Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Snohomish Health And Rehabilitation Of Cascadia during CMS and state inspections, most recent first.
Unsafe smoking supervision and disposal practices were identified for two residents. One resident who used continuous O2 was observed smoking while a portable O2 tank was attached to the wheelchair, with ashes on the ground and on the resident’s shoes. Another resident who could not safely light a cigarette or dispose of ashes was observed smoking a cigar near the facility entrance, while staff passed by without intervening. Surveyors also found cigar butts on the ground and no ashtrays or cigarette receptacles near the entrance or smoking locations.
Food items were stored in two nourishment refrigerators that were above the required temperature, with no temperature logs observed. One unit refrigerator read 47 degrees Fahrenheit and the other read 46 degrees Fahrenheit, and both contained items such as yogurts, applesauce, sandwiches, juices, and shakes. Staff gave conflicting statements about whether kitchen or nursing staff were responsible for monitoring the refrigerators.
Facility Assessment Did Not Address Resident Smoking Needs: The facility’s assessment listed 9 residents with tobacco use but did not document smoking-related physical environment, equipment, or service needs. A resident was observed smoking while using O2 in a wheelchair, another resident was seen smoking a cigar near the entrance, and cigar butts were found near the office windows. Staff stated the facility knew one resident smoked, did not know how cigarettes were extinguished, did not provide ashtrays, and had not searched the resident or room for smoking paraphernalia.
Failure to respond to Resident Council concerns left multiple issues unresolved and made the council process ineffective. Resident Council minutes documented ongoing complaints about call light wait times, care delivery, meal service, TV problems, smoking, language barriers, and other resident concerns, but the follow-up sections were blank and the grievance log showed no resolution for those issues. Interviews confirmed concerns were discussed with the AD and Administrator, but documentation and resolution were inconsistent.
A facility failed to periodically inform 7 sampled residents of their rights after admission. During a resident council meeting, the residents stated staff did not review resident rights and that rights were not reviewed at council meetings, and meeting minutes from several months showed no documentation that rights were reviewed. The Administrator stated they did not know whether resident rights were routinely reviewed with residents.
The facility used outdated CMS-approved NOMNC and ABN forms and did not document that appeal rights or financial liability information was explained to residents or their representatives. For several residents, facility staff signed in the resident/representative signature area instead of the resident or representative, and there was no record that copies of the notices were provided. One resident had dementia, another had severe cognitive impairment, and staff acknowledged they were unaware the forms were outdated and that documentation of the explanations was missing.
The facility failed to ensure 3 residents were free from unnecessary psychotropic medications. One resident received PRN antianxiety medication without documented target behaviors or documented non-pharmacological interventions before administration. Two other residents had antidepressant and antipsychotic orders, but MAR/TAR records did not show ASE monitoring documentation, and staff could not provide evidence that the required monitoring had been completed.
PASRR Level 2 Screening Not Completed or Documented: The facility failed to complete or document required PASRR follow-up for multiple residents with SMI, dementia, depression, anxiety, or developmental delay. Several residents had Level 1 PASRRs showing Level 2 was needed or short-stay exemptions that required follow-up after 30 days, but the EHRs contained no Level 2 evals, invalidations, or documentation that the PASRRs were sent for review.
A dietary service deficiency occurred when staff failed to keep snacks consistently available, and meal service did not reliably honor resident dislikes, allergies, and diet restrictions. Residents reported limited snack choices, pantry observations showed sparse stock, and staff said snacks were restocked only once daily. During meal service, staff omitted disliked items without providing similar substitutes, and one resident with documented food dislikes was served beef meatballs despite the dietary slip.
Resident records were not kept accurate, complete, or readily accessible. One resident’s guardianship letters had expired and staff did not know they needed updating, another resident on hospice lacked a current hospice certification and had missing hospice visit notes, and a third resident’s chart contained conflicting discharge paperwork showing both a hospital transfer and discharge to an AFH.
Failure to honor resident choice for nighttime care routines: A cognitively intact resident reported being awakened multiple times each night for meds and VS checks, despite telling the med nurse they did not want to be disturbed. The resident’s albuterol was scheduled around the clock, including midnight, and VS were ordered every shift, including nights. An LPN said the resident’s concern was not reported to the RCM, and the RCM was unaware of the preference.
A resident with a PASRR indicating SMI indicators but no level II need due to stability on psychotropic meds experienced worsening anxiety, including acute episodes requiring hydroxyzine and a later antidepressant cross-taper from venlafaxine to Zoloft. The facility did not document a new PASRR or request a level II evaluation after these mental status changes, and SS staff stated they only pursued a new PASRR if a new diagnosis was added.
The facility failed to follow ordered medication parameters for two residents, check a resident’s blood sugar before breakfast, and provide treatment for a resident’s buttock wound. One resident had a documented open area on the buttock with no treatment orders or TAR documentation, while two residents received BP meds even though their HR or SBP was outside the provider’s hold parameters. An LPN also checked a resident’s blood sugar after the breakfast tray had already been removed.
Failure to restore continence and provide appropriate toileting support. A resident who had been continent before admission was placed in a brief and documented as frequently incontinent, while records showed no voiding pattern was completed and a toileting program was not attempted. The care plan included prompted and routine toileting, but documentation lacked detail, and observations showed the resident was sometimes assisted to the bathroom only when they indicated a need, while at other times they remained at the nurse’s station without toileting.
Oxygen care was not provided as ordered for two residents with COPD. One resident’s concentrator was repeatedly observed set above the ordered rate, with an empty, undated humidifier and undated tubing, while staff described the resident as using oxygen continuously despite a PRN order. Another resident’s concentrator was also observed set above the ordered 2 lpm, and an RN later confirmed the setting should have been checked against the MAR/orders.
Unnecessary and improperly administered pain meds were identified for several residents. One resident with dementia and chronic pain received oxycodone outside documented pain levels and without recorded non-pharm interventions, while another resident had acetaminophen orders that could total above standard daily limits. A resident with fractures and DM had PRN oxycodone given outside ordered pain parameters with no documented non-pharm measures, and another resident had pain episodes and PRN acetaminophen given without documentation of non-pharm interventions.
