Below average — CMS composite of the measures below.
A standard survey is most likely before 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 Seattle Medical Post Acute Care during CMS and state inspections, most recent first.
A resident admitted with chronic bronchitis had an order for methylprednisolone 40 mg IV daily, but the EMAR showed the steroid was not administered because it was on order from the pharmacy. The resident later had a sudden change in condition, was sent to the hospital, and was diagnosed with hypotensive shock thought to be secondary to adrenal crisis from not receiving the IV steroids as ordered.
Medication administration services failed for multiple residents when two nurses documented meds as given on the MAR even though the meds remained on the cart and were not administered. Residents with severe neurologic impairment, heart disease, diabetes, and HTN missed ordered meds including antihypertensives, anticoagulants, antidiabetics, and an anticonvulsant, and the DON confirmed the doses were not given.
A resident admitted with mucopurulent chronic bronchitis had an order for Methylprednisolone 40 mg IV daily, but the medication was marked as on order from the pharmacy and was not administered on two days. Nursing notes did not show that the physician was notified that the steroid was unavailable, and staff interviews confirmed the physician should have been contacted when the medication could not be given as ordered.
A facility audit of electronic health records revealed that an RN documented administering a controlled pain medication to a resident who had no active MD order for that drug, and the MAR contained no corresponding entry. During the subsequent investigation, the RN stated the controlled medication had been given despite the lack of a valid order and could not account for the medication’s whereabouts. The DON reported that misappropriation of property could not be ruled out and affirmed that residents are expected to be free from abuse, including misappropriation of property.
Misappropriation and diversion of controlled medications occurred when an LPN entered an unauthorized narcotic order for a resident without a provider’s authorization and documented administration of that narcotic despite the resident stating he had not requested or needed it. Additional discrepancies were identified for three other residents, including documentation of PRN narcotic doses that residents reported they did not receive, documentation of higher-dose narcotic tablets than residents stated they were given, and failure to provide requested pain medication while charting that it had been administered. The DON reported that these documentation and order discrepancies led to an investigation, during which the LPN was found to have acted outside her license and admitted intent to misappropriate medications.
A resident with aphasia, encephalopathy, and on chronic anticoagulation was care-planned and assessed as requiring two-person assistance for bed mobility. Despite this, a CNA attempted to reposition the resident alone, without adjusting the bed position or using bed controls, and did not call for help until after the resident slid off the bed and fell. The resident sustained a head laceration and was hospitalized, where imaging showed a new L frontal IPH with increased ventricular size compared to a prior scan. The nurse manager and DON confirmed the resident’s two-person assist requirement and stated the fall was an avoidable accident caused by failure to follow the plan of care.
Environmental Maintenance and Housekeeping Deficiencies: Surveyors observed multiple room and common-area maintenance issues, including holes in a bathroom wall and floor, a raised floor piece that a resident said caused a trip, nonworking light bulbs, damaged drywall, a torn screen, and a wall fan that was partially mounted and unsafe. They also observed condensation at hallway ceiling areas, stained bed linen that had not been changed, peeling veneer on a bed footboard, and scraped elevator jambs, while staff stated these conditions should have been maintained or repaired.
The facility failed to accurately complete MDS assessments for four residents. Two residents had hospice documentation showing a prognosis of 6 months or less, yet J1400 was coded no. Another resident’s PU/PI history and reentry status were coded inconsistently across MDS assessments, and a resident with a tracheostomy but no ventilator order was incorrectly coded as being on a mechanical ventilator. The MDS Coordinator and DON acknowledged the inaccuracies.
Failure to provide ADL assistance for nail and oral care affected four dependent residents. One resident had brown matter under the nails despite needing extensive grooming help, two residents had long fingernails despite care plans calling for nail care, and another resident with severe cognitive impairment had a mouth with dry brown crust and mucus despite staff stating oral care should be provided routinely. Staff responses showed inconsistent responsibility for nail care and acknowledged the observed hygiene issues.
Expired and undated supplies were found in a medication refrigerator, and another medication refrigerator was out of range with missing temperature logs. In addition, medications and supplements were observed at the bedside or stored in resident rooms for three residents, while staff stated these items should have been secured in a medication cart, locked drawer, or lockable storage and that the residents were not on a self-medication program.
Expired food items were found in the kitchen walk-in refrigerator, a second-floor refrigerator, and kitchen dry storage. An unopened heavy whipping cream, an opened thickened apple juice, and two unopened nutritional supplements were observed past their best-buy or use-by dates, and staff stated they should have been discarded. The facility policy required food products to be used within the stated expiration timeframe, and the ED confirmed expired items should have been discarded.
A resident with a tracheostomy did not have EBP signage posted, and a CNA entered the room without gown or gloves while providing care and repositioning the resident. Sharps were found unsecured in a shower room and a full sharps container was stored in a clean utility room instead of the dirty utility area. In addition, a respiratory therapist and a housekeeping aide did not perform hand hygiene between glove use during resident care and room cleaning.
Failure to Maintain Resident Dignity and Privacy: Staff entered a resident's room multiple times without knocking or introducing themselves, and the resident's oxygen concentrator was labeled with another resident's name. In a separate incident, a CNA transferred a severely cognitively impaired resident with a mechanical lift in the hallway while the resident's bottom was exposed and visible to others.
Failure to Provide Transfer/Discharge Notices and Ombudsman Notification: The facility did not document timely written transfer/discharge notices for two residents who were sent to the hospital, and did not initially show that the Ombudsman was notified. One resident had a change in condition before transfer, and another was transferred to the ER; records later showed a notice to the representative was completed long after the transfer, along with a fax to the Ombudsman.
PASARR Referral Not Made for Resident With SMI Indicators: A resident admitted with schizophrenia, bipolar disorder, and major depressive disorder had a Level I PASARR showing SMI indicators marked yes, but no Level II PASARR referral was made. The Social Service Director, DON, and Executive Director stated the resident should have been referred for a Level II evaluation when SMI was indicated.
A resident receiving hospice services had redness and moist skin under the neck folds, and hospice wrote an order for Nystatin powder. The order did not appear on the MAR, staff said they verbally notified the hospice nurse but did not document the communication or follow up, and the DON stated the facility expected timely communication and treatment when skin changes were identified.
Unsafe Mechanical Lift Transfer: A CNA transferred a resident with severe cognitive impairment and total dependence from a shower bed using a mechanical lift without a second trained staff member present. A respiratory therapist supervisor was nearby holding ventilator tubing but stated they were not trained to use the lift and were only managing the tubing. The CNA, RCM, and DON all stated that two trained staff were required for mechanical lift transfers.
The facility failed to obtain nurse aide registry verification before allowing an aide to begin work as a CNA. Staff M's record lacked registry documentation, and the DON stated the verification was not completed before the start date. The ED stated the facility expected registry verification prior to hire.
Medication administration was not documented in accordance with policy for a resident with HTN, DM, AFib, and GERD who was dependent on staff for all care. Multiple ordered meds, including a PPI, BP meds, anticoagulant, insulin, oral DM meds, bowel meds, a muscle relaxant, a statin, vitamins, protein supplement, and Tylenol, were marked as not given on the MAR without nursing notes explaining why.
A resident with hypotension was prescribed midodrine three times daily with instructions to hold the dose if BP exceeded set parameters, but BP checks were not consistently obtained before administration. Review of the BP log showed readings were documented only once daily on several days and twice on one day, despite the order requiring monitoring before each dose. An LPN confirmed the BP readings were not consistently obtained and documented as ordered, and the RCM and DON stated staff were expected to obtain and document BP prior to giving the medication.
Failure to document or provide pneumococcal vaccination for two residents after consent was obtained. The facility policy stated PCV-20 is recommended for adults 65 and older and that refusals and reasons are documented. For two residents, the consent forms showed the representatives agreed to vaccination, but the EHRs contained no documentation that the vaccine was administered or that the residents were ineligible; the DON stated there was no evidence the vaccine was given.
Failure to Offer and Document COVID-19 Vaccination: The facility failed to offer the COVID-19 vaccine to one resident reviewed for immunizations and failed to document that it was offered. The resident’s EHR showed the last documented COVID-19 vaccine was given in 2023, and there was no documentation that the most recent vaccine was offered. The DON stated that COVID vaccinations were offered per CDC guidance but could not find documentation for the resident.
Unclean and Odorous Resident Room: A shared resident room had a strong unpleasant odor, cluttered surfaces, clothing and shoes on the floor, food and drink containers, dried spills, and visible stains and debris in the bathroom. Staff statements and observations showed the room had not been fully cleaned, including the bathroom sink, toilet area, and door stains, despite expectations for daily room and bathroom cleaning.
The facility did not ensure appropriate care for pressure ulcers and failed to prevent new ulcers from developing, as evidenced by surveyor findings that necessary interventions were not consistently implemented for affected residents.
