardiac, respiratory, and pain medications, as well as omitted catheter care and bladder scans. Facility policy requires administration and documentation of medications per provider orders, but this was not followed, as confirmed by the DON.
The facility failed to obtain informed consent before administering psychotropic medications to two residents. One resident received Wellbutrin for depression without being informed of the risks and benefits, while another was given Prochlorperazine Maleate for nausea related to end-stage renal disease without a signed consent. Staff acknowledged the oversight, highlighting a lapse in ensuring residents were fully informed about their treatment.
A resident with severe malnutrition and diabetes experienced significant weight loss, but the facility failed to accurately document and monitor this change. Despite a care plan and directives for weekly weight monitoring, weights were not recorded due to an order entry error, leaving the RD unable to review the resident's nutritional status.
A facility failed to follow PASARR Level II recommendations for a resident with Alzheimer dementia and major depression. The resident's cognition was not assessed, and the necessary Level II assessment by a mental health professional was not documented in the medical record. Although a request was sent to the evaluator, the facility did not follow up to ensure services were initiated.
The facility failed to initiate timely baseline care plans for two residents, one with fall risks and another with communication needs, within 48 hours of admission. A resident with cognitive impairment experienced multiple falls before a care plan was developed, and another resident with limited English proficiency had delayed communication support.
The facility failed to complete neurological assessments for a resident after an unwitnessed fall, did not manage weight monitoring for two residents with CHF, and did not initiate bowel protocols for two residents experiencing prolonged periods without bowel movements. Additionally, the facility did not coordinate dental services for a resident needing dentures.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices or wounds, as staff only used gloves and did not wear gowns during care. Observations showed a lack of EBP signage and PPE at room entrances. Interviews revealed staff confusion about EBP requirements, contributing to the deficiency.
A resident tested positive for COVID-19, but the facility failed to notify the resident or their representative in a timely manner, as required by their policy. The resident was informed of the positive result three days later by a doctor. Staff acknowledged the oversight and stated that the notification should have occurred within 24 hours.
The facility failed to create comprehensive and individualized care plans for six residents, resulting in incomplete and non-specific plans. These deficiencies involved residents with various medical conditions, such as congestive heart failure, diabetes, and multiple sclerosis. The care plans lacked specific interventions and goals, leaving critical areas like ADLs, pain management, and discharge planning unspecified, placing residents at risk for unmet care needs.
A facility failed to administer medications as ordered for four residents, leading to significant medication errors. One resident with congestive heart failure and other conditions missed doses of Atorvastatin and Levo-T. Another resident with severe cognitive impairment and diabetes missed multiple medications after a hospital visit. A third resident did not receive prescribed Hydrocortisone cream, and a fourth resident's daily weight was not monitored as ordered. The DON acknowledged the omissions and noted that the MAR should indicate reasons for missed medications.
A resident at risk for falls due to impaired balance and cognitive deficits fell from bed because fall mats were not placed as required by the care plan. Staff confirmed the absence of fall mats at the time of the incident, contrary to the intervention initiated in the care plan.
Incomplete and Non-Individualized Care Plans for Multiple Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, individualized care plans with complete, resident-specific information for four of seven sampled residents. For a cognitively intact resident with spinal stenosis, osteoarthritis, and an artificial knee joint, the care plan initiated in early February 2026 contained incomplete segments for communication impairment, fall risk, and anticoagulant use, with the sections intended to describe the underlying causes or related diagnoses left blank. Another resident with severe cognitive impairment, hypertension, and chronic heart failure had an admission care plan with incomplete segments related to diuretic and opioid use, where the diagnoses or conditions necessitating these medications were not documented. A resident with type 2 diabetes mellitus and moderate cognitive impairment, who required moderate assistance with ambulation, had a care plan segment for vision impairment that lacked individualized information about the cause of the impairment. A cognitively intact resident admitted with a traumatic subdural hemorrhage had multiple incomplete care plan segments, including fall risk, need for rehabilitation and assistance with activities of daily living, and risk for constipation, all missing the specific related causes or diagnoses. The DON stated that unit managers are responsible for writing the comprehensive nursing care plans and acknowledged that the incomplete segments for these residents should have been completed.