Medication storage and cart security were not maintained when an unlocked treatment cart and an unlocked med cart were found unattended, each containing medications and supplies. Two residents also had medications kept in their rooms, including a topical pain relief aerosol and a rescue inhaler on an overbed table, while the RCM and DON stated room medications required an order, a lockbox, and an evaluation before bedside use.
Staff failed to follow infection control practices during EBP, pericare, equipment sanitation, and med pass. Two residents on EBP were transferred or toileted without the required gown use, a CNA performed pericare without hand hygiene or glove changes before handling clean linens and a brief, a mechanical lift was left unsanitized after use, and an RN placed resident-specific meds/devices on a meal tray and returned them to the med cart without a barrier.
Failure to complete required pre-hire reference checks was cited after the facility did not have reference checks in the files for 4 of 4 staff reviewed. The facility policy required at least two reference checks from prior/current employers, but HR stated the facility no longer did them, the CNO said HR oversaw hiring, and the CEO said they were not aware of the policy.
Surveyors found that the facility did not develop or update person-centered care plans for four residents after falls that resulted in fractures, facial injuries, and new mobility restrictions. Despite provider orders for slings, splints, non‑weight‑bearing status, and increased assistance with ADLs, the comprehensive care plans and Kardexes continued to show residents as independent or omitted the new injuries and devices. RNs and LPNs acknowledged that fractures, braces, slings, weight‑bearing status, and changes in mobility and ADL ability were not accurately or timely reflected in the care plans, contrary to facility policy requiring timely, measurable, interdisciplinary care planning based on changes in condition.
The facility failed to obtain accurate MD orders and provide appropriate monitoring for fall-related injuries and devices for several residents. One resident with cognitive impairment and a prior fracture had a left arm fracture treated with a sling and non–weight-bearing instructions, but orders and TAR entries were written for the right arm instead, and monitoring for the actual injured arm was not documented. Another cognitively impaired resident’s fall-related humeral fracture was omitted from the investigation summary, and the reporting log contained incorrect fall details. A third resident with dementia sustained a broken nose and a sutured forehead laceration, yet the laceration was not recorded on the reporting log and had no associated orders or TAR monitoring. A fourth resident with stroke-related deficits suffered a left hand fracture, forehead laceration with sutures, and facial bruising; the reporting log omitted the laceration, orders initially referenced the wrong wrist for brace use and non–weight-bearing status, and there was no TAR documentation for monitoring the left-hand brace, forehead laceration, or facial bruising.
A resident with moderate cognitive impairment, impaired vision, and use of a front-wheeled walker left AMA after signing out and not returning, later reporting by phone that they were staying in a motel and did not wish to come back. Despite facility policy and staff descriptions that AMA departures should include resident education, safety checks, discharge instructions, provider and family notification, APS reporting, and EHR documentation, there were no discharge instructions or discharge summary in the EHR and no documented notifications to the emergency contact, provider, or APS for this resident.
A resident with complex medical needs did not receive a prescribed IV normal saline treatment, and the event was not documented or investigated as a medication error. Staff interviews confirmed that no incident report or investigation was initiated, contrary to facility policy and state guidelines.
A resident with a complex medical history did not receive ordered IV normal saline for diarrhea and elevated creatinine because the physician's order remained unconfirmed and unadministered in the electronic medical record. Nursing staff did not document attempts to start the IV or notify the provider, and the incident was not recorded in facility error logs.
A resident with hemiplegia, hemiparesis, and moderate cognitive impairment experienced a fall that was not investigated by facility staff. Required incident reporting and documentation were not completed, and the event was not logged, as confirmed by interviews with RNs, an LPN, and the DON.
The facility did not ensure that required PASARR screenings and Level II evaluations were accurately completed prior to admission for several residents with mental health diagnoses. Inaccurate documentation, missing evaluations, and a lack of understanding of the PASARR process led to residents being admitted without proper mental health assessments or determination letters.
The facility did not ensure that residents and their representatives were given the opportunity to participate in care conferences, as required. For three residents, there was no documentation of required care plan meetings, and staff interviews confirmed that care conferences were not being held as scheduled. This resulted in residents not being involved in discussions about their person-centered care.
A resident who expressed interest in formulating an Advance Directive was not provided with information or assistance by social services, and there was no documentation of follow-up or support, despite the resident's clear request and cognitive ability.
Surveyors found that care plans were not properly reviewed or updated for three residents, including one on long-term antiviral therapy, one at risk for pressure ulcers who was not using prescribed heel protection, and one with a lower limb amputation whose prosthesis use was not documented in the care plan. Staff interviews and observations confirmed that interventions were either missing, not implemented, or not updated to reflect current care practices.
A resident with severe cognitive impairment and on hospice care was found with their bed placed against the wall and a scoop mattress on the floor, without any physician's order, signed consent, or care plan documentation authorizing this setup as a restraint. Staff confirmed the bed had always been positioned this way and described it as a restraint, but the required assessment, order, and documentation were not completed.
A resident with Type 2 Diabetes Mellitus received Insulin Glargine on multiple occasions when their blood sugar was below the physician-ordered threshold, and in several instances, insulin was administered without any blood sugar being recorded. Documentation and staff interviews confirmed that the process for checking blood sugar prior to insulin administration was not consistently followed, and the care team was not informed of these deviations.
A resident with moderate cognitive impairment and a history of falls was found to have a broken lower denture with a missing tooth, resulting in discomfort when eating. Despite staff awareness of the broken denture, there was no documentation of a dental appointment being scheduled, and several staff members were unaware of the issue or had not initiated a referral for dental services.
Staff did not use required PPE, specifically gowns, during high-contact care activities for two residents on enhanced barrier precautions for wounds. In both cases, staff either misunderstood or disregarded EBP signage and care plan instructions, resulting in transfers and personal care being performed without proper gown use as required by CDC guidelines.
The facility failed to assess and manage the risk of pressure ulcers for four residents, leading to the development and worsening of PUs. Residents were not provided with timely interventions such as air mattresses and pressure-relieving devices, and documentation was inconsistent. These failures resulted in significant harm, including the deterioration of a Stage 2 PU to a Stage 4 PU with osteomyelitis in one resident.
The facility failed to consistently implement care plan interventions related to bed height and mattress type to prevent accidents and falls for a resident. The resident fell out of bed, sustained a left hip fracture, and required hospitalization. Staff were unaware of the specific fall interventions, and the care plan was not updated after the incident.