A resident did not receive enough food and fluids to maintain their health, as observed and documented by surveyors. The facility did not meet the nutritional and hydration needs required to support the resident's well-being.
A resident with a traumatic brain injury and persistent vegetative state experienced significant weight loss, but neither the physician nor the resident's representative was notified as required by facility policy. Staff interviews and record reviews confirmed the absence of notification and documentation regarding this change.
A resident experienced a significant decline, including progression of pressure ulcers and substantial weight loss, but the facility did not complete a Significant Change in Status Assessment (SCSA) MDS as required. Staff confirmed that the criteria for a significant change were met and the assessment should have been performed.
A resident with a history of stroke was evaluated and approved for a specific number of PT and OT sessions, but received significantly fewer sessions than planned due to staffing shortages. The Rehab Director confirmed the missed sessions, and the administrator acknowledged that the therapy staff were expected to provide the full course of treatment.
Three residents with documented goals to discharge to the community did not have comprehensive, person-centered discharge care plans developed or implemented, despite facility policy and assessment findings. Staff interviews confirmed that discharge planning was expected but not completed for these residents.
A resident in a persistent vegetative state, fully dependent and unable to consent, was subjected to nonconsensual sexual contact by a cognitively intact roommate with a history of aggressive and inappropriate behaviors. Despite documented incidents of threatening, grabbing, and wandering, no behavioral care plan or ongoing monitoring was in place for the roommate, leading to a failure to prevent sexual abuse.
A resident in a persistent vegetative state was the victim of a substantiated sexual assault by a roommate. Facility staff did not offer or arrange for immediate transfer to the ER for evaluation and evidence preservation, as required by policy and professional guidelines. The responsible party was not informed of the option for ER evaluation until two days after the incident, and clinical staff were not provided full details, resulting in delayed and incomplete care.
Two residents requiring substantial toileting assistance were left with unemptied bedside commodes and urinals for extended periods, despite staff and policy expectations for prompt care. Direct observations and resident interviews confirmed that toileting needs were not met in a timely manner, and staff acknowledged that equipment should have been emptied after each use.
A resident with schizophrenia did not receive clozapine for four days due to unavailability, and the facility failed to notify the physician. The resident exhibited increased anxiety and suicidal ideation, requiring hospitalization. Staff interviews confirmed the oversight in notification and the significant impact on the resident's condition.
A resident with schizophrenia did not receive clozapine for four days due to unavailability, leading to increased anxiety, behaviors, and suicidal ideation, requiring hospitalization. Nursing staff failed to notify the physician or take appropriate action, resulting in significant negative outcomes for the resident.
A resident with an indwelling urinary catheter experienced delays in a urology referral and urine analysis, leading to potential risks. Despite a physician's recommendation for a urology follow-up in October, the referral was not made until December, with an appointment scheduled for April. Additionally, a urine analysis ordered in December was not completed due to an improper specimen, and no follow-up was documented. Staff interviews revealed a lack of clarity and follow-up in the referral process.
A resident with a recent stroke diagnosis went missing from the facility, and the staff failed to notify the resident's Power of Attorney, despite being listed on the face sheet. The nursing notes showed law enforcement was informed, but not the representative. Interviews with staff confirmed the oversight, and the resident's representative expressed concern over the lack of communication.
A resident in a persistent vegetative state received enteral nutrition through an incorrect route and in incorrect amounts due to unclear physician orders and staff oversight. The facility's records showed inconsistencies in the administration route, and the resident received double the prescribed amount of feeding formula on multiple occasions.
A resident's narcotic medication, specifically 42 tablets of Oxycodone, went missing in the facility. Despite protocols requiring narcotics to be counted and secured, the medication was misplaced by an LPN and never found. The facility pharmacy replaced the missing medication.
The facility did not ensure survey results were accessible to residents and their representatives, as required. The survey result binder was not readily available in the designated area and lacked documentation for several complaint surveys over the past three years. Residents were unaware of their right to access these results, and staff confirmed the binder was kept behind the receptionist desk, requiring residents to request it.
The facility failed to maintain a safe and homelike environment, with several resident rooms and a hallway in disrepair. Observations showed damaged walls, loose baseboards, and a detached headboard, while the second-floor hallway had loose handrails. Staff interviews revealed a lack of awareness and communication regarding these issues, as they were not logged in the maintenance system, indicating a breakdown in the reporting and repair process.
The facility failed to provide written notices of transfer or discharge to residents and their representatives, and did not notify the LTC Ombudsman for four residents transferred to hospitals. Staff interviews and record reviews revealed reliance on verbal communication and lack of documentation, contrary to the facility's policy requiring written notices and Ombudsman notification.
A registered nurse in an LTC facility failed to follow professional standards for medication administration via G-tube and insulin administration for two residents. The nurse did not check gastric residuals or flush the G-tube properly and administered insulin against physician orders. Additionally, an unlabeled urine specimen was improperly stored in the facility's refrigerator.
The facility failed to provide consistent restorative services for six residents, leading to a risk of decline in range of motion. Residents with conditions such as hemiplegia, anoxic brain damage, and traumatic brain injury did not receive prescribed splint and ROM programs due to missing documentation and lack of staff coverage. Interviews revealed that restorative aides were not replaced during absences, resulting in non-compliance with care plans.
The facility failed to post daily nurse staffing information consistently and prominently across all floors. Observations showed missing postings on the Second and Third floors on multiple days, and on the First floor on one occasion. The staffing coordinator only posted the information at the reception desk, and the weekend supervisor, responsible for posting on weekends, was off for two weekends. This led to a lack of accessible staffing information for residents and visitors.
The facility failed to properly label and store medications, including expired and controlled substances, in two medication carts and a storage room. Undated and expired medications were found, and a controlled substance was improperly stored in an unlocked refrigerator.
The facility failed to maintain food safety standards in the kitchen and resident personal refrigerators. Raw chicken was improperly thawed in the kitchen, exceeding safe temperature limits, and Resident 6's personal refrigerators were not maintained, with doors unable to close due to ice buildup and blank temperature logs. Staff were unsure of responsibilities, despite policies requiring daily checks.
The facility failed to follow infection control protocols, including Contact Precautions and Enhanced Barrier Precautions (EBP), for staff and residents. Staff MM and LL did not wear gloves in contact precaution rooms, and Resident 6 lacked EBP signage and PPE. Staff BB and GG did not perform hand hygiene between glove changes, and Staff R failed to disinfect medical equipment between uses.
A resident with hemiparesis following a stroke had their call light placed out of reach, contrary to their care plan, which required it to be accessible on their right side. Observations showed the call light was consistently placed on the left side or on the bedside table, leading to a risk of delayed care. Staff confirmed the expectation for the call light to be within reach, highlighting a deficiency in accommodating the resident's needs.
The facility did not conduct required reference checks for a newly hired CNA, Staff W, as per their policy to prevent abuse and neglect. Despite the policy requiring at least two reference checks before employment, none were completed for Staff W. This oversight was confirmed by the Executive Director during interviews.
A resident's admission MDS was completed four days late, beyond the required 14-day period. This delay was confirmed by the MDS Coordinator and the DON, who acknowledged the assessment should have been timely. The delay risked unmet care needs and diminished quality of life.
Missed IV Steroid Medication Led to Hospitalization
Penalty
Summary
The facility failed to provide and administer methylprednisolone 40 mg IV daily for one resident who was admitted from the hospital with a diagnosis that included mucopurulent chronic bronchitis. The hospital discharge medication list and the April 2026 EMAR both showed the steroid order was to start on 04/04/2026, but the EMAR documented the medication as 00's on 04/04/2026 and 04/05/2026 because it was on order from the pharmacy and was not administered. On 04/06/2026, the resident had a sudden change in condition, emergency services were called, and the resident was transported to the hospital. The hospital summary stated the resident was admitted to the medical intensive care unit for hypotensive shock, and that the shock was ultimately thought to be secondary to adrenal crisis in the setting of not receiving IV steroids at the facility after discharge. Staff interviews confirmed the medication had not been administered as ordered and that the missed steroid medication could have potentially caused the resident's change in condition and hospitalization.
Medication Administration Not Provided or Documented Correctly for Multiple Residents
Penalty
Summary
Pharmaceutical services were not provided to meet the needs of 5 of 7 residents reviewed for medication administration. The facility policy stated medications are to be administered as prescribed and documented immediately after being given on the MAR. An investigation report dated 04/28/2026 showed two identified nurses allegedly documented medications as administered for Residents 2, 3, 4, 6, and 7 even though the medications remained on the medication carts and were not actually given. Resident 2 had a brain injury causing a vegetative state and diagnoses including heart failure, diabetes, and high blood pressure, and was reported to have missed morning doses of Spironolactone, Metoprolol, Metformin, and Warfarin. Resident 3, also in a vegetative state and dependent on staff for all care, was reported to have missed Levetiracetam. Resident 4, likewise in a vegetative state and dependent on staff, was reported to have missed Lisinopril. Resident 6 had heart disease and diabetes and was dependent on staff for all care; the report showed missed doses of Carvedilol, Lisinopril, Apixaban, and Metformin on two days. Resident 7 had a brain injury and high blood pressure and was dependent on staff for all care; the report showed missed doses of Amlodipine on two days. The investigation summary confirmed these residents did not receive their medications as ordered, and the DON stated the medications were not administered.