Recurring Medication Administration Errors and Omissions
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors by not administering medications in accordance with prescriber orders and within the facility’s stated administration time parameters. The facility’s policy, dated January 2023, required medications to be administered according to written prescriber orders, documented on the MAR immediately after administration, and given within 60 minutes of the scheduled time. Surveyors’ review of MARs, TARs, and medication administration audit reports for multiple residents showed omitted doses and frequent administration of medications outside the accepted nursing standard of practice window of one hour before to one hour after the ordered time. For one cognitively intact resident with diagnoses including spinal stenosis, PTSD, and chronic kidney disease, the February MAR and TAR showed several omitted evening medications and treatments on a specific date, including ketoconazole cream for wound care, monitoring of bruised areas on multiple body sites, sedative/hypnotic monitoring for insomnia, and anticoagulant medication monitoring. The medication administration audit for this resident over a defined period showed numerous medications given outside the two-hour administration window, including acetaminophen, estradiol, fluticasone propionate, furosemide, heparin, hydromorphone, ketoconazole, losartan, phentermine, prazosin, rosuvastatin, senna, sertraline, and topiramate, with multiple late or early administrations documented for many of these drugs. For a second cognitively intact resident with COPD, chronic pain syndrome, type 2 diabetes mellitus, and a psychotic disorder, review of the January MAR and TAR showed that on one evening multiple scheduled medications and supplements were omitted, including Arnuity Ellipta, Cymbalta, melatonin, olanzapine, omega-3, vitamin C, Zetia, zinc, and potassium chloride. The audit report for this resident over another specified period showed repeated administration of several medications outside the two-hour window, including Arnuity Ellipta, Cymbalta, furosemide, Incruse Ellipta, insulin glargine, levothyroxine, melatonin, olanzapine, omega-3, potassium chloride, vitamin C, Zetia, and zinc. For a third cognitively intact resident admitted with a traumatic subdural hemorrhage, the medication administration audit over a defined period showed multiple medications administered outside the two-hour window. These included acetaminophen, amlodipine, aspirin for CVA prevention, atorvastatin, donepezil, levetiracetam, lisinopril, multivitamins, senna, and zinc, each with one or more instances of administration outside the permitted timeframe. During an interview, the RN/Director of Resident Services confirmed that blank spots on the MAR or TAR indicated medications or treatments were omitted or not charted and acknowledged that the identified administration times were outside the permitted two-hour timeframe. The deficiency was cited under WAC 388.97.1060(3)(k)(iii) and noted as a recurring deficiency previously cited on three earlier survey dates.
Failure to Complete Dialysis Assessments and Follow Dialysis-Related Physician Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide safe and appropriate dialysis-related care and to follow physician orders for a resident with end stage renal disease (ESRD) who was dependent on hemodialysis. The resident had severe cognitive impairment and required hemodialysis three times weekly. The facility had a service agreement with the dialysis provider requiring interchange of necessary information and ensuring appropriate information accompanied the resident at transfer. Physician orders directed staff to complete a Pre HD Assessment in the EMR before transport, provide a copy to the transport/dialysis center, and complete a Post HD Assessment upon the resident’s return, including updating the resident’s weight. Record review showed multiple dates on which the Pre and/or Post HD Assessments were incomplete or blank, and the resident’s care plan did not address pre/post dialysis assessments or ongoing communication and coordination with the dialysis provider after each treatment. The facility also failed to follow specific physician orders related to premedication and other dialysis-related needs. Orders dated 02/05/2026 required staff to premedicate the resident with Norco prior to dialysis, ensure dentures were in place, and send a donut seat and blanket with the resident. Additional orders required daily weights. Review of the MAR showed that Norco was not consistently documented as given prior to dialysis on several treatment days, with blank entries and “9 – see progress notes” not supported by any corresponding progress note documentation. Dialysis facility notes documented that the resident reported severe pain and stated he was not receiving pain medication at the SNF, and dialysis staff confirmed with the SNF RN that pain medication was available but not being given, and that dialysis patients were often premedicated but this was not occurring for this resident. Further, the facility did not consistently ensure that the resident was sent to dialysis with required items and appropriate clothing, nor did it consistently send the communication binder. Dialysis staff documented that the resident often arrived in pain, without the communication binder, not properly clothed, and frequently without food, dentures, or a blanket. On one occasion, dialysis notes indicated the resident was visibly cold and had been sent without a blanket, jacket, or shoes, and that this was at least the second time the dialysis staff had called the facility about the need for warm clothes and having the resident’s teeth in. The resident also missed a scheduled dialysis treatment on one date. In interview, the DON acknowledged that blank MAR entries indicated medication omissions or lack of charting, and that information from the communication binder should have been entered into the pre and post dialysis assessments, which were found to be incomplete or blank on multiple dates.
Expired Medications in Carts and Unsecured Resident Medications
Penalty
Summary
Expired and beyond-use-date medications were found in two medication carts during observation and review. In the E Wing medication cart, two pill packs contained expired Torsemide 20 mg with an expiration date of 09/21/2025 and Hydralazine 10 mg with an expiration date of 10/11/2025, and one Ondansetron 4 mg pack had a beyond-use date of 10/13/2025. In the B Wing medication cart, two packages of Ondansetron 4 mg were found with beyond-use dates of 10/30/2025 and 12/05/2025. Staff stated that expired medications should not be kept in the cart and that expired medications should be removed and destroyed, and one staff member said the pharmacist would go through the cart once a month to remove expired medications. Unsecured medications were also observed in Resident 80’s room. Resident 80 had diagnoses including unspecified visual field defects and was documented as alert and oriented on the annual MDS dated 10/13/2025. During observation, a plastic basin on shelves near the front of the bed contained medication bottles including Super Enzymes, Alpha lipoic 100 mg, multivitamins, Melatonin 3 mg, Niacin 500 mg, Cranberry capsules 500 mg, and Vitamin D3 gummies. Resident 80 said he occasionally took the medications in his room and kept them in the plastic basin. Staff observed the medications and stated they should have been kept in a lockbox accessible only to Resident 80 and licensed staff, while the DON stated the expectation was that Resident 80 had been educated and provided a lock box for storage.