A resident with severe cognitive impairment fell and sustained a fracture. The facility's investigation was incomplete, lacking staff statements and a root cause analysis. Staff interviews confirmed that proper protocols were not followed, and this is a repeat citation.
The facility failed to ensure timely review and revision of the care plan for a resident with vascular dementia and a left femur fracture. Observations revealed inconsistencies in implementing fall prevention interventions, such as the absence of a perimeter mattress and fall mat. Staff interviews indicated reliance on outdated Kardex information, leading to inconsistent care practices and placing the resident at risk for unmet care needs.
Unsafe Smoking Supervision and Disposal Practices
Penalty
Summary
The facility failed to ensure residents who smoked were adequately supervised and that smoking practices were controlled to keep the environment safe from burns and fire. The deficiency involved two residents who were identified as smokers, including one resident who was dependent/assisted for smoking and another who could not safely light a cigarette or demonstrate safe disposal of ashes. The facility’s non-smoking policy stated the campus was smoke-free and that staff were responsible for enforcing the policy, but staff interviews showed inconsistent awareness of where residents were smoking and how smoking materials were being managed. Resident 51 had a smoking/nicotine evaluation that documented the resident did not understand that smoking was not permitted while using oxygen and that smoking materials were to be used in designated smoking areas. The resident was ordered continuous O2 at 1-2 L/min by nasal cannula. During observation, the resident was seen outside on the driveway holding a cigarette while a portable O2 tank was hanging on the back of the wheelchair and running at 2 L/min. Ashes were observed on the ground and on the resident’s shoes, and there was an odor of smoke. Staff interviews indicated some staff believed there was a smoking area by the shed or by the trees, while the CNO stated the facility knew the resident smoked but did not know how the resident extinguished cigarettes and had not searched the resident or the room for smoking paraphernalia. Resident 32’s records showed the resident smoked cigars and cigarettes and could not safely light a cigarette or safely dispose of ashes. The resident’s smoking evaluation designated the resident as dependent/assisted for smoking, and the care plan did not address smoking until after the observation. During observation, the resident was seen smoking a cigar outside the facility entrance with a spouse, within about 25 feet of the office front windows. The spouse stated other residents smoked by the trees, and staff walked past without addressing the smoking. Surveyors later found cigar butts on the ground near the office windows and no cigarette receptacles near the entrance or the trees. The resident reported extinguishing the cigar by rubbing it on the concrete and throwing the butt in a garbage can, and the CNO acknowledged there were no cigarette disposal containers because the facility was a non-smoking facility.
Nourishment Refrigerators Not Monitored or Kept at Safe Temperatures
Penalty
Summary
Food items were not stored under sanitary conditions in two nourishment refrigerators, and refrigerator temperatures were not monitored or maintained below 41 degrees Fahrenheit. On unit 2, the nourishment refrigerator temperature was observed at 47 degrees Fahrenheit with no temperature log present, and the refrigerator contained individual yogurts, applesauce, one carton of thickened lemon drink, one carton of fortified shake, and half sandwiches wrapped in plastic. On unit 1, the nourishment refrigerator temperature was observed at 46 degrees Fahrenheit with no temperature log present, and the refrigerator contained yogurts, sandwiches, applesauce, and cartons of juices and shakes. Staff E stated the kitchen staff stocked the refrigerator and monitored temperatures, Staff Z stated the kitchen took care of the refrigerators, and Staff X stated nursing staff were responsible for monitoring the nourishment refrigerators on the units.
Facility Assessment Did Not Address Resident Smoking Needs
Penalty
Summary
The facility failed to conduct and document a facility-wide assessment that addressed the physical environment, equipment, services, and other physical plant considerations necessary to care for its identified resident smoking population. The facility assessment documented that the resident population included 9 residents identified with tobacco use, but it did not include further documentation related to smoking-specific environmental, equipment, or service needs. Staff B, the Chief Nursing Officer, stated they assisted in completing portions of the facility assessment, that it was reviewed annually, and that they were unaware of specifics related to residents who smoked being included in the assessment. During observation and interview, Resident 51 was seen outside on the driveway near trees, sitting in a wheelchair and holding a cigarette while a portable O2 tank was hanging on the back of the wheelchair and running at 2 L/PM. Ashes were observed on the ground and on the resident’s shoes, and there was an odor of smoke. Resident 51 stated they smoked cigarettes and kept smoking supplies in their room or on their person. Resident 32 was also observed smoking a cigar outside the facility entrance with their spouse, who stated other residents smoke down by the trees. Staff V walked in the front door while Resident 32 was smoking but did not say anything about smoking on facility property. Three cigar butts were later observed on the ground in the parking stalls near the office windows, and no cigarette receptacles were observed near the facility entrance or at the group of trees in the parking lot. Staff B stated the facility knew Resident 51 was a current smoker, did not know how the resident extinguished cigarettes, did not provide ashtrays because the facility was non-smoking, and had not searched the resident or the resident’s room for smoking paraphernalia.
Failure to Respond to Resident Council Concerns
Penalty
Summary
The facility failed to respond to concerns raised by the Resident Council, leaving multiple issues unresolved and making the resident council process ineffective at improving resident quality of life. Resident Council minutes from December 2025 through April 2026 documented repeated concerns including beverages arriving before meals, nursing assistants not providing care properly or not getting residents up when preferred, staff complaints about employment, televisions not working in some rooms, medications not being given on time, nursing assistants choosing bedtimes, staff not answering the doorbell after 6 pm, long call light wait times, limited food variety and snacks, laundry detergent odor, grievances not being taken seriously, cold food being placed on warm plates, mislabeled and watered down juice, missed activities due to showers, therapy visits and vitals, smoking and smoke odor in the facility, rules not being followed, and a language barrier between staff and residents. For each month reviewed, the section labeled Recommendations/Follow-up on the Resident Council minutes was blank, and the Grievance Resolution Log showed no documentation or resolution for the concerns raised by the Resident Council. The only logged entries in January 2026 were titled Resident Council for flies and snack rotation, but there was no documentation addressing the broader concerns raised in the council meetings. In interviews, the Resident Council President stated call light wait times could be up to an hour, smoking remained an issue, and televisions worked inconsistently. The Activities Director stated they acted as a go-between for residents and staff and asked whether concerns required grievance documentation, while the Administrator stated concerns were sometimes placed on a grievance and other times were not because it was hard to tell whether they needed to be on a grievance.