Failure to Notify Physician When Ordered Steroid Was Unavailable
Penalty
Summary
The facility failed to ensure the physician was notified when the pharmacy could not provide Methylprednisolone for one resident who had been admitted from the hospital with a diagnosis of mucopurulent chronic bronchitis. The hospital discharge medication list included an order for Methylprednisolone 40 mg IV daily starting the day after admission, and the April 2026 EMAR showed the medication was marked as on order from the pharmacy and not administered on two consecutive days. Nursing progress notes for those dates did not show that the physician had been notified that the medication was unavailable or missed. During interviews, an LPN stated that when a medication was not available, the physician should be contacted so the order could potentially be changed to a medication in stock, a different time, or a different date. The RN/unit manager, DON, and Administrator also stated the physician should have been notified when the medication was not delivered and not administered as ordered.
Failure to Protect a Resident From Possible Misappropriation of Controlled Medication
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from misappropriation of controlled pain medication, as required by its own policy on freedom from abuse, neglect, and misappropriation of resident property. The facility’s policy, updated in March 2025, identifies missing prescription medications or diversion of a resident’s medications, including controlled substances, as examples of misappropriation. An investigation summary dated 03/23/2026 documented that a registered nurse (Staff B) recorded the administration of a controlled substance to Resident 1 even though Resident 1 had no active physician orders for that medication. The resident’s Medication Administration Records also did not contain any documentation supporting that the controlled substance had been ordered or properly administered. During the facility’s internal audit of Resident 1’s electronic health records, the DON (Staff A) identified this discrepancy and initiated an investigation into possible misappropriation of property involving Staff B. The investigation noted that Staff B claimed to have administered the controlled medication to Resident 1 without a valid physician order and with no corresponding documentation indicating whether the medication was actually given. Staff A stated that misappropriation of property could not be ruled out and that Staff B was unable to explain where the controlled medication went. Staff A also stated an expectation that residents would be free from abuse, including misappropriation of property, as required by regulation WAC 388-97-0640.
Misappropriation and Diversion of Controlled Medications by Nursing Staff
Penalty
Summary
The deficiency involves misappropriation and diversion of residents’ controlled (narcotic/opioid) medications by a licensed nurse, resulting in inaccurate medication orders and documentation. For one resident, who did not have an active order for a narcotic medication, the nurse entered a narcotic order into the electronic health record (PCC) without provider authorization and administered the narcotic on a night shift, despite the resident stating he was certain he did not ask for or need it. Review of the February medication administration record (MAR), physician orders, and the facility narcotic book confirmed that the order had been entered by the nurse without a valid physician order. For another resident with an as-needed narcotic pain medication order, the February MAR showed the narcotic was administered during a night shift, but the resident reported he did not request or receive it. A third resident’s narcotic book documentation showed the nurse recorded administration of two doses of 15 mg narcotic medication on two separate dates; however, in interview the resident stated nurses only ever gave her two tablets and she never requested three tablets (15 mg). A fourth resident reported that he requested pain medication from the same nurse on an early morning shift and did not receive it; when he later asked about it, the nurse told him he had already taken the medication. The DON stated that discrepancies in the first resident’s MAR and narcotic orders prompted an investigation into potential drug diversion, and that the nurse practiced outside her license by entering a physician order with the intent of misappropriating medication, with misappropriation of resident property not ruled out for the four residents.
Failure to Provide Required Two-Person Assist for Bed Mobility Resulting in Fall and Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received required two-person assistance for bed mobility, resulting in an avoidable accident and injury. The resident had diagnoses including aphasia following cerebral infarction and encephalopathy, and chronically received anticoagulant medication for valvular atrial fibrillation. Her Activities of Daily Living care plan, revised on 03/22/2023, and her quarterly MDS dated 12/26/2025 both documented that she was dependent on two or more helpers for bed mobility, including rolling and repositioning in bed. On the date of the incident, a nursing progress note documented that the resident fell from the bed, hit the back of her head, sustained a 2 cm laceration, and was sent to the hospital for further evaluation. Hospital records showed that she presented to the emergency department after a fall from bed at the SNF and was found to have a new left frontal intraparenchymal hemorrhage that increased slightly in size on a four-hour repeat CT scan, with increased ventricular size compared to a prior scan from 2019. A nurse practitioner stated that, based on the notes, after the fall the resident was found to have new bleeding in the brain and that the ventricles had increased in size, showing swelling to the brain, and that her anticoagulant medication was held because it can cause bleeding. The facility’s investigation and staff interviews showed that the CNA providing care repositioned the resident in bed without obtaining the required second person assist and did not adjust the bed position before attempting the task. The CNA reported noticing the resident at the edge of the bed, pushing her upper body toward the middle, then moving to the opposite side and using the draw sheet to pull her, without lowering the head of the bed or using bed controls, and without calling for help until after the resident slid off the bed. The CNA acknowledged that the incident could have been prevented if another staff member had been present to assist and act as a barrier. The weekend nurse manager and the DON both confirmed that the resident required two-person assistance for bed mobility per her plan of care, that staff were expected to follow this plan, and that the fall was an avoidable accident because the CNA did not obtain a second person to assist.
Environmental Maintenance and Housekeeping Deficiencies
Penalty
Summary
The facility failed to maintain resident rooms and common areas in a safe, clean, and homelike condition. Surveyors observed multiple environmental issues in Resident 66’s bathroom, including a hole in the wall between the faucet and toilet, a hole in the floor, and a round raised metal piece attached to the floor. Resident 66 stated they had tripped on the raised metal piece. The maintenance logbook had no entry for the room, and staff stated they were not aware of the condition before the surveyor observation. In another resident room, surveyors observed a bathroom light fixture with two of three bulbs not working, a deep gauge in the bathroom wall, visible drywall tape around an area where sheetrock appeared to have been cut out, multiple areas of drywall damage on the wall, and a torn window screen. In a separate room, an electric wall fan was observed partially mounted, with the top screw one inch out of the wall and the fan tilted downward. Staff stated the fan was not safe. Surveyors also observed condensation dripping from ceiling piping and under air conditioning units in hallway areas on the third floor and first floor, with black spots near an exposed ceiling gap. Resident 30’s bed linen had orange and brown stains on the fitted sheet on multiple observations, and Resident 30 stated staff had not offered to change the sheets in a while. Resident 1’s bed footboard had veneer peeling off in multiple areas. Elevator jambs on the first, second, and third floors had scraped, damaged, and scratched paint. Staff and leadership stated these conditions should have been maintained, repaired, or changed, but the conditions remained observed during the survey.
Inaccurate MDS Assessments for Prognosis, Skin Conditions, and Ventilator Status
Penalty
Summary
The facility failed to accurately assess 4 of 24 residents reviewed for MDS accuracy, involving prognosis, pressure ulcers/pressure injuries, and mechanical ventilation. The report states that accurate assessment requires information from multiple sources, including the resident, direct care staff, the medical record, physician documentation, and family or representatives as appropriate, and that the facility’s policy required MDS completion in accordance with state and federal regulations and the RAI manual. For two residents, the MDS Section J1400 prognosis item was coded incorrectly. One resident had a hospice certification of illness showing a prognosis of six months or less if the disease ran its normal course, but the SCSA MDS marked J1400 as no. Another resident had a hospice certification of illness showing a terminal diagnosis and a prognosis of six months or less, but the SCSA MDS also marked J1400 as no. During record review and interview, the MDS Coordinator stated they used physician determination documentation for J1400 and acknowledged that both MDS assessments were not accurate. For the skin and respiratory assessments, one resident was readmitted with three stage 4 PU/PI, but later MDS assessments coded multiple unstageable and stage 4 wounds inconsistently, including wounds marked as acquired at the facility and others marked as present on reentry. The MDS Coordinator stated the resident was refusing wound assessment and that coding was based on the physician diagnosis list, and also stated the quarterly MDS may not be accurate. Another resident was admitted with a tracheostomy requiring ongoing care and cool humidified air, was not on a mechanical ventilator, and had no ventilator order, yet the quarterly MDS coded the resident as being on a mechanical ventilator. The respiratory therapist and MDS Coordinator both stated the resident had never been on a ventilator and that the quarterly MDS was inaccurate.