Failure to Perform Hand Hygiene During Meal Tray Delivery
Penalty
Summary
The facility failed to ensure staff performed hand hygiene during the lunch hallway meal pass in C-Wing. During the lunch dining observation, Staff Q, a Nursing Assistant, delivered multiple meal trays to resident rooms, placing trays on bedside tables and pulling the tables up to residents. After delivering trays to several rooms, Staff Q left the rooms without washing or sanitizing her hands. In one instance, after placing a tray on the bedside table and asking another NA for help repositioning a resident, Staff Q did wash her hands. During interview, Staff Q stated she was supposed to wash her hands before delivering trays and that if she touched the bedside table or anything not clean, she was supposed to sanitize or wash her hands. She also stated that when moving the bedside table in several rooms, she was supposed to sanitize her hands and realized she did not perform hand hygiene. The Infection Preventionist/LPN stated staff were supposed to wash or sanitize their hands after delivering trays to resident rooms.
Failure to Obtain Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain a signed consent before administering Sertraline, a psychotropic medication, to Resident 6. Resident 6’s record showed an annual MDS documenting that the resident was admitted on [DATE], was alert and oriented, and had diagnoses including anxiety disorder and bipolar disorder. The Order Summary Report showed Sertraline 25 mg, 2 tablets by mouth one time a day for MDD, ordered on 11/27/2025. Review of the electronic medical record did not show documentation of informed consent for Sertraline. In a joint interview, the DON/RN and the regional nurse consultant/RN stated Resident 6 did not have a consent for Sertraline in the record and that their expectation was that residents on psychotropic medications had consents signed prior to administration.
Failure to Disburse Interest on Resident Trust Accounts
Penalty
Summary
The facility failed to ensure that residents with personal fund accounts received accrued interest on those accounts for 3 of 3 sampled residents reviewed for trust fund interest accrual. Resident 16's quarterly resident fund statement for 10/01/2025 through 12/31/2025 showed four credits totaling $7,140.40, four debits totaling $6,801.64, an ending balance of $381.58, and year-to-date interest paid of $0.00. Resident 76's statement for the same quarter showed four credits totaling $2,761.00, three debits totaling $2,343.66, an ending balance of $852.02, and year-to-date interest paid of $0.00. Resident 98's statement for the same quarter showed three credits totaling $6,789.00, five debits totaling $6,671.66, an ending balance of $123.12, and year-to-date interest paid of $0.00. During interview, the BOM stated that Residents 16, 76, and 98 had their money in an interest-bearing account, but over the last quarter the interest accrued was not being dispersed properly. The Administrator, Regional Director, and Regional BOM were also interviewed, and the Regional BOM stated the interest was not divided correctly to the residents and that every resident account with over fifty dollars accrued interest. The report cites WAC 388-97-0340(a).
Failure to Issue Medicare SNF ABN
Penalty
Summary
The facility failed to provide a Medicare Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) to Resident 16, who was readmitted to the facility and had an annual MDS documenting severe cognitive impairment. Record review showed a Notice of Medicare Non-Coverage form was issued to the resident's representative by phone, informing them that Medicare Part A coverage would end on 09/05/2025, but the electronic health record did not show that a SNF ABN was issued. During interviews, the Social Services Director stated the resident was not issued a SNF ABN because staff were unclear which department was responsible for Medicare Part A services, including issuing SNF ABNs, and the Director stated social services was responsible and that the resident should have received the notice but did not.
Unclean Resident Room Environment
Penalty
Summary
The facility failed to maintain a clean, homelike environment in 1 of 11 rooms reviewed for environment, specifically C Wing room [ROOM NUMBER]. Review of the Environmental Services Department in-service on Daily Resident Room Cleaning stated that the entire floor is to be dust mopped, especially behind and under beds and behind dressers. During observations on 01/06/2026, 01/07/2026 at 10:03 AM, and 01/08/2026 at 8:40 AM, a hospital wristband was observed on the right side of the bed and a tied-up plastic bag containing trash was observed on the floor next to the dresser on the left side of the bed, and both items remained in the same location across the observations. During interview and observation on 01/08/2026 at 8:49 AM, the Housekeeping Aide stated she cleaned all rooms daily and that her cleaning included sweeping and mopping the floors, and when shown the items on the floor said she was supposed to sweep and pick up the stuff around and under the bed. During interview on 01/08/2026 at 8:56 AM, the Housekeeping Supervisor Director stated trash should be picked up and the floor should be dust mopped daily, and that the HAs had a guidance checklist to follow.
Missing AIMS Assessments for Residents Receiving Antipsychotic Medication
Penalty
Summary
The facility failed to complete AIMS assessments for 2 of 5 sampled residents reviewed for unnecessary medications. Resident 4 was admitted with multiple diagnoses including a psychotic disorder and was alert and oriented on the 5-Day MDS dated 12/08/2025. A physician order dated 12/19/2025 showed Resident 4 was prescribed quetiapine fumarate 25 mg at bedtime, and the December 2025 and January 2026 EMAR showed the medication was being administered. The care plan dated 12/13/2025 identified antipsychotic use as a focus and included AIMS assessment as an intervention, but the EHR did not show documentation of an AIMS test. The consultant pharmacist’s medication regimen reviews dated 12/01/2025 and 12/20/2025 also noted that a current AIMS test could not be located in the chart. Resident 118 was admitted with diagnoses including depression and dementia, and the admission MDS showed severe cognitive impairment and antipsychotic use. A physician order dated 12/31/2025 showed Resident 118 was prescribed quetiapine fumarate 37.5 mg at bedtime, and the December 2025 and January 2026 EMAR showed the medication was being administered. Review of Resident 118’s EHR did not show documentation of an AIMS test. During interviews, Staff H stated an AIMS assessment was needed for a resident on an antipsychotic medication and could not find one for Resident 4, Staff E stated there was not an AIMS test done for Resident 118 and there should have been one, and the DON stated an AIMS test should be done upon admission for a resident taking an antipsychotic medication or when a new antipsychotic medication was started.