Failure to Review Resident Rights
Penalty
Summary
The facility failed to periodically inform residents of their rights after admission for 7 of 7 sampled residents (Residents 7, 20, 35, 40, 49, 67, and 75) reviewed for resident rights. During a resident council meeting on 04/28/2026 at 2:07 PM, all seven residents stated that staff did not talk about or review resident rights in the facility, and they said resident rights were not reviewed at resident council meetings. Review of resident council meeting minutes from November 2025 through April 2026 showed no documentation or confirmation that resident rights were reviewed. In an interview on 04/30/2026 at 3:17 PM, the Administrator stated they did not know whether resident rights were routinely reviewed with residents in resident council or otherwise.
Outdated Medicare Non-Coverage Notices and Missing Documentation of Explanation
Penalty
Summary
The facility failed to ensure complete and updated Notification of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) forms were provided for sampled residents whose Medicare-covered services were discontinued. Review of CMS guidance showed the NOMNC form (CMS-10123) was last updated in January 2025, and the ABN form was last updated in 2024, but the facility used outdated versions of both forms, including a 2011 NOMNC and a 2018 ABN. For Resident 15, whose Medicare service was discontinued while remaining in the facility, the NOMNC dated 02/13/2026 stated the resident could not sign due to dementia and that the form was served to the son by phone, but Staff C signed in the patient/representative signature area. There was no documentation that the representative received an explanation of the NOMNC, appeal process, phone number, deadline, or that a copy was provided. The ABN for this resident was also signed by Staff C, with no documentation that an explanation was given or that a copy was sent. For Resident 63, the NOMNC and ABN were both signed by the resident, but the EHR contained no documentation that an explanation of appeal rights or the ABN was provided, and there was no confirmation that copies were received. For Resident 91, the NOMNC was documented as served to the daughter, but Staff C signed the patient/representative line, with no documentation of an explanation or copy provided. For Resident 90, who had severe cognitive impairment on the discharge MDS, the NOMNC was signed by the resident, but there was no documentation that the appeal process was explained or that a copy was given. Staff C stated they were responsible for issuing and explaining the NOMNC and ABN forms, that they signed because they were serving the forms for the facility, and that they were not aware of the current CMS versions. Staff PP stated the outdated forms were still being used, and Staff A and Staff QQ confirmed the forms were the incorrect version and that facility staff were not supposed to sign for residents or representatives.
Unnecessary Psychotropic Medication Use and Missing Monitoring Documentation
Penalty
Summary
The facility failed to ensure 3 of 5 residents selected for medication review were free from unnecessary psychotropic medications. Resident 4 had an order for an antianxiety medication available every 4 hours as needed for anxiety, and the MAR showed it had been given six times since it was ordered. However, the MAR did not document target behaviors for the medication or what anxiety-related behaviors occurred before administration, and none of the listed non-pharmacological interventions were documented as attempted. Resident 34 had orders for an antidepressant and an antipsychotic medication, but the MAR/TAR showed no adverse side effect monitoring in place. Resident 6 had three antidepressants ordered, yet the MAR and TAR for March and April 2026 did not show documentation of adverse side effect monitoring. Staff stated that residents taking these medications should be monitored and that the monitoring should be documented in the MAR and progress notes, but they were unable to provide documentation showing that this had been done for Resident 6 or Resident 34.
PASRR Level 2 Screening Not Completed or Documented
Penalty
Summary
The facility failed to ensure PASRR screening requirements were completed for 6 of 8 residents reviewed for pre-admission screening and resident review. Resident 9 was admitted with schizoaffective disorder and mild cognitive impairment, and their PASRR dated 06/16/2025 showed an exemption from Level 2 because the stay was expected to be less than 30 days; however, the EHR contained no documentation of the 30-day exempted PASRR or any request for a Level 2 evaluation after 30 days. Staff C stated they had tried to keep up with PASRR accuracy by reviewing them quarterly, keeping a list, and that they were not up to date. Resident 34 was admitted with Alzheimer’s disease, dementia with other behavioral disturbance, and a history of stroke, and their PASRR dated 03/20/2026 also showed a short-stay exemption with no documentation in the EHR of follow-up after 30 days. Resident 42 was admitted with depression and anxiety, had a PASRR dated 02/12/2026 with the same short-stay exemption, and the EHR again showed no documentation of a Level 2 evaluation being sought after 30 days; Staff C stated the PASRR was not faxed to the evaluator after 30 days and should have been. Resident 6 was admitted with depression and anxiety, and their PASRR dated 01/01/2026 required a Level 2 referral on admission, but no Level 2 evaluation or invalidation was found in the EHR. Resident 4 was admitted with dementia, anxiety, and developmental delay, and their Level 1 PASRR dated 12/15/2025 indicated Level 2 was required based on SMI indicators, but no referral, evaluation, or invalidation was documented. Resident 51’s Level 1 PASRR dated 01/13/2026 also required Level 2 prior to admission, and no Level 2 evaluation was found until an invalidation dated 04/28/2026 was later provided, which documented that the resident had been admitted without the Level 2 determination being completed.
Food Service Did Not Honor Resident Diets, Preferences, or Snack Availability
Penalty
Summary
The facility failed to ensure residents received food that matched their allergies, intolerances, dislikes, and preferences, and failed to provide appealing snack and meal options. Resident council minutes documented that snacks were never available and that staff did not know where they were located, and another meeting noted that cold food was being placed on warm plates during meals. During interviews, residents stated snacks were often unavailable or limited to a few items such as peanut butter and jelly sandwiches or teddy graham cookies, while unit pantry observations showed only small amounts of snack items and staff stated the pantries were stocked only once a day in the evening. On unit 1 and unit 2, observations of snack storage areas showed limited food items available, including a few yogurts, applesauce cups, sandwiches, thickened drinks, and a small amount of packaged snacks. Staff stated day shift did not stock snacks and that the kitchen or night shift was responsible for restocking them, with one staff member noting there should be a variety of items such as fruit snacks, chips, crackers, cheeses, and puddings. A dietary manager also stated residents could choose from five alternate meal choices and could mix and match items, but during meal service staff were observed omitting disliked items without replacing them with similar alternatives, such as leaving off rice or broccoli without adding another starch or vegetable. Resident 44, who reported being gluten free, dairy free, and on a diabetic diet, stated the menu offered only a limited number of meals and snacks that met those restrictions, and a grievance documented that oat milk was unavailable for several days and extra protein was not provided at breakfast. Resident 77 stated the facility did not follow the dietary slip and that bread preferences were not honored; the resident’s meal ticket listed a dislike of bread, Mexican food, and beef. During lunch observation, Resident 77 was served meatballs made of beef despite the documented dislike, and staff acknowledged the meatballs were beef and that they generally did not substitute similar items when disliked foods were omitted from a tray.