Failure to Provide ADL Assistance for Nail and Oral Care
Penalty
Summary
The facility failed to provide necessary assistance with ADLs for four residents who were dependent on staff for personal hygiene. For Resident 4, the care plan stated that ADL needs were to be met and that extensive assistance with grooming was needed, yet observations on multiple occasions showed brown matter under the nails on the right hand, including after the resident returned from the shower room. Staff stated that CNAs were responsible for cleaning hands, including under the nails, and facility leadership stated they expected dependent residents to receive help with ADLs, including nail care and hand washing. Resident 33 had diagnoses including persistent vegetative state, type 2 diabetes, and contractures, with the MDS showing dependence on staff for personal hygiene and functional limitation in both upper extremities. The baseline care plan directed staff to check nail length and trim and clean nails on bath day and as necessary, but repeated observations showed fingernails on both hands were long. Staff gave differing statements about who was responsible for nail care, and one nurse trimmed the nails after acknowledging they were long. Resident 7 had anoxic brain injury and type II diabetes and was dependent on staff for ADLs. The care plan called for weekly diabetic nail care and referral to a podiatrist if staff could not provide it, but observation showed both hand fingernails were long and untrimmed. Resident 23 had diffuse traumatic brain injury and was dependent on staff for ADLs; observations showed the mouth was wide open with dry brown crust on the tongue, and later the tongue had brown crust and dry yellow mucus hanging on the roof of the mouth. A respiratory therapist stated oral care for ventilator residents was provided once a shift and as needed, and said Resident 23's mouth did not look clean.
Expired Supplies, Out-of-Range Refrigerator Temperatures, and Improper Medication Storage
Penalty
Summary
The facility failed to ensure medical supplies were dated and discarded when expired and failed to maintain required temperature ranges for two medication refrigerators. On the first-floor medication refrigerator, a joint observation with the RCM showed expired and undated medical supplies, including ultrasound gel with an expiration date of 03/25/2025 and cornstarch powder with no manufacturer or expiration date. Staff stated the items were expired and should have been discarded. On the third-floor medication refrigerator, the freezer read 49°F and the refrigerator read 48°F, with ice melting and water draining into the refrigerator compartment. Staff stated the expected temperatures were 34 to 40°F for the refrigerator and 0 to negative 2°F for the freezer, and the temperature logs were missing for 08/09/2025, 08/10/2025, and 08/26/2025. The facility also failed to ensure medications were properly stored and secured for three residents. Resident 37 had opened bottles of Flonase, Mucinex, normal saline nasal spray, and Derma Daily powder on the bedside table during multiple observations. Staff stated the resident’s medications should not be stored at the bedside and should be kept in a medication cart or locked drawer. Staff later stated the resident was preparing for discharge and had been trained to self-administer medications, but medications were still observed on the bedside table. Resident 3 had an opened bottle of turmeric and ginger supplement on the nightstand during repeated observations. Staff stated medications and supplements should be stored in medication carts and locked containers, that there was no order for the supplement, and that it should not have been on the nightstand. Resident 11 had an unopened box of lidocaine pain-relief gel patches on the dresser and clear plastic drawers containing multiple medications, including eye drops, bisacodyl suppositories, a mini enema kit, and an over-the-counter muscle rub. Staff stated residents on that floor were not on a self-medication administration program, residents were not to store medications in their rooms, and medications stored in resident rooms should be in lockable storage.
Expired Food Items Found in Refrigerator and Dry Storage
Penalty
Summary
The facility failed to ensure expired food items were discarded in the Kitchen Walk-In Refrigerator, the Second Floor Refrigerator, and the Kitchen Dry Storage Room. During observation and interview, one unopened Darigold heavy whipping cream in the walk-in refrigerator was found with a best buy date of 08/29/2025, and Staff J stated it should have been discarded. In the Second Floor Refrigerator, an opened thickened apple juice was observed with a used-by-once-open date of 08/29/2025, and Staff L stated it should have been discarded. In the Kitchen Dry Storage Room, two unopened Medplus 2.0 vanilla flavored nutritional supplements were observed with used-by dates of 12/28/2024 and 08/24/2025, and Staff J stated both should have been discarded. The facility policy titled Food Storage stated food products are used within one year unless the manufacturer's expiration date is different, and the manufacturer's expiration date, when available, is the use-by date for unopened items. The Executive Director stated expired or past-use-by-date food items in refrigerators and/or dry storage should have been discarded.
Infection Control Failures in EBP, Sharps Disposal, and Hand Hygiene
Penalty
Summary
Enhanced Barrier Precautions were not followed for a resident with a tracheostomy. The resident’s comprehensive care plan showed the tracheostomy, and the facility policy stated that EBP are indicated for residents with indwelling medical devices and require gown and glove use during high-contact care activities, including transferring residents. On two observations, there was no EBP signage outside the resident’s room. During one observation, a CNA entered the room without a gown or gloves, delivered the resident’s meal tray, and assisted the resident to sit up in bed while having contact with the resident’s body and clothes. The CNA stated there was no sign and that they did not know the resident was on EBP. Sharps were not stored or disposed of properly in two areas. In the second floor shower room, a red sharps container was observed unsecured and on the floor, with an opening on the lid and used razors visible and accessible through the opening. Staff confirmed the container was open and should have been covered and secured. In the first floor clean utility room, a full sharps container containing contaminated sharps and used blood draw items was observed stored in the bottom cabinet. Staff stated that full sharps containers should be placed in the biohazard bin in the dirty utility room and should not be stored in the clean utility room. Hand hygiene and glove-use practices were not followed during resident care and environmental cleaning. During tracheostomy care for a resident, a respiratory therapist removed gloves and applied new gloves without performing hand hygiene between tasks while handling the resident’s inner cannula, dressing, gauze, and secretions. During cleaning of a room with EBP signage, a housekeeping aide emptied trash, mopped and swept, removed gloves, and then returned with new gloves and supplies to continue cleaning another room without performing hand hygiene between glove use or between rooms. The respiratory therapist and housekeeping aide both stated hand hygiene should have been performed after glove removal, and the DON stated staff should perform hand hygiene before glove use and between dirty and clean tasks.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to provide care and services in a manner that maintained and promoted dignity and respect for 2 residents reviewed for dignity. For Resident 23, who was admitted with diffuse traumatic brain injury, staff entered the room on multiple occasions without knocking or introducing themselves. On 09/04/2025 at 10:49 AM, a CNA opened the closed door and entered with another CNA without knocking or introducing themselves, and later that day at 2:39 PM an LPN entered the room without knocking, requesting permission, or introducing themselves. On 09/08/2025 at 10:38 AM, a respiratory therapist also entered without knocking or introducing herself, and later stated staff were expected to knock and introduce themselves before entering a resident's room. Resident 23's oxygen concentrator was observed on 09/05/2025 with another resident's name sticker on it, and a respiratory therapist confirmed the name on the concentrator was wrong and should have been Resident 23's name. For Resident 55, who had severe cognitive impairment and was totally dependent on staff for activities of daily living, a CNA transferred the resident in a hallway using a mechanical lift while covering the upper body with a sheet, but the resident's bottom back side was completely exposed and visible to people in the hallway. The CNA stated they had not checked to ensure the resident was covered during the transfer. The Resident Care Manager and DON stated staff were expected to knock, introduce themselves, request permission to enter, ensure equipment was labeled with the correct resident's name, and properly cover residents to ensure privacy during transfer.
Failure to Provide Transfer/Discharge Notices and Ombudsman Notification
Penalty
Summary
The facility failed to provide written notices of transfer/discharge to residents and/or their representatives and failed to notify the Office of the State Long Term Care Ombudsman for two residents who were transferred from the facility to the hospital. The facility policy titled, Transfer and Discharge, updated in May 2025, stated that when a transfer or discharge is initiated, the resident receives written notice that includes the date of notice, effective date, reason for the transfer/discharge, destination, and Ombudsman contact information, and that a copy is sent to the State Long-term Care Ombudsman. Resident 101 was admitted to the facility and later transferred to acute care hospital after a change in condition on 07/17/2025. Review of the resident’s EHR did not show documentation that a written transfer/discharge notice was provided to the resident and/or representative, and did not show that the Ombudsman was notified. Resident 8 was transferred to the emergency room on 07/03/2025, and the EHR initially did not show documentation of a written notice or Ombudsman notification. A later review showed a Nursing Home Transfer or Discharge Notice dated 09/04/2025 indicating the notice was provided to the resident’s representative 63 days after the hospital transfer, and a facsimile transmission to the Ombudsman dated 09/05/2025.