Missing Written Transfer/Discharge Notice After Hospital Transfer
Penalty
Summary
The facility failed to ensure that a written transfer/discharge notice was provided to Resident 115 or the resident representative in a language and manner they understood when the resident was transferred to the hospital. Resident 115’s MDS documented moderate cognitive impairment. A nursing note stated that at 12:02 a.m., the resident’s granddaughter, who was present in the room, spoke with the resident’s daughter, who requested that the resident be transferred to a hospital for evaluation of potential sepsis. Emergency services were called at 12:05 a.m., and the resident was transferred to Legacy Hospital; the on-call provider was notified. Record review showed no documentation of a written transfer/discharge notice in the resident’s electronic medical record. The Nursing Home Discharge MDS documented that Resident 115 had an unplanned discharge. In interviews, the DON and Regional Nurse Consultant stated they could not find a Discharge/Transfer notice form for Resident 115 and said residents transferred to the hospital should be sent with an Interact SNF/NF to Hospital Transfer Form. They also stated that for emergent transfers, the resident or representative is notified verbally by phone and the written notice is sent the next business day, but confirmed Resident 115 did not have a Hospital Transfer Form filled out, given in person, or mailed to the resident or representative.
Inaccurate MDS Coding for Dialysis and Hospice Services
Penalty
Summary
The facility failed to ensure the MDS was completed accurately for 2 sampled residents. For Resident 39, who was admitted with acute kidney failure and chronic kidney disease stage 4, the Quarterly MDS documented the resident as cognitively intact, having acute kidney failure, and not being on dialysis. However, physician orders showed dialysis was ordered every Tuesday, Thursday, and Saturday at 3:30 PM at a dialysis center, the care plan identified community dialysis for ESRD, and progress notes and the October 2025 ETAR showed the resident went to dialysis appointments on 10/23/2025 and 10/25/2025. During interview, the MDS nurses reviewed the record and acknowledged dialysis should have been captured on the MDS but was not. For Resident 22, who was admitted with Alzheimer’s disease and was documented on the Annual MDS as severely cognitively declined, the physician order showed the resident was admitted to hospice services and the care plan documented hospice with expected decline in condition due to terminal progressive disease. The Annual MDS, however, showed the resident was not receiving hospice care. During interview, the MDS nurses stated the resident was receiving hospice services and confirmed hospice was not captured on the MDS even though it should have been.
Delayed Comfort Care Care Plan Update
Penalty
Summary
Resident 116 was admitted to the facility and later had a Significant Change MDS dated 11/18/2025 that documented moderate cognitive impairment. Record review showed a Portable Orders for Life-Sustaining Treatment dated 11/11/2025 documenting that Resident 116 was on comfort care. The resident’s care plan, dated 12/11/2025, showed that a comfort care care plan was developed a month after the resident was placed on comfort care. In an interview on 01/08/2026 at 12:50 PM, the DON/RN stated it was the expectation that Resident 116’s care plan would be updated when the resident’s level of care changed to comfort care.
Failure to Assist Resident With Shaving
Penalty
Summary
The facility failed to provide assistance with grooming for Resident 80, who was admitted with diagnoses including unspecified visual field defects and was documented on the annual MDS as alert and oriented. Record review showed the resident was scheduled for and received showers on Tuesday, Friday, and Sunday, but the resident stated staff did not help him shave his facial hair and that he was unable to shave himself and needed staff assistance. During interviews and observations on 01/06/2026, 01/08/2026, and 01/09/2026, Resident 80 was repeatedly observed with unkempt facial hair and said staff did not assist him with shaving, stating that the electric shaver had never worked. A CNA stated the resident received evening showers and staff were to assist with shaving, and the DON stated it was the expectation that staff assist residents with shaving.
Failure to Document Bowel Interventions and Ordered Weights
Penalty
Summary
The facility failed to ensure bowel interventions were initiated for a resident who was alert and oriented and had orders for Polyethylene Glycol powder 17 grams by mouth as needed for constipation and Bisacodyl 10 mg rectal suppository every 24 hours as needed for constipation. The resident’s bowel and bladder elimination task sheet showed a bowel movement on 01/01/2026 at 8:33 PM and then no other documented bowel movement until 01/06/2026 at 6:00 PM, leaving more than 117 hours between documented bowel movements. The January 2026 MAR did not show the bowel protocol being initiated during that interval. The facility also failed to perform ordered daily weights for a resident who was renal insufficient and required dialysis treatment and was alert and oriented. The resident had an order for weight one time a day, but the December 2025 and January 2026 MARs showed multiple dates with no documented weights, and the dialysis communication log also lacked documentation for those same dates. During interview, the Unit Manager/LPN stated weights should be documented in the EHR and that refusals should be documented if the resident refused, and while reviewing the EHR she observed several weights were not completed.