Resident Records Were Inaccurate and Incomplete
Penalty
Summary
The facility failed to ensure resident records were accurate, complete, and readily accessible for three residents. For one resident with a guardian, the electronic record contained letters of guardianship with expiration dates, and staff in Social Services and Medical Records stated they were unaware the guardianship documents had expired and that there was no process they knew of to ensure the documents were updated after expiration. For another resident admitted on hospice services, the record showed an initial hospice certification and plan of care that ended after the admission period, but there was no updated hospice certification in the chart and only four hospice-related notes were found since admission, with no nursing, home health aide, or occupational therapy visit notes or summaries located in the record. For a third resident, the record contained conflicting discharge documentation. One discharge evaluation and one transfer/discharge notice indicated the resident was discharged to an adult family home, while another transfer/discharge notice indicated the resident was transferred to the hospital. Staff stated the resident was transferred to the hospital, that the discharge evaluation was incomplete, and that the notice showing discharge to the adult family home was predated and should not have been in the medical record. Staff also stated there was no standard process for full chart audits and that they did not know who was responsible for auditing missing notes or summaries from outside providers.
Failure to Honor Resident Choice for Nighttime Care Routines
Penalty
Summary
The facility failed to allow a cognitively intact resident to make choices about daily routines, specifically nighttime interruptions for medications and vital sign checks. Resident 51, admitted to the facility on [DATE], reported during interview that they were awakened at least three times each night for medications and to have blood pressure and heart rate checked, and that it was difficult to get back to sleep after being awakened. The resident also stated they had told the medication nurse they did not want to be awakened at night, but the schedule was not adjusted. Record review showed Resident 51 had an albuterol order scheduled at 6 AM, 12 PM, 6 PM, and 12 AM, and an order for vital signs every shift, including the night shift. Staff P, LPN, stated the resident had mentioned on several occasions not liking to be awakened at night, but the schedule was not adjusted and the concern was not reported to the RCM. Staff D, RCM, stated that if a resident did not want to be awakened at night, staff would look at the care needs and try to rearrange the schedule, but Staff D was not aware of Resident 51's preference. Staff B, CNO, stated staff were expected to report such concerns to the RCM so the schedule could be adjusted.
Failure to Notify PASRR Coordinator After Significant Mental Status Change
Penalty
Summary
The facility failed to notify the State PASRR Coordinator after a significant change in mental condition for one resident who had been identified on PASRR as having indicators of serious mental illness but did not require a level two evaluation because the resident was stable on venlafaxine and buspar. The resident was admitted with diagnoses including Parkinson's disease, major depressive disorder, and anxiety. A psychiatric provider later documented that venlafaxine may have been contributing to the resident's anxiety and recommended changing the antidepressant. Subsequent records showed escalating anxiety-related events, including a one-time dose of hydroxyzine for an acute anxiety episode, a later PRN hydroxyzine order for increased anxiety, another episode of anxiety and panic requiring hydroxyzine for three days, and an order to cross-taper venlafaxine with Zoloft and discontinue venlafaxine. Review of progress notes from the period showed no documentation that a new PASRR was completed or that a level two evaluation was requested after these changes in mental status. In interview, Social Services staff stated they reviewed PASRRs quarterly for accuracy and would not complete a new PASRR or seek a level two evaluation for changes in psychotropic medications unless a new diagnosis was added.
Failure to Follow Medication Parameters, Blood Sugar Timing, and Wound Treatment
Penalty
Summary
The facility failed to ensure professional standards were met for Resident 6’s skin observation and treatment. Resident 6 was re-admitted with cognitive impairment and was identified as at risk for pressure ulcers/injuries on the admission MDS. On 04/22/2026, a skin inspection evaluation documented a small open area to the left buttock, and the resident later stated they had an open area on their buttocks and that it was painful when sitting in the wheelchair. The resident also reported knowing about the open area after a doctor’s appointment several days earlier, which matched the progress note showing the appointment occurred on the same day the open area was documented. Despite the documented skin concern, Resident 6’s April 2026 TAR did not show any treatments or documentation for the open area, and there were no orders in the electronic chart for treatment of the wound. During an observation on 04/30/2026, a small open area consistent with a Stage 2 wound was seen on the left buttock, and there was no bandage or ointment applied. Staff EE stated the nurse was aware of the open area and would be told that the bandage was off. Staff DD, the LPN, stated this was the first time they had seen it and said it had previously been just red and blanchable. Staff BB, the RCM, also stated Resident 6 did not have any open areas on the buttocks. The facility also failed to follow physician-ordered medication parameters for Resident 6 and Resident 52. Resident 6 had an order for a blood pressure medication twice daily with instructions to hold if SBP was less than 100 or HR was less than 60, yet the MAR showed the medication was given outside those parameters on multiple days in March and April 2026. Resident 52 had an order for a blood pressure medication twice daily with instructions to hold if HR was below 60 bpm, but the medication was administered when the resident’s HR was below 60 bpm on several occasions in April 2026. In addition, Resident 29’s blood sugar was checked after the breakfast tray had already been removed from the bedside, and the LPN stated there was not enough time to check all blood sugars before breakfast.