PASARR Referral Not Made for Resident With SMI Indicators
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed correctly for one resident reviewed for PASARR screening. The facility failed to ensure a Level II Preadmission Screening and Resident Review referral was made for Resident 77, who was admitted with diagnoses including schizophrenia, bipolar disorder, and major depressive disorder. The facility policy titled PASRR Process Policy and Procedure stated that when a Level II PASRR is indicated, the Social Worker ensures a timely referral to a Licensed Mental Health Professional. Resident 77's Level I PASARR dated 03/14/2025 showed Section 1A, the SMI indicator, marked yes for schizophrenia and mood disorders, but the form indicated that no Level II evaluation was required. During a joint record review and interview, the Social Service Director stated that Resident 77's hospital Level I PASARR indicated no Level II was required, but further review showed schizophrenia and mood disorders were marked yes, and the resident should have been referred for a Level II PASARR evaluation and was not. The DON and Executive Director also stated that if the Level I PASARR indicated SMI, the resident should have been referred for a Level II PASARR evaluation.
Failure to Coordinate Hospice Orders and Skin Treatment
Penalty
Summary
The facility failed to follow hospice physician orders and to effectively communicate and coordinate the hospice plan of care for a resident receiving hospice services. The resident’s significant change assessment showed hospice involvement, and the terminal diagnosis care plan stated the resident had been admitted to hospice and that the facility would provide daily care and management while working cooperatively with the hospice team. The facility policy required the hospice and center to communicate and agree upon a coordinated plan of care, including medications, supplies, and services needed for the resident. A hospice nurse visit note documented erythema and moistened skin under the folds of the resident’s neck, and a hospice physician order was written for Nystatin powder to be applied to the affected area twice daily for seven days. However, the resident’s August and September medication administration records did not show an order for Nystatin powder. Observations on multiple dates showed redness on the resident’s neck, and during a joint observation the resident pointed to the redness on the neck. When staff attempted to lift the neck fold for closer inspection, the resident winced and pushed the staff member’s hand away. Staff stated they had verbally notified the hospice nurse about the redness but did not receive an order, did not document the communication, and did not follow up with the hospice team. Staff also stated they were unaware of the Nystatin order until it was shown during record review. The DON stated the facility expected timely communication and written documentation from hospice, and that when a resident had redness on the neck, the nurse should assess the resident, communicate findings to the physician or hospice team, and initiate the plan of care if needed.
Unsafe Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure staff followed safe transfer practices when using a mechanical lift for Resident 55. Resident 55 was admitted to the facility and, according to the annual MDS dated 07/09/2025, had severe cognitive impairment and was totally dependent on staff for activities of daily living. During an observation on 09/05/2025 at 9:24 AM, Staff W, a CNA, transferred Resident 55 from a shower bed using a mechanical lift without a second person present. Staff DD, the Respiratory Therapist Supervisor, was present holding ventilator tubing but was not assisting with the transfer. In interviews, Staff DD stated they were not trained to use the mechanical lift and were only managing the ventilator tubing. Staff W stated that normally two staff would assist with a mechanical lift transfer and that enough staff were present on the floor but were not utilized. Staff F, the Resident Care Manager, stated that mechanical lift transfers required two trained staff, and Staff B, the DON, stated that two staff were expected for mechanical lift transfers and that respiratory therapists were not considered the second staff.
Failure to Verify Nurse Aide Registry Before Hire
Penalty
Summary
The facility failed to obtain nurse aide registry verification before allowing Staff M to work as a Certified Nursing Assistant. Staff M was hired on 08/01/2025, but their personnel record did not include documentation from the nurse aide registry. The facility policy titled, Screening, stated that registry checks are conducted for all employees before hire, annually, and more frequent as required by state law and regulation. During interview, the DON stated that Staff M's registry verification was not completed before the employee's start date and that it should have been obtained before Staff M began working at the facility. The Executive Director also stated that the facility's expectation was to obtain staff registry verification prior to the hire date.
Medication Administration Not Documented for Multiple Ordered Medications
Penalty
Summary
Pharmaceutical services were not provided to meet the needs of one resident who had diagnoses including high blood pressure, diabetes, chronic arterial fibrillation, and GERD. The resident’s quarterly MDS showed impaired cognition and dependence on staff for all aspects of care. Review of the July 2025 MAR showed multiple ordered medications were not administered on 07/26/2025 and 07/27/2025 and were documented as 9, including lansoprazole, liquid protein supplement, lisinopril, multiple vitamins-minerals, rosuvastatin calcium, apixaban, carvedilol, insulin glargine, metformin, MiraLax, senna, baclofen, insulin lispro, and Tylenol. The nursing progress notes for those dates did not show why the medications were not given. During a joint record review and interview, the DON stated the expectation was for staff to follow physician orders in medication administration and that when a medication is not administered and documented as 9, there should be a nursing note explaining why it was not given. The DON stated they would start an investigation into the issue.
Inconsistent BP Monitoring Before Midodrine Administration
Penalty
Summary
The facility failed to ensure adequate monitoring before administering midodrine, a blood pressure medication ordered for a resident with hypotension. The physician’s order, printed on 09/11/2025, directed that midodrine be given three times daily at three- to four-hour intervals, with the last dose before 6:00 PM, and to hold the medication if systolic pressure was greater than 150 or diastolic pressure was greater than 90. Review of the September 2025 MAR showed the medication was administered as ordered. However, review of the resident’s BP log before the 6:00 PM dose showed BP was not taken three times daily as ordered. Documentation showed BP was taken once daily on 09/02/2025 through 09/07/2025, and twice on 09/01/2025. During interview and joint record review, an LPN stated BP should always be checked prior to giving midodrine and confirmed the readings were not consistently obtained and documented in accordance with the physician’s order. The RCM and DON also stated staff were expected to obtain and document BP prior to administering BP medication.
Failure to Document or Provide Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure pneumococcal vaccination was provided for 2 of 5 residents reviewed for immunizations and infection control. The facility policy titled, Pneumococcal Vaccination of Residents, dated March 2022, stated that PCV-20 is recommended for all adults 65 or older, that the CDC guidance is followed for adults 19 through [AGE] years old with certain underlying medical conditions or other risk factors, and that residents may refuse vaccination. The policy also stated that vaccination refusal and reasons why are documented. For Resident 9, the facility's Pneumococcal Vaccine Informed Consent form showed the representative consented for the resident to receive the vaccine, but the EHR from May 2025 through September 2025 contained no documentation that the vaccine was given. For Resident 77, the consent form showed the representative consented for the resident to receive the vaccine, but the EHR from March 2025 through September 2025 also contained no documentation that the vaccine was provided. The DON stated vaccines were offered on admission and whenever recommended, and during record review stated there was no evidence the vaccine was given and no documentation showing the residents were not eligible or that follow-up occurred.
Failure to Offer and Document COVID-19 Vaccination
Penalty
Summary
The facility failed to ensure the COVID-19 vaccine was offered to Resident 3, one of five residents reviewed for immunizations. Review of the facility policy showed that residents are to be offered recommended COVID-19 vaccinations upon admission and as eligible per CDC recommendations. Review of the CDC guidance showed that the 2024-2025 COVID-19 vaccine is recommended for most adults ages 18 and older and is especially important for people living in a long-term care facility. Review of Resident 3’s EHR, including the medication administration record, progress notes, attachments, and immunizations tab, showed the last documented COVID-19 vaccine was administered on 12/06/2023. A review of the record from September 2024 through September 2025 showed no documentation that Resident 3 was offered the most recent COVID-19 vaccine. During interview, the DON stated that COVID vaccinations were offered to residents per CDC recommendation, but could not find documentation that it was offered to Resident 3.
Unclean and Odorous Resident Room
Penalty
Summary
The facility failed to maintain a clean, comfortable, homelike, and safe environment for one shared resident room. Observation of the room showed a strong unpleasant odor, a nightstand full of drink bottles, piles of clothing and shoes on the floor, empty and half-full drink bottles, food items on bedside tables, an empty canned pasta can on the floor, dried drink stains on the floor, dried brown splatter marks on the bathroom door, and brown stains and debris in the bathroom sink area. The report also noted brown organic matter under the toilet seat and debris around the faucet handles and basin. Resident 30 stated that staff would come in and mop the floors but did not clean the room. A housekeeping aide stated that daily room cleaning included mopping, dusting, and cleaning the bathroom sink and toilets, but also stated that only the floor had been mopped in the room. The housekeeping supervisor stated that resident bathrooms were expected to be cleaned every day, including the sink and toilet, and that staff should inform the nurse if residents refused room cleaning. The executive director stated that daily room cleaning was expected to include cleaning spills, wall stains, bathroom sinks, and toilets.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that the necessary interventions to manage existing pressure ulcers and prevent additional ones were not consistently provided to affected residents.
Failure to Provide Adequate Food and Fluids
Penalty
Summary
The facility failed to provide sufficient food and fluids to maintain a resident's health. This deficiency was identified by surveyors based on observations and records indicating that the nutritional and hydration needs of at least one resident were not adequately met. The lack of appropriate provision of food and fluids resulted in a failure to support the resident's overall health status.