Missing Physician Order for Oxygen Use
Penalty
Summary
The facility failed to obtain a physician order for oxygen use for Resident 83, who was admitted, later discharged with return anticipated, and then re-admitted on hospice. The admission MDS dated 11/11/2025 showed the resident was cognitively intact and receiving oxygen therapy. During observations on 01/06/2026 and 01/07/2026, the resident was lying in bed with oxygen via nasal cannula running at 3 liters per minute. Record review showed the care plan dated 12/24/2025 identified a respiratory disease focus and documented oxygen 2 liters via nasal cannula for comfort. The readmission progress note dated 12/23/2025 documented that the resident was on oxygen, and progress notes dated 01/06/2026 and 01/07/2026 documented that the resident used continuous oxygen via nasal cannula. Review of the EHR showed no physician order related to oxygen use after readmission. In interviews, the Unit Manager/LPN stated a physician order was needed for residents using oxygen and said she did not see an order in the EHR after readmission, and the DON stated it was her expectation that residents using oxygen had physician orders in place.
Failure to Post Daily Nursing Staffing Information
Penalty
Summary
The facility failed to ensure resident census and nursing hours were accurately posted and updated daily on the Daily Nursing Staffing Information postings for 30 of 30 days reviewed. Record review of the facility policy titled, Posting Nursing Staffing Information Policy dated 10/06/2022, stated that the posting should be completed daily at the beginning of each shift and should include staff absence on each shift due to call-outs and illness, as well as resident census. Review of the postings from 12/07/2025 to 01/06/2026 showed that resident census was not posted daily. During interview, Staff H, Staffing, stated the postings did not include resident census and that nurse staffing data reflecting staff absence or changes at the beginning of each shift was updated the next day rather than on the actual date and shift when the changes occurred. Staff B, DON/RN, stated it was the expectation that staffing changes were adjusted every shift and the resident census was updated daily on the Daily Nursing Staffing Information postings.
Failure to Use PPE for Contact Precautions
Penalty
Summary
The facility failed to ensure staff properly donned PPE for a resident room on contact precautions. The facility policy titled Transmission-Based Precautions, dated 02/01/2022, stated that staff and visitors must wear gloves and a gown when entering the room for all interactions that may involve contact with the resident and/or the resident's environment, and must remove PPE and perform hand hygiene before leaving the room. A contact precautions sign posted outside the room also directed providers and staff to clean their hands before entering and when leaving the room, and to put on gloves and a gown before room entry and discard them before room exit. During an observation, a CNA entered the room with a lunch tray without donning gloves or a gown. The CNA placed the tray on the bedside table, spoke with the resident who was lying in bed, then picked up the tray and exited the room without cleaning her hands before placing the tray back on the food cart. A visitor was observed in the room sitting next to the bed wearing a gown and mask. In interview, the CNA stated she should have gowned and gloved whenever she went into the room after reviewing the contact precautions sign. The IP/LPN stated staff were expected to put on a gown and gloves when entering the room for a resident on contact precautions, even when delivering a food tray, and the DON/RN stated staff were expected to follow the TBP indicated for the resident and room per the IP's directions and the directions posted at the door.
Failure to Provide Scheduled Bathing Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide required bathing assistance to residents dependent on staff for activities of daily living, specifically bathing, in accordance with its policy requiring at least two full baths or showers per week. One resident with end stage renal disease, weakness, reduced mobility, moderate cognitive impairment, and frequent bowel and bladder incontinence was care planned as dependent on staff for personal hygiene and bathing. Review of this resident’s Treatment Administration Records (TARs) for October and November 2025 showed that bathing was scheduled on specific days of the week but was only provided for a portion of the scheduled times. The TARs also showed the resident was routinely out of the facility three days per week for dialysis, and showers were scheduled on days and times that conflicted with these dialysis appointments, resulting in multiple missed showers. The resident reported frequently not being assisted with bathing because they were at their regularly scheduled dialysis appointments. Another resident with cancer, reduced mobility, weakness, severe cognitive impairment, and dependence on staff for bathing assistance was also care planned to require help with personal hygiene. Review of this resident’s October 2025 TAR showed they did not receive a scheduled shower on one date, and review of the progress notes for the same month showed no documentation explaining why the scheduled shower was not provided. During an interview, the DON stated that residents were scheduled for bathing assistance twice per week and that nurses were expected to document in the progress notes if a resident did not receive a scheduled bath. The DON acknowledged that the first resident’s bathing schedule had been set for the same days of the week as their dialysis appointments.
Failure to Administer and Document Ordered Medications and Treatments
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications and treatments were administered and documented in accordance with prescriber orders and facility policy, resulting in multiple omissions for two residents. The facility’s medication administration policy dated January 2023 required that medications be administered per written prescriber orders and that the individual administering the medication immediately record the administration on the MAR. During review of October and November 2025 MARs and TARs, surveyors identified numerous blank entries, which the Director of Resident Services confirmed meant the medications or treatments were not done or not documented, and stated those areas should not be blank. For one resident with metastatic cancer, chronic respiratory failure, hypertension, reduced mobility, weakness, and severe cognitive impairment, the October and November 2025 MAR/TAR showed multiple omitted treatments and monitoring tasks. These included missed catheter care and failure to document urinary output on several shifts, missed weekly skin observations, and omitted application of Triad barrier cream and other barrier creams to the buttocks and posterior thighs for skin breakdown and redness. Additional omissions included ordered bladder scans every six hours with straight catheterization for post-void residuals greater than 350 cc at several scheduled times, and failure to ensure bilateral heel boots were in place while the resident was in bed. For another resident with metabolic encephalopathy, a UTI, and severely impaired cognition, the October and November 2025 MAR/TAR also showed omitted medications and treatments. These included missed doses of levothyroxine and acetaminophen at scheduled administration times, as well as failure to complete ordered orthostatic blood pressure measurements and weekly weights. The records further showed omissions in applying barrier cream to the coccyx every shift and as needed for redness, and failure to elevate the head of the bed every shift as ordered to alleviate or prevent shortness of breath while lying flat. The Director of Resident Services confirmed that the blank MAR/TAR entries for these residents indicated the orders were not carried out or not documented.