Failure to Restore Continence and Provide Appropriate Toileting Support
Penalty
Summary
The facility failed to ensure that a resident who had been continent of bladder prior to admission received appropriate treatment and services to restore continence to the extent possible. The resident was admitted with diagnoses including falls with concussion, Alzheimer's disease, and a history of stroke. A collateral contact stated the resident had been continent at home, did not use a brief, and was independent prior to the fall and hospitalization, but was now being kept in a brief at the facility because of fall risk and should be allowed to use the bathroom with supervision. Records showed the resident’s hospital discharge summary included an order for Flomax, but did not document continence status. A clinical evaluation summary later documented bowel and bladder incontinence. A bladder status evaluation documented the resident was incontinent prior to admission, no voiding pattern had been completed, and the resident was not able to communicate toileting needs or follow directions for a training program. The admission MDS documented frequent incontinence and that a toileting program had not been attempted. The CAA documented the resident was dependent on staff for toileting hygiene and transfers and was frequently incontinent of bladder, but it lacked details about bladder incontinence, brief use, and the overall toileting goal. The care plan identified risk for urinary complications related to impaired mobility and cognition and included prompted voiding and routine toileting. OT notes documented toileting-related cueing and education to the spouse, but without specific details. Task records showed the resident was continent 14 times out of 87 opportunities, without indicating whether those episodes occurred during prompted or scheduled toileting. During observation, staff assisted the resident to the bathroom when the resident indicated a need to void, but another continuous observation showed the resident remained outside the nurse’s station for an extended period and was not toileted. Staff interviews described toileting as prompted or scheduled before and after meals, but the RCM stated a voiding pattern was not completed because the resident was thought unable to understand or follow directions, despite the resident being observed indicating a need to use the bathroom.
Oxygen Orders and Supplies Not Maintained as Ordered
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for 2 of 4 residents reviewed for respiratory care and services. A facility policy titled Oxygen Administration, Safety, Storage and Maintenance stated that oxygen parameters should be monitored as needed and/or as ordered, oxygen supplies should be changed weekly, equipment should be dated when set up or changed out, and humidifiers should be dated and replaced every seven days regardless of water level. Resident 42, who had COPD, was observed with an oxygen concentrator set to 3 lpm and an empty humidifier attached with no date; the nasal cannula was also not dated. The resident’s order was for oxygen at 1-3 lpm via concentrator every four hours as needed for oxygen desaturation or distress, with orders to monitor oxygen saturation and titrate per protocol. Later observations showed the oxygen set at 3.5 lpm, the humidifier still empty, and the tubing not dated. Resident 42 stated they were on oxygen all the time. Staff later stated the resident was on continuous oxygen at 2 lpm, that the PRN order should be changed to continuous, and that the resident did not have a humidifier ordered. Resident 37, who also had COPD, had an April 2026 MAR order for oxygen at 2 lpm, but the resident stated they used oxygen continuously and that the settings were at 2.5 lpm. Observations on two separate days showed the oxygen concentrator set to 3 lpm. An RN later stated the concentrator settings should have been checked and confirmed the order was for 2 lpm.
Unnecessary and Improperly Administered Pain Medications
Penalty
Summary
The facility failed to ensure residents were free from unnecessary medications and failed to follow ordered pain medication parameters and non-pharmacological pain interventions for multiple residents. The deficiency involved Resident 4, Resident 6, Resident 20, and Resident 52, with survey findings showing pain medications were administered outside ordered parameters, duplicate or excessive acetaminophen exposure occurred, and non-pharmacological interventions were not documented before PRN pain medication administration. Resident 4 had diagnoses including dementia and chronic pain. The physician’s orders included acetaminophen every four hours as needed for pain rated 1-5 and oxycodone every four hours as needed for pain. The resident’s routine pain monitoring from April 1-27, 2026 documented pain ratings of 0 on most days, with only a few days showing low pain scores. The MAR showed no acetaminophen doses were given, but oxycodone was administered three times, including once when pain was documented as 0 and twice when pain was documented as 5 and 3. No non-pharmacological interventions were documented before the oxycodone doses. The side effect monitor documented no side effects, although the MAR showed four doses of bowel-stimulating medication related to constipation. Staff stated the orders were from Hospice and acknowledged the documentation did not capture the resident’s pain and that the acetaminophen should have been attempted first based on the documented pain levels. Resident 20 had diagnoses including a history of stroke, history of fractures, and chronic pain. The resident had a routine acetaminophen order of 650 mg twice daily, a 7-day order for acetaminophen 1000 mg every 8 hours, and then a new PRN acetaminophen order of 650 mg every 4 hours. The report documented that the 7-day order provided 4,100 mg of acetaminophen in 24 hours and that the later combination of routine and PRN orders allowed a potential total of 5,000 mg in 24 hours. The orders did not address maximum allowable acetaminophen dosage guidelines. Staff stated the pharmacist normally reviews orders for duplication or missing parameters, but follow-up should have occurred and nurses and nurse managers should have identified the issue. Resident 6 was re-admitted with diagnoses including repair of a right hip fracture, a left proximal humerus fracture, and type 2 diabetes mellitus. The resident had PRN oxycodone orders for moderate and severe right hip pain, but the orders did not include non-pharmacological interventions before administration. The care plan referenced reassurance and encouraging non-pharmacological methods, but did not specify what interventions should be offered. The MAR showed oxycodone was given multiple times when the documented pain level did not match the ordered parameters, including doses given at pain levels outside the prescribed ranges. The MAR, TAR, and progress notes did not document any non-pharmacological interventions before PRN oxycodone was administered. Staff gave differing descriptions of the interventions they said were used, but could not show documentation that they were provided. Resident 52 had an order to encourage non-pharmacological interventions before administering pain medication when pain or signs and symptoms of pain were present. The MAR documented verbal and non-verbal pain on multiple days, but there was no documentation that non-pharmacological interventions were provided. The resident also had PRN acetaminophen orders, and the MAR showed acetaminophen was administered on two dates without documentation of non-pharmacological interventions beforehand. Progress notes likewise did not show that non-pharmacological interventions were attempted or provided. Staff stated the interventions should have been offered and documented in the MAR, but the record did not contain that documentation.