Failure to Notify Physician and Representative of Significant Weight Loss
Penalty
Summary
The facility failed to notify both the physician and the resident's representative of a significant change in a resident's condition, specifically a substantial weight loss. According to the facility's policy, licensed nurses are required to notify the physician and the resident's responsible party of significant weight changes and document this notification in the progress notes. For one resident with a history of traumatic brain injury and persistent vegetative state, weight records showed a loss of over 25% of body weight within a short period. However, a review of the resident's progress notes from the time of the weight loss did not show any documentation that the physician or the resident's representative had been notified. Interviews with facility staff, including the Registered Dietitian and the Assistant Director of Nursing, confirmed that it was the responsibility of the Resident Care Manager to notify the physician and the resident's representative in such cases, and that this should be documented in the medical record. The resident's representative also stated they were not informed of the significant weight loss. The lack of notification and documentation was confirmed through joint record reviews and staff interviews.
Failure to Complete SCSA MDS After Significant Resident Decline
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) for a resident who experienced multiple significant declines in health status. According to the Long-Term Care Resident Assessment Instrument (RAI) manual, an SCSA is required when a resident has a major decline or improvement affecting more than one area of health. The resident in question was admitted with a stage 2 pressure ulcer and no significant weight loss. Subsequent assessments documented a progression to an unstageable pressure ulcer on the sacrum, which later advanced to a stage 4 pressure ulcer with exposed bone and additional unstageable pressure ulcers on the left lower leg. The resident also experienced a significant weight loss of 25.6% over a short period. Despite these documented changes, which met the criteria for a significant change in status, there was no evidence that an SCSA MDS was completed for the resident. Staff interviews confirmed that the facility followed the RAI manual and that an SCSA should have been completed within 14 days of the significant change. Both the MDS Coordinator and the Assistant Director of Nursing acknowledged that the resident had two areas of decline and that the required assessment was not performed.
Failure to Provide Required Rehabilitative Therapy Sessions
Penalty
Summary
The facility failed to provide the required specialized rehabilitative services for one resident who had been readmitted with a primary diagnosis of stroke. According to the resident's physical therapy (PT) and occupational therapy (OT) evaluations, the plan of care required three sessions per week for eight weeks, totaling 24 sessions each for PT and OT. Insurance authorization was obtained for the full course of therapy. However, documentation showed that only 16 PT sessions and 14 OT sessions were completed during the treatment period. Interviews with the Rehab Director confirmed that the shortfall in therapy sessions was due to staffing issues, which prevented adherence to the scheduled number of sessions. The resident's collateral contact also reported that the resident did not receive enough therapy services while in the facility. The facility's administrator stated that the expectation was for therapy staff to provide the required treatment sessions as outlined in the resident's care plan.
Failure to Develop and Implement Discharge Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered discharge care plans for three residents who had expressed goals to discharge to the community. Review of the Minimum Data Set (MDS), Care Area Assessment (CAA), and care conference notes for these residents confirmed that their discharge goals were documented, but the corresponding care plans did not include individualized discharge planning. The facility's policy and the Long-Term Care Resident Assessment Instrument (RAI) User's Manual require that discharge care plans be completed within seven days of the CAA, incorporating the resident's goals, preferences, and needs. Interviews with the Director of Nursing and Social Service Director revealed that the expected process was to include a discharge plan of care as part of the comprehensive care plan upon admission and after the comprehensive MDS was completed. However, record reviews and staff interviews confirmed that no such discharge care plans were present for the three residents in question, despite their stated goals and the facility's policy. The Executive Director also confirmed that the expectation was for discharge care plans to be completed per policy.
Failure to Protect Resident from Sexual Abuse Due to Inadequate Behavioral Monitoring
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse, resulting in a substantiated incident of nonconsensual sexual contact. A resident with anoxic brain damage and in a persistent vegetative state, who was completely dependent on staff and unable to consent, was found by a CNA to be the victim of a sexual act performed by their roommate. The CNA observed the roommate with their head and face in the resident's private area, with the resident's incontinence brief unfastened and their private area exposed. The incident was immediately reported to the Resident Care Manager, who confirmed the resident's condition and lack of awareness or ability to respond. Prior to the incident, the roommate had a documented history of behavioral symptoms, including threatening, scratching, grabbing others, wandering, and physical aggression, as recorded in December and January. Despite these behaviors, there was no evidence that a behavioral care plan was developed or implemented to address these risks. Behavioral monitoring for the roommate was discontinued after a hospital stay and was not reactivated upon readmission, and the social services director and DON were unaware of the extent of the documented behaviors. The facility's policy required assessment and intervention for residents exhibiting behaviors towards others, but the roommate's behaviors were not addressed in their care plan. The lack of ongoing monitoring and intervention for the roommate's aggressive and inappropriate behaviors contributed to the failure to prevent the sexual abuse of a vulnerable, non-responsive resident.
Failure to Provide Timely Post-Assault Care and ER Transfer
Penalty
Summary
The facility failed to act in a timely manner and ensure that a resident received necessary care and services following a substantiated incident of sexual assault. The incident involved a resident in a persistent vegetative state, fully dependent on staff for all care, who was observed by a staff member to be the victim of an unwanted sexual act performed by a roommate. Facility policy and CDC guidelines require immediate medical evaluation and evidence preservation in such cases, including prompt transfer to the emergency room (ER) for examination and possible collection of forensic evidence. Despite these requirements, the facility did not offer or arrange for the resident to be transferred to the ER immediately after the incident. Documentation and interviews revealed that the responsible party was not offered the option to transfer the resident to the ER until two days after the event, at which point the offer was declined. Staff interviews confirmed that the on-call provider was notified but only advised monitoring the resident, and that the responsible party was not informed of the option for ER evaluation at the time of the incident. Further, the on-call provider and physician assistant were not given full details of the incident, which limited their ability to make appropriate clinical recommendations. The facility's Director of Nursing and Executive Director both stated that the expected protocol would have been to send the victim to the ER immediately to preserve evidence and provide appropriate care, but this did not occur. The failure to follow established protocols resulted in a delay in care and services for the resident following the sexual assault.
Failure to Provide Timely Toileting and Hygiene Assistance
Penalty
Summary
The facility failed to provide necessary assistance with toileting care for two residents who required substantial or maximal help with toileting and hygiene. One resident, who had intact cognition and required moderate assistance, was observed to have a bedside commode (BSC) containing a large, formed bowel movement that had not been emptied for several hours despite the resident's requests to staff. Staff interviews confirmed that the BSC should be emptied after each use, but this was not done. The facility's investigation could not substantiate abuse or neglect due to uncertainty about whether the resident had informed staff, but direct observation and resident statements indicated the BSC remained unemptied for an extended period. Another resident, also with intact cognition and requiring substantial assistance, reported waiting one to two hours for care after activating the call light and typically relied on staff to empty their urinals. Observations showed two urinals at the bedside, one full and one half full, which had not been emptied since the morning. Staff interviews confirmed that urinals should be emptied frequently and not left to fill. The facility's policy required individualized care plans and prompt toileting assistance, but these were not followed, resulting in residents' toileting needs not being met in a timely manner.
Failure to Notify Physician of Missed Medication Doses Leads to Resident Hospitalization
Penalty
Summary
The facility failed to ensure timely notification of the primary care physician when medications were not administered to a resident diagnosed with schizophrenia. The resident was prescribed clozapine, a medication critical for managing their condition, but it was not administered for four consecutive days due to unavailability. During this period, the resident exhibited increased anxiety, behaviors, and suicidal ideation, ultimately requiring hospitalization. The medication administration record indicated that clozapine was not given on four specific days, and the facility's investigation revealed that the responsible nursing staff did not notify the physician or place the resident on alert monitoring. Despite the resident's escalating symptoms, including anxiety and pacing, the physician was not informed of the missed doses until the resident's condition worsened significantly. Interviews with facility staff confirmed that the missed doses of clozapine were a significant concern, and the lack of timely notification to the physician was a critical oversight. The resident's condition deteriorated, leading to hospitalization for suicidal ideation and other related symptoms, highlighting the serious impact of the facility's failure to adhere to proper medication administration and notification protocols.