Incorrect Medication Sent Home at Discharge Due to Failed Medication Reconciliation
Penalty
Summary
Surveyors identified a deficiency in the facility’s discharge process related to medication reconciliation and accuracy of prescriptions provided at discharge. The facility’s own Discharge Planning policy, dated 10/01/2021, required that when discharge is anticipated, the facility prepare a discharge summary that includes reconciliation of all pre-discharge medications with the resident’s post-discharge medications. For one resident with a diagnosis including rhabdomyolysis and moderate cognitive impairment, the admission MDS dated 11/28/2025 documented this cognitive status. The resident reported that after discharge they were taking four medications daily, and later discovered with their case worker that one of the medications provided by the facility had another person’s name on the container. Record review of the resident’s December 2025 MAR showed only three prescribed medications ordered to be sent home at discharge, indicating a discrepancy between the reconciled medication list and what was actually provided. During an interview, the DON acknowledged the facility had been made aware that an incorrect medication, belonging to another resident, was sent home with this resident at discharge. The DON also stated that the nurse who provided the wrong medication had been identified. This sequence of events demonstrated that the prescriptions and medications supplied at discharge did not accurately reflect the reconciled medication list in the discharge summary for this resident.
Failure to Administer and Document Wound Care Treatments as Ordered
Penalty
Summary
The facility failed to ensure that medications and treatments were administered in accordance with provider orders for a resident with multiple chronic conditions, including Diabetes Mellitus II and Peripheral Vascular Disease. The resident had documented skin impairments, including open areas on the lower extremity, buttocks, and right heel, with care plan interventions specifying that wound care treatments be provided as ordered. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed that the resident did not receive prescribed wound care treatments on several specific dates. There was no documentation on the MAR/TAR or in the resident's progress notes explaining why the treatments were missed, except for one instance where wound care was provided by an outside provider but not recorded appropriately. Facility policy required that medications and treatments be administered according to prescriber orders and documented immediately after administration. The interim Director of Nursing confirmed that the expectation was for nurses to follow provider orders for medications and treatments. The lack of administration and documentation for the resident's wound care treatments constituted a medication and/or treatment error, as the facility did not follow its own policy or provider orders, and failed to document reasons for missed treatments.
Failure to Notify Physician of Significant Change in Condition
Penalty
Summary
The facility failed to notify a resident's physician about a significant change in the resident's physical condition. Specifically, a resident with a history of acute kidney failure and acute pancreatitis experienced a clinically significant episode of hypotension, with a recorded blood pressure of 73/48. Despite this event, there was no documented communication to or with the provider regarding the hypotensive episode, as confirmed by a review of the resident's progress notes and the electronic provider communication tool. The facility's policy requires nurses to notify the attending physician or practitioner when there is a significant change in a resident's physical, mental, or psychosocial status, including clinical complications. The care plan for the resident included monitoring for cardiac complications, but there was no evidence that the physician was informed of the low blood pressure event. The Director of Nursing stated that nurses are expected to assess and notify the doctor of any new or concerning symptoms, but this did not occur in this instance.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
The facility failed to provide adequate bathing assistance to a resident who was admitted with acute kidney failure, muscle weakness, and acute pancreatitis, and was assessed as cognitively intact. According to facility policy, residents are to be offered at least two full baths or showers per week, with refusals documented and reported to a licensed nurse. Review of the resident's records showed that bathing was not provided as scheduled, with only a few documented instances of bathing during the resident's stay. Staff interviews confirmed that showers were expected to be performed according to a set schedule, but this was not consistently followed for the resident in question.
Failure to Accurately Document and Assess Pressure Ulcer
Penalty
Summary
The facility failed to assess and accurately document a resident's wound, specifically a coccyx wound, for one of three residents sampled for wound care. According to the facility's policy, licensed nurses are required to conduct and document weekly skin observations, including the status of any pressure injuries. The resident in question was admitted with multiple diagnoses, including acute kidney failure, muscle weakness, and acute pancreatitis, and was cognitively intact. Medical records showed an order for weekly skin assessments, and initial documentation noted an open area on the coccyx. However, subsequent weekly skin observations and progress notes failed to consistently address the presence or status of the coccyx wound, with several entries indicating no skin concerns despite the initial finding. There was no documentation indicating that the coccyx wound had healed, and later observations described a red blanchable area and scar tissue at the same location. The Director of Nursing confirmed that nurses should have been documenting the wound each week or providing evidence of healing. This lack of consistent and accurate documentation regarding the resident's wound status constituted a failure to follow facility policy and placed residents at risk.