Medication Storage and Cart Security Lapses
Penalty
Summary
The facility failed to store medications securely for 2 of 2 residents reviewed for medications kept in their rooms, and failed to ensure 1 of 4 medication carts and 1 of 2 treatment carts were locked when left unattended. On 04/26/2026 at 9:39 AM, the treatment cart outside nursing station two was observed unlocked and contained scissors, zinc oxide ointment, hydrocortisone cream, Vaseline, iodine antiseptic pads, silicone cream, and medicated wound dressings. In interview at that time, the DON stated treatment carts were expected to be locked when not in use and secured by staff. Later that day at 12:15 PM, the medication cart on the second hall was observed unlocked outside nursing station two while the assigned LPN was sitting behind the nurse's station; when asked, the LPN immediately locked the cart and stated it should always be locked when unattended. On 04/28/2026 at 4:05 PM, Resident 49 had a can of topical pain relief sitting on the windowsill, and Resident 37 had a red inhaler on the overbed table. Resident 37 stated the inhaler was their rescue inhaler and needed it in case of a sudden attack. In interview, the Resident Care Manager stated residents needed an order, a lockbox for medications in the room, and an evaluation to ensure they could administer medications safely, and the DON stated medications were not allowed at a resident's bedside without an evaluation to ensure they could be used safely.
Infection control lapses during EBP, pericare, equipment cleaning, and med pass
Penalty
Summary
The facility failed to ensure staff complied with Infection Prevention and Control Guidelines and standards of practice during Enhanced Barrier Precautions, pericare, reusable equipment sanitation, and medication administration. The report states that these failures involved 2 residents reviewed for Enhanced Barrier Precautions, 1 observation of pericare, 1 observation of medical equipment sanitation, and 1 nurse during medication administration, and that the failures placed all residents and staff at risk of potential infection. Resident 11 had an order and care plan for Enhanced Barrier Precautions, with signage at the room entrance indicating gowns and gloves were required for high-contact care activities including transferring and toileting. During an observation, a CNA pushed Resident 11 in a wheelchair to the in-room toilet without wearing a gown. The CNA stated they were assisting with toileting and confirmed the resident was on EBP and required a gown for toileting care and transferring. Staff later stated they expected staff to follow the precaution signage and care plan instructions. Resident 79 also had an order and care plan for Enhanced Barrier Precautions. During an observation, two CNAs transferred the resident from a wheelchair to bed while wearing gloves but not gowns. One CNA stated gowns and gloves were used for brief changes, and after reviewing the EBP sign, stated they should have worn gowns before transferring the resident. In other observations, a CNA performed pericare on Resident 6 and used the same gloves to place clean linens and a brief, remove dirty linens, and fasten the brief without hand hygiene or changing gloves. A CNA also used a mechanical lift to weigh a resident and left the lift in the hallway without sanitizing it, and an RN placed an inhaler and eye drop bottle on a resident’s meal tray and later returned them to the medication cart without using a barrier.
Failure to Complete Required Pre-Hire Reference Checks
Penalty
Summary
Develop and implement policies and procedures to prevent abuse, neglect, and theft was cited after the facility failed to follow its own hiring policy requiring at least two reference checks from previous or current employers for 4 of 4 staff reviewed (Staff F, G, H, and I). The facility policy titled, Preventing Abuse, revised 08/01/2023, stated reference checks would be completed as part of the screening process upon hire. During survey review, the facility provided hiring documentation but no reference checks were received for the four staff members. Staff Q, the Human Resources/payroll coordinator, stated the identified staff did not have reference checks in their files and reported the facility no longer did reference checks because prior facilities would not give any information when called. Staff B, the Chief Nursing Officer, stated Staff Q oversaw the hiring process and would be the person responsible for obtaining reference checks, and if they were not in the files there would not be anyone else to speak with. Staff A, the Chief Executive Officer, stated they were not aware of the facility policy requiring two reference checks prior to hire.
Failure to Update Person-Centered Care Plans After Falls and Fractures
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable goals and interventions for multiple residents following falls and injuries. Facility policy required timely, person-centered comprehensive care plans that reflect individual conditions, risks, needs, behaviors, cultural values, preferences, and include measurable goals, appropriate interventions, and realistic timeframes, with updates as needed for changes in condition. Despite this, the care plans and Kardexes for four residents did not reflect new fractures, use of slings or splints, non‑weight‑bearing orders, changes in mobility, or increased assistance needs after documented falls and hospital evaluations. For one resident with moderate cognitive impairment and a history of falls and a left femur fracture, records showed a fall resulting in a non‑displaced humeral neck fracture and subsequent hospital visit, after which the resident returned with a sling and instructions not to move the left arm and to remain non‑weight‑bearing on that arm. Orthopedic documentation confirmed sling use and non‑weight‑bearing status. However, the comprehensive care plan did not include the left arm fracture, sling use, non‑weight‑bearing status, or increased ADL assistance needs, and the Kardex continued to list the resident as independent with transfers, bed mobility, and ambulation with a walker. Staff interviews confirmed that the care plan and Kardex had not been updated to reflect these changes and that the resident was no longer using a walker or getting out of bed. Another resident with severe cognitive impairment and diagnoses including falls, muscle weakness, and unsteadiness on feet had an X‑ray showing a possible non‑displaced humeral neck fracture and a provider order for a sling to the left arm, but the care plan did not address the fracture, sling use, or non‑weight‑bearing status, and a mobility‑related care plan focus was incomplete. The Kardex still showed the resident as independent with mobility and did not mention the sling or non‑weight‑bearing status. A third resident with dementia and severe cognitive impairment sustained a broken nose, facial abrasion, and a forehead laceration with sutures after a fall, but none of these injuries were added to the care plan. A fourth resident with severe cognitive impairment, stroke, and right‑sided weakness had a fall resulting in a fracture to the left fifth finger, a splint to the left hand, and a forehead laceration with sutures; the care plan did not include the left finger fracture, facial laceration, or bruising, and instead documented non‑weight‑bearing and a brace to the right wrist, which staff acknowledged was the wrong hand and initiated later than the injury. Staff interviews consistently confirmed that fractures, braces, slings, weight‑bearing status, and changes in mobility and ADL ability were not accurately or timely reflected in the care plans.