Failure to Administer Clozapine Leads to Resident Hospitalization
Penalty
Summary
The facility failed to administer clozapine, a medication significant to the health of a resident diagnosed with schizophrenia, for four consecutive days. This lapse occurred from February 22 to February 25, 2025, during which the medication was unavailable and not administered. The resident's Medication Administration Record (MAR) indicated that the medication was on order from the pharmacy, but no further action was taken by the nursing staff to address the unavailability. The nursing staff, including Staff H and Staff G, did not notify the physician or place the resident on alert monitoring despite the missed doses. As a result, the resident exhibited increased anxiety, behaviors, and suicidal ideation, which ultimately required hospitalization. The facility's investigation revealed that the nursing staff failed to follow the facility's policy on medication error reporting and adverse drug reaction prevention, which mandates notifying the physician and taking appropriate steps when a medication is unavailable. Interviews with facility staff, including the Consultant Pharmacist, Licensed Practical Nurse, Physician, and Resident Care Manager, confirmed the significance of the missed doses and the resulting negative outcomes for the resident. The resident experienced symptoms such as anxiety, insomnia, racing thoughts, confusion, irritability, and suicidal ideation, which were attributed to the missed doses of clozapine. The Director of Nursing acknowledged that the facility could not manage the resident's behaviors, leading to the decision to send the resident to the hospital for further evaluation and treatment.
Failure in Timely Urology Referral and UTI Management
Penalty
Summary
The facility failed to ensure timely action for a urology referral and urine analysis for a resident with an indwelling urinary catheter. The resident, who was admitted with neuromuscular dysfunction of the bladder, had ongoing issues with catheter blockage and cloudy urine. Despite a physician's note in October recommending a urology follow-up, the referral was not made until December, and the appointment was not scheduled until April of the following year. Interviews with staff revealed a lack of clarity and follow-up regarding the referral process, contributing to the delay. Additionally, the facility did not properly manage the resident's urinary tract infection (UTI) concerns. A nursing progress note indicated that a urine analysis was ordered in December due to cloudy and strong-smelling urine. However, the lab results showed that the test was not performed due to an improper specimen. Although staff noted the need to collect another specimen, there was no documentation of a follow-up or collection of a new sample in the resident's records. The deficiency highlights a breakdown in the facility's processes for managing specialty referrals and ensuring timely follow-up on medical orders. The lack of documentation and follow-up on both the urology referral and the urine analysis placed the resident at risk for further complications related to their urinary care management.
Failure to Notify Resident's Representative of Missing Resident
Penalty
Summary
The facility failed to notify the responsible parties of a resident's change in status, specifically when the resident went missing. The resident, who had a recent diagnosis of stroke and did not possess a cellphone, left the facility and did not return. The nursing progress notes indicated that law enforcement was notified, but there was no documentation showing that the resident's representative, who was listed as the Power of Attorney, was informed of the situation. This lack of communication was confirmed during interviews with the facility staff, including the Infection Preventionist/Resident Care Manager, Social Services, and the Director of Nursing, all of whom acknowledged that the representative should have been notified. The resident's representative expressed concern during an interview, stating they were unaware of the resident's admission to the facility and their subsequent disappearance. The representative emphasized the importance of being informed, especially given the resident's medical condition. The Executive Director of the facility also stated that it was expected for all responsible parties to be notified of changes in the resident's care. The failure to notify the resident's representative placed the resident at risk of not having their representative make timely decisions for their care and services.
Failure to Administer Enteral Nutrition as Ordered
Penalty
Summary
The facility failed to administer enteral nutrition in accordance with physician's orders and professional standards of practice for a resident in a persistent vegetative state. The resident was supposed to receive enteral feeding through a specific route, either a G-tube or J-tube, as per the physician's order. However, the facility's records showed inconsistencies in the administration route, with the order not clearly specifying whether the feeding should be through a G-tube or J-tube. This lack of clarity led to the resident receiving the feeding formula through the incorrect route. Additionally, the facility did not adhere to the prescribed amount of enteral feeding formula. The resident was ordered to receive 600 cc of Nutren 2.0 formula per 24 hours, but records indicated that the resident received 1200 cc on multiple occasions. This discrepancy in the amount administered was not identified or corrected by the staff, despite the Director of Nursing's expectation that staff should follow physician orders and document the amount of formula administered. These failures placed the resident at risk for adverse health outcomes and complications.
Misappropriation of Resident's Narcotic Medication
Penalty
Summary
The facility failed to protect a resident from the misappropriation of their property, specifically involving the loss of a narcotic medication. The incident involved a resident who was admitted with a diagnosis that included pain and multiple fractures. During an investigation, it was reported that a bingo card containing 42 tablets of Oxycodone, a narcotic pain reliever, was missing. The floor nurse, identified as Staff D, admitted to possibly misplacing the medication and only realized it was missing during the end-of-shift narcotic count. Despite efforts to locate the missing medication, it was never found. Interviews with various staff members, including LPNs and the Director of Nursing Services, revealed that the facility had protocols in place for counting and securing narcotic medications. However, these protocols were not effectively followed, as evidenced by the missing medication. Staff members confirmed that narcotics should never be left unattended and should be counted at the beginning and end of each shift. The Director of Nursing Services and the Administrator acknowledged the medication as the resident's property and confirmed that it was replaced by the facility pharmacy after it could not be located.
Failure to Provide Accessible Survey Results
Penalty
Summary
The facility failed to ensure that survey results were posted in a location that was easily accessible to residents and their legal representatives. This deficiency was identified through observations, interviews, and record reviews. Residents and staff were unaware of the location of the survey results, and the survey result binder was not readily available in the designated area. Instead, it was kept on a small shelf behind the receptionist desk, and residents had to request access to it. Furthermore, the binder was missing results from several complaint surveys that resulted in citations over the past three years. During a Resident Council meeting, two residents expressed that they were not informed of their right to access the facility's survey results or where to find them. Observations confirmed that the survey results were not displayed in the main lobby as indicated. The Executive Director acknowledged that the survey result binder should be accessible to residents and their representatives, but it lacked the necessary documentation for complaint surveys from 2021, 2022, and two from 2023. This oversight prevented residents and their representatives from exercising their right to review past survey results and the facility's plan of correction.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for residents, as evidenced by the poor condition of several resident rooms and a hallway. Observations revealed that rooms had scraped and damaged walls, exposed drywall, and loose baseboards. In one instance, a room had a hole in the wall below the bathroom light switch, and another room had a detached headboard and a hole in the wall behind the bed. These conditions were not logged in the maintenance system, indicating a lapse in communication and adherence to the facility's preventative maintenance policy. Interviews with staff, including the Maintenance Director and Executive Director, highlighted a lack of awareness and communication regarding the disrepair in resident rooms. Staff members stated that issues should be logged in a maintenance log for non-emergent repairs, but this was not consistently done. The Maintenance Director was unaware of the specific damages until they were pointed out during joint observations, suggesting a breakdown in the reporting and repair process. Additionally, the facility's second-floor hallway had loose handrails, with exposed screws and anchors coming out of the wall. These issues were observed during multiple inspections, and staff acknowledged the need for repairs. The Executive Director expressed expectations that such environmental issues should be communicated to the maintenance department and addressed promptly, but this was not effectively implemented, leading to the deficiencies noted in the report.
Failure to Provide Written Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide written notices of transfer or discharge to residents and their representatives, as well as to notify the Office of the State Long Term Care Ombudsman, for four residents who were transferred to hospitals. This deficiency was identified through interviews and record reviews, which revealed that the facility did not adhere to its own policy requiring written notices and notifications to the Ombudsman. The policy mandates that residents receive a written notice of transfer or discharge, including the reason for the transfer, at least 30 days in advance, except in urgent medical situations where notice should be given as soon as practical. For Resident 9, there was no documentation of a written notice of transfer or discharge provided to the resident or their representative, nor was there evidence that the Ombudsman was notified. Staff interviews confirmed that while a change in condition was documented, the required notices were not issued. Similarly, for Resident 75, the facility failed to provide written notices, relying instead on verbal communication via phone calls to families, with no documentation of Ombudsman notification. Resident 52's representative reported not receiving written notices for hospital transfers in August and September, and staff interviews corroborated the lack of written documentation. Additionally, Resident 15 was discharged to a hospital without a written notice, and staff were unaware of the requirement to provide such notices. Throughout the interviews, staff acknowledged the expectation to follow the facility's policy and state regulations, yet failed to provide the necessary documentation to demonstrate compliance.
Medication and Specimen Handling Deficiencies
Penalty
Summary
The facility failed to ensure proper medication administration via a gastrostomy tube (G-tube) for one resident and did not adhere to insulin administration orders for another. A registered nurse, identified as Staff GG, was observed administering medications to a resident through a G-tube without checking the gastric residual volume or verifying the tube placement. The nurse also failed to administer water flushes before, between, and after each medication, as required by the facility's policy and professional standards. Instead, the nurse mixed all the medications together and administered them simultaneously, contrary to the guidelines that specify each medication should be given separately. In another instance, Staff GG administered insulin to a resident despite the physician's order to hold the medication if the resident's capillary blood glucose level was below 100 mg/dL. The nurse checked the resident's blood sugar, which was 81 mg/dL, but proceeded to administer the insulin regardless. This action was against the physician's directive and placed the resident at risk of hypoglycemia. Additionally, the facility failed to properly label and store a urine specimen in the second-floor specimen refrigerator. Observations over several days revealed an unlabeled urine specimen in the refrigerator, which was not expected to be held for more than 24 hours. Staff members acknowledged the oversight, indicating that specimens should be labeled with at least two patient identifiers and not stored beyond the specified time frame.