Failure to Administer Medications and Treatments as Ordered
Penalty
Summary
The facility failed to ensure that medications and treatments were administered in accordance with provider orders for one resident. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for this resident revealed multiple instances where prescribed medications and treatments were omitted or not administered as ordered. These included missed doses of Quetiapine Fumarate, Rosuvastatin Calcium, Vitamin C, Fluticasone Propionate, Spiriva Respimat, Metoprolol Succinate, Potassium Chloride, as well as missed daily weights, catheter care, hydromorphone for pain, and scheduled bladder scans. The facility's policy requires medications to be administered according to prescriber orders and documented immediately after administration, but this was not followed in these cases. The resident involved had diagnoses including acute kidney failure, chronic obstructive pulmonary disease, and acute pancreatitis, and was assessed as cognitively intact. The omissions were identified through review of the resident's records for April and May, which showed specific dates and times when medications and treatments were not given as ordered. During an interview, the DON confirmed that the expectation is for nurses to administer medications and treatments according to provider orders.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents were fully informed and provided with the necessary information to give informed consent before administering psychotropic medications. This deficiency was identified for two residents. Resident 32, who was admitted with a diagnosis of depression, received Wellbutrin, an antidepressant, on 10/25/2024, without having been informed of the risks and benefits, and without signing a consent form. Staff J, a Unit Manager and LPN, acknowledged that the medication was administered before obtaining the necessary consent. Similarly, Resident 78, who was alert and oriented, was prescribed Prochlorperazine Maleate, an antipsychotic, for nausea related to end-stage renal disease. The medication was administered without an informed consent form being signed. Staff B, the Director of Nursing Services and RN, confirmed that any use of psychotropic medication should have a consent form signed by the resident or their representative. These failures placed the residents at risk of not being fully informed about their care and treatment.
Failure to Accurately Document Resident's Weight Loss
Penalty
Summary
The facility failed to accurately assess and document significant weight loss for a resident diagnosed with severe malnutrition and Diabetes Mellitus. The resident was admitted with a care plan goal to maintain stable weights within 3-5 pounds, with interventions including diet as ordered, weights per protocol, and supplements as ordered. However, a Nutrition/Dietary progress note documented a significant weight loss of 11.73% of total body weight, and a subsequent nutritional assessment recommended weekly weight monitoring. Despite these directives, the facility did not record the resident's weights as requested by the Registered Dietician (RD), due to an order not being correctly entered, which led to the absence of weight records for review. Staff interviews revealed that the weights were not recorded in the medical record as required, and the RD was unable to provide missing weights for the resident. The Director of Nursing Services confirmed the absence of recorded weights after a certain date. The facility's policy indicated that weight changes of 10% are significant, and greater than 10% are severe, necessitating accurate weight documentation to prevent, monitor, or intervene with undesirable weight changes. The failure to record and monitor the resident's weight placed them at risk for nutritional and functional decline.
Failure to Follow PASARR Level II Recommendations
Penalty
Summary
The facility failed to ensure the recommendations of the Preadmission Screen and Resident Review (PASARR) Level II were followed for a resident reviewed for PASARR. The resident was admitted with diagnoses including Alzheimer dementia and major depression. The Quarterly Minimum Data Set assessment indicated that the resident's cognition was not assessed. The PASARR Level I indicated the need for a Level II assessment by a licensed mental health professional or mental health agency for individual services. However, the PASARR Level II recommendations were not found in the resident's medical record. The facility had a fax confirmation for a PASARR Level II request sent to the evaluator, but did not follow up to ensure services were started.
Failure to Initiate Timely Baseline Care Plans for Fall Risk and Communication Needs
Penalty
Summary
The facility failed to develop a baseline care plan to address fall risks and communication needs for two residents within 48 hours of their admission, as required. Resident 66, who was severely cognitively impaired and had a history of cerebrovascular accident, experienced three falls after admission, with the first two occurring before a fall risk care plan was initiated. The care plan was only developed after the second fall, despite the resident being assessed for falls upon admission. The Director of Nursing Services acknowledged that the fall risk care plan should have been initiated at the time of admission. Similarly, Resident 82, who was alert and oriented but had limited English proficiency, did not have a communication needs care plan initiated until several days after admission. The resident was observed having difficulty communicating in English and requested assistance with a phone. Staff used a translator service to communicate with the resident, but the communication care plan was delayed. The Director of Nursing Services confirmed that the communication needs care plan should have been initiated upon admission.
Deficiencies in Neurological Assessments, Weight Management, Bowel Protocol, and Dental Services
Penalty
Summary
The facility failed to perform ongoing neurological assessments for a resident who experienced an unwitnessed fall. The resident, who was severely cognitively impaired and had a history of cerebrovascular accident, did not receive complete neurological checks as required. The Director of Nursing Services acknowledged that the neuro checks were incomplete, which was against the facility's expectations for handling unwitnessed falls. The facility also failed to manage weight monitoring for two residents with congestive heart failure. One resident had a physician's order for weekly weights, but several weekly weights were missing from the electronic health record. Another resident had an order for daily weights, but numerous daily weights were not recorded. Staff members, including the Unit Manager and Director of Nursing Services, recognized the lack of documentation and stated that it was expected for CNAs to weigh residents as ordered. Additionally, the facility did not initiate bowel protocols for two residents who experienced extended periods without bowel movements. Despite having physician orders for laxatives to be administered after specific durations without bowel movements, the medication administration records showed no interventions were initiated. Staff admitted that the bowel protocol was not followed, and there was inconsistency in documentation. Furthermore, the facility failed to coordinate dental services for a resident who expressed a need for dentures, with no documentation of attempts to address the resident's dental care needs.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for four out of five residents reviewed for infection prevention and control. These residents had indwelling medical devices or wounds, which required the use of gowns and gloves during high-contact care activities as per the facility's policy. Observations revealed that staff only used gloves and did not wear gowns when providing care to these residents. Additionally, there was no EBP signage or personal protective equipment (PPE) available at the entrances of the residents' rooms. Resident 62, who had an indwelling urinary catheter, was observed multiple times without EBP signage or PPE at their room entrance. Similarly, Resident 240, with an abdominal drain, and Resident 241, with a peripherally inserted central catheter (PICC line), reported that staff only used gloves during care, and no EBP signage or PPE was present at their room entrances. Resident 339, who used a suprapubic catheter, was also observed without EBP signage or PPE, and staff were seen entering and exiting the room without applying PPE. Interviews with staff, including the Infection Control Nurse and Director of Nursing Services, revealed a lack of understanding and implementation of EBP. Staff members incorrectly equated EBP with standard precautions and believed gowns were unnecessary unless an infection was present. The Infection Control Nurse stated that EBP should be initiated by the admission nurse and verified by the nurse manager, but this process was not effectively carried out, leading to the observed deficiencies.
Failure to Notify Resident of Positive COVID-19 Test
Penalty
Summary
The facility failed to notify a resident's family and/or representative of a positive COVID-19 test result, which was a requirement according to their policy. The policy, dated May 15, 2020, stated that the facility must inform residents, their representatives, and families by 5:00 p.m. the next calendar day following a confirmed COVID-19 infection. Resident 75, who was alert and oriented, tested positive for COVID-19 on September 27, 2024, as documented in their Treatment Administration Record. However, there was no documentation in the resident's Electronic Health Record indicating that the resident or their representative was informed of the positive result. Interviews with the resident and staff revealed that the resident was not notified of the positive COVID-19 test until about three days later, when a doctor mentioned it in passing. Staff D, the Infection Preventionist and RN, stated that the facility's practice was to notify residents and their representatives as soon as possible, ideally within 24 hours of the test. Staff B, the Director of Nursing Services and RN, acknowledged that the facility failed to notify Resident 75 as per the policy, admitting that they missed this notification.
Incomplete and Non-Specific Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive and individualized care plans for six residents, which resulted in incomplete and non-specific care plans. These deficiencies were identified during a review of the care plans for residents with various medical conditions, including congestive heart failure, diabetes mellitus, aortic valve stenosis, urinary tract infection, multiple sclerosis, and obesity. The care plans lacked specific interventions and goals tailored to each resident's needs, leaving critical areas such as assistance with activities of daily living (ADLs), pain management, mobility, cognitive function, and discharge planning unspecified. For instance, one resident with moderate cognitive impairment and mobility issues had a care plan that did not specify the level of assistance required for ambulation, toileting, and eating. Another resident with severe cognitive impairment and diabetes had a care plan that failed to detail pain management strategies and discharge arrangements. Similarly, a resident with aortic valve stenosis and muscle weakness had a care plan that omitted specific interventions for communication problems, behavior issues, and intravenous medication management. The lack of individualized care plans placed residents at risk for unmet care needs and diminished quality of life. The Director of Nursing Services acknowledged that the Resident Care Managers were responsible for writing these care plans and recognized the need for education to address the incomplete segments. However, the report does not detail any corrective actions taken to rectify the deficiencies.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as medications were not administered according to provider orders for four of the six sampled residents. Resident 1, who had diagnoses including congestive heart failure, hypothyroid, and hyperlipidemia, did not receive Atorvastatin Calcium and Levo-T as ordered. Resident 2, with severe cognitive impairment and conditions such as type 1 diabetes mellitus and hypertension, experienced a significant lapse in medication administration after returning from the hospital, missing multiple doses of critical medications including Losartan Potassium, Namenda, Basaglar KwikPen, and Humalog, among others. Resident 5, diagnosed with multiple sclerosis and paraplegia, did not receive Hydrocortisone External Cream as ordered for a facial rash. Resident 6, with congestive heart failure and class III obesity, did not have their daily weight monitored as ordered, which is crucial for managing their heart condition. The Director of Nursing Services acknowledged the omissions and indicated that the MAR should reflect valid reasons for any missed medications, which was not the case in these instances.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that fall mats were in place on either side of a resident's bed as directed in the comprehensive care plan. This deficiency was identified for a resident who was at risk for falls due to a history of falls, impaired balance, poor coordination, potential medication side effects, unsteady gait, and cognitive deficits. The resident's care plan, initiated in November 2020, included an intervention to place fall mats on either side of the bed at all times. However, during a facility investigation, it was found that on May 14, 2024, the resident fell from the bed onto the floor, and there were no fall mats present at the time of the fall. Staff members confirmed the absence of fall mats, which was contrary to the care plan requirements.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 501 citations issued within 25 miles in the last 12 months — including the 4 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 Vancouver
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bridge Crest Post Acute | 4.5 mi | ★★★★★ | 29 | 0 |
| The Oaks At Timberline | 5.5 mi | ★★★★★ | 15 | 0 |
| Brookfield Health And Rehab Of Cascadia | 6.5 mi | ★★★★★ | 0 | 0 |
| Vancouver Specialty And Rehab Care | 6.9 mi | ★★★★★ | 29 | 0 |
| Hudson Bay Health And Rehabilitation | 7 mi | ★★★★★ | 14 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.