Failure to Provide Consistent Restorative Services
Penalty
Summary
The facility failed to consistently provide restorative services to maintain or improve the range of motion (ROM) for six residents, leading to a risk of decline in ROM and unmet care needs. Resident 14, diagnosed with hemiplegia, was on a restorative program requiring the use of a left elbow and hand splint for up to six hours daily. However, documentation showed missing records of splint use for 11 out of 30 days, and observations confirmed the absence of splints on specific days. Interviews with staff revealed that the restorative aide responsible for applying the splints was not covered when absent, leading to lapses in care. Resident 59, with anoxic brain damage, was also on a restorative program requiring bilateral hand/wrist splints for six to eight hours daily. Similar to Resident 14, documentation was missing for 11 out of 30 days, and observations confirmed the absence of splints. Staff interviews indicated that the restorative aide was solely responsible for applying the splints, and no coverage was provided during their absence, resulting in non-compliance with the care plan. Other residents, including Residents 37, 28, 35, and 10, experienced similar deficiencies in their restorative programs. Resident 37, with upper extremity impairments, received passive ROM only three out of 29 days, and no splint use was documented for 30 days. Resident 28, with a traumatic brain injury, reported not receiving ROM exercises for two to three weeks, and documentation was lacking. Resident 35, with hemiparesis, did not have a left elbow splint applied as required, and Resident 10, in a persistent vegetative state, did not receive the prescribed splint program. Staff interviews consistently highlighted issues with staffing and documentation, leading to the failure to implement the restorative programs as outlined in the care plans.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the daily nurse staffing information was posted consistently and in prominent locations across the building. Observations on multiple occasions revealed that the nurse staffing information was not visible on the Second and Third floors on specific days. Additionally, the staffing information was not posted on the First floor on one occasion. Interviews with staff indicated that the staffing coordinator was responsible for creating the nurse staffing forms after checking for call-outs and preparing schedules for the weekend supervisor to post. However, the weekend supervisor had been off for the last two weekends, leading to a lack of posting on those days. The staffing coordinator admitted to only posting the nurse staffing information in a glass case by the reception desk and not throughout the building. The administrator confirmed the expectation for daily posting of nurse staffing information but acknowledged the absence of the weekend supervisor. This oversight placed residents, their representatives, and visitors at risk of not being fully informed of the current staffing levels, as the information was not readily accessible in the designated areas.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly label and store medications, as well as dispose of expired medications in a timely manner, which was observed in two medication carts and one medication storage room. On the second floor, an open and undated bottle of Milk of Magnesia with an expiration date of August 2024 was found in a medication cart, and staff acknowledged it should have been discarded. On the third floor, two open and undated bottles of Chlorhexidine Gluconate and an expired bottle of Fish Oil gel capsules were found in another cart. Staff admitted that the mouthwash bottles should have been dated when opened and the expired Fish Oil should have been removed. In the second floor medication storage room, an unlocked refrigerator contained an unopened bottle of lorazepam, a controlled substance, which should have been stored in a locked compartment. Additionally, an open and unlabeled vial of tuberculin was found, which should have been labeled with the date it was opened. Staff interviews confirmed the expectations for proper labeling and storage of medications, including the requirement for controlled substances to be stored in locked compartments.
Food Safety Deficiencies in Kitchen and Resident Refrigerators
Penalty
Summary
The facility failed to adhere to professional standards of food safety in the kitchen and in resident personal refrigerators, leading to potential risks of foodborne illness. During an observation, raw chicken breasts were found thawing in a sheet pan under running water in the kitchen preparation sink without a time sticker to indicate when the thawing process began. The temperature of the chicken was measured at 64.9°F, which did not meet the food safety preparation standards, as it exceeded the safe temperature of 41°F. Staff members acknowledged the failure to maintain the required temperature and decided to discard the chicken. Additionally, the facility did not maintain the personal refrigerators of Resident 6 according to their policy. Observations revealed that Resident 6 had two personal refrigerators with doors that would not close due to ice buildup, and the temperature logs on the refrigerators were blank. The resident confirmed that the facility staff never cleaned, maintained, or checked the temperature of their refrigerators. Staff members were unsure who was responsible for maintaining these refrigerators, despite the facility's policy requiring daily checks. Interviews with staff, including the Dietary Manager and Registered Dietician Nutritionist Consultant, confirmed that the facility followed the FDA 2022 Food Code and expected staff to adhere to these standards. However, the lack of proper monitoring and maintenance of both the kitchen and resident personal refrigerators demonstrated a failure to comply with these standards, placing residents at risk for foodborne illnesses.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to Contact Precautions for two staff members, Staff MM and Staff LL, who did not wear gloves when entering rooms designated for contact precautions. Observations showed Staff MM entering a contact precautions room without gloves to deliver and pick up meal trays, despite signage indicating the requirement to wear gloves. Similarly, Staff LL was observed entering a contact precautions room without gloves on two separate occasions. Interviews with both staff members and the Infection Preventionist confirmed the expectation to follow signage instructions, which included wearing gloves before entering such rooms. The facility also failed to implement Enhanced Barrier Precautions (EBP) for Resident 6, who had an indwelling catheter. Observations over several days revealed the absence of EBP signage and a PPE cart outside Resident 6's room. Interviews with staff, including the Resident Care Manager and the Infection Preventionist, confirmed that EBP should have been initiated with appropriate signage and PPE availability. However, there was no order or care plan in place for EBP for Resident 6, indicating a lapse in infection control measures. Additionally, the facility did not ensure proper hand hygiene practices and glove use among staff. Staff BB and Staff GG were observed failing to perform hand hygiene between glove changes during resident care activities. Staff BB did not perform hand hygiene between glove use while attending to a resident's foot care, and Staff GG failed to perform hand hygiene between glove changes while administering medication and handling a feeding tube. Furthermore, Staff R did not disinfect medical equipment between resident use, using regular wipes instead of the required disinfectant wipes. Interviews with staff confirmed the expectation to perform hand hygiene and disinfect equipment as per facility policy and CDC guidelines.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a call light was within reach for a resident, identified as Resident 35, who was reviewed for accommodation of needs. Resident 35 was readmitted to the facility with hemiparesis following a cerebral infarction, affecting their left non-dominant side. The resident's care plan specified that a soft touch call light should be placed within reach on their right side, near their right hand, to accommodate their condition. However, multiple observations revealed that the call light was consistently placed out of reach, either next to or below the resident's left hand, or on the bedside table. During a joint observation and interview, the Resident Care Manager, Staff F, confirmed that the call light was not within reach and acknowledged the expectation for it to be placed near the resident's right hand. The Director of Nursing, Staff B, also stated that staff were expected to place call lights within reach according to each resident's needs and preferences. This oversight placed the resident at risk for delayed care, accidents, falls, and a diminished quality of life, as the call light was not accessible to them as required by their care plan.
Failure to Conduct Reference Checks for New Hire
Penalty
Summary
The facility failed to implement its abuse policy and procedure by not conducting reference checks prior to hiring a staff member, identified as Staff W, a Certified Nursing Assistant. The facility's policy, updated in October 2022, mandates that prospective employees undergo screening, including at least two reference checks, to prevent abuse, neglect, exploitation, or misappropriation of resident property. However, upon review of Staff W's employee records, there was no evidence of such reference checks being conducted before their hire date of September 15, 2023. Interviews with the Executive Director, Staff A, confirmed that reference checks were not completed for Staff W during the onboarding process, which should have been done prior to their start date.
Delayed MDS Completion for a Resident
Penalty
Summary
The facility failed to complete the admission Minimum Data Set (MDS) for one resident within the required 14-day period following admission. Specifically, Resident 26 was admitted to the facility, and their admission MDS was completed four days late, on 07/08/2024. This delay was confirmed during interviews and joint record reviews with the MDS Coordinator and the Director of Nursing, who acknowledged that the assessment should have been completed within the stipulated timeframe. The failure to complete the MDS on time placed the resident at risk for delayed and/or unmet care needs, potentially affecting their quality of life.
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What surveyors actually found near you
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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.
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Nursing homes near Seattle
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Transitional Care Of Seattle | 0.9 mi | ★★★★★ | 49 | 0 |
| The Terraces At Skyline | 0.9 mi | ★★★★★ | 1 | 0 |
| Bailey-boushay House | 1.2 mi | ★★★★★ | 0 | 0 |
| Mirabella | 1.2 mi | ★★★★★ | 2 | 0 |
| Park Shore | 2.4 mi | ★★★★★ | 36 | 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.