Failure to Obtain Accurate Orders and Monitor Fall-Related Injuries and Devices
Penalty
Summary
The deficiency involves the facility’s failure to obtain accurate physician orders and provide monitoring for fall-related injuries and interventions for multiple residents. For one resident with a history of falls and a left femur fracture, the resident sustained a non-displaced humeral neck fracture to the left arm after rolling out of bed. Hospital and orthopedic documentation indicated the left arm required a sling and non-weight-bearing status, but the physician orders and Treatment Administration Record (TAR) were written for the right upper extremity instead. There were no physician orders or TAR documentation for monitoring the sling or non-weight-bearing status to the left arm, despite observations showing the resident wearing a sling on the left arm and staff acknowledging that orders and monitoring should have been in place for the correct extremity. Another resident with severe cognitive impairment and a history of falls had a possible non-displaced humeral neck fracture to the left arm identified on an X-ray following a fall. The facility’s investigation summary for this fall did not document that the resident sustained a fracture, and the reporting log contained incorrect date and time information for the fall with fracture. A third resident with dementia and severe cognitive impairment experienced a fall resulting in a broken nose and a forehead laceration requiring sutures, as documented in a hospital After Visit Summary. However, the facility’s reporting log did not document the laceration injury, and there were no physician orders or TAR documentation for monitoring the forehead laceration, which staff later acknowledged was missing. A fourth resident with stroke, hemiplegia, hemiparesis, muscle weakness, and a history of falls sustained a fracture to the fifth metacarpal of the left hand and a forehead laceration with sutures, along with facial bruising, as documented in hospital records. The resident was placed in an ulnar gutter brace and ordered to remain non-weight-bearing through the left hand with specific range-of-motion allowances. The facility’s reporting log did not document the forehead laceration, and physician orders did not include monitoring of the left wrist brace until several weeks later, instead initially referencing non-weight-bearing status and brace use for the right wrist. The TAR lacked documentation of monitoring for the left wrist brace, the forehead laceration, and facial bruising, despite observations of the resident wearing the left-hand brace and staff interviews confirming the absence of appropriate monitoring orders and documentation. The report states that these failures placed residents at risk for further injury, unmet care needs, and diminished quality of life.
Failure to Ensure Safe AMA Discharge and Required Notifications
Penalty
Summary
Surveyors found that the facility failed to ensure a safe discharge plan for one resident who left the facility against medical advice (AMA). The resident had moderate cognitive impairment, impaired vision, and used a front-wheeled walker. A recent hospital discharge summary documented that psychiatry had determined the resident did not have decisional capacity and that the resident’s son was the surrogate decision maker. The facility’s transfer/discharge policy required evidence of discussion with the resident to make an AMA departure a safe discharge. On the date in question, the resident signed out of the facility in the Patient Sign In & Out Log but did not sign back in, and later told a nurse by phone that they were staying in a motel and did not want to return, except possibly to retrieve belongings. Record review showed no discharge instructions or discharge summary in the resident’s EHR, and no documentation that the resident’s emergency contact, provider, or Adult Protective Services (APS) had been notified. Multiple staff, including RNs, Social Services, and the Administrator, described that their usual process when a resident leaves AMA or stays out overnight includes educating the resident on risks, ensuring safety, notifying the Administrator, Social Services, APS, the provider, and the resident’s emergency contact, and documenting these actions in progress notes. Social Services staff also stated they would attempt to arrange home health services, instruct the resident to contact their primary care provider, and provide resources, with all steps documented in the EHR. However, staff were unable to provide any documentation that these steps were taken for this resident, and there was no evidence in the progress notes of APS notification or other required communications related to the AMA discharge.
Failure to Investigate Medication Error Incident
Penalty
Summary
The facility failed to thoroughly investigate a medication error incident involving one resident who was admitted with a fistula of the vagina to the small intestine and an ileostomy. The resident experienced diarrhea and elevated creatinine, for which a physician ordered a one-time intravenous administration of 1 liter of normal saline. Review of the Medication Administration Record (MAR) showed no documentation that the IV normal saline was administered, and the facility's incident reporting logs did not reflect a medication error for this resident. Interviews with facility staff, including LPNs and the Director of Nursing, confirmed that no incident report or investigation was initiated regarding the potential medication error. Staff acknowledged that, according to facility policy and state guidelines, an investigation should have been conducted to determine the circumstances and cause of the incident. The lack of investigation left unanswered questions about the occurrence and whether it was related to neglect or unmet care needs.
Failure to Administer Ordered IV Hydration Due to Unconfirmed Physician Order
Penalty
Summary
A deficiency occurred when a resident with a history of a fistula between the vagina and small intestine, and an ileostomy, was not administered intravenous (IV) normal saline (NS) as ordered by the physician. The physician had ordered 1 liter of NS to be given intravenously for three days due to the resident experiencing diarrhea and elevated creatinine levels. Review of the Medication Administration Record (MAR) showed the order was entered but remained in a pending status and was never confirmed or administered. There was no documentation that the IV NS was given to the resident. Interviews with nursing staff and the Director of Nursing (DNS) revealed that nurses are responsible for checking and confirming pending orders in the electronic medical record system. Staff acknowledged that the order for IV NS was not processed, confirmed, or administered, and that the order was eventually discontinued. The DNS stated that if nurses are unable to start an IV, they are expected to notify the provider and document the attempts, but no documentation of provider notification was found. The incident was not recorded in the facility's incident or medication error logs.
Failure to Investigate Resident Fall
Penalty
Summary
The facility failed to conduct an investigation following a fall experienced by a resident with a history of hemiplegia and hemiparesis after a cerebral infarction, who also had moderate cognitive impairment. The incident occurred when the resident dropped herself to the floor while staff were opening the door for medics, after which she was transported to the hospital. Review of facility records, including the State Incident Reporting log and progress notes, revealed that there was no investigation documented for this fall, nor was the incident logged as required. Interviews with nursing staff confirmed that standard protocol following a fall includes assessment, notification, obtaining staff statements, and completing an incident report in the computer system. However, the Director of Nursing acknowledged that no incident report was completed and the event was not entered into the reporting log. The lack of investigation meant that the root cause and contributing factors of the fall were not identified, and there was no documentation to rule out abuse, as required by state guidelines.
Failure to Complete Accurate PASARR Evaluations Prior to Admission
Penalty
Summary
The facility failed to ensure that four out of six reviewed residents had an accurate Pre-Admission Screening and Resident Review (PASARR) completed on or before admission. For several residents with documented mental health diagnoses such as bipolar disorder, anxiety disorder, and depression, the PASARR forms were either incorrectly completed, missing required Level II evaluations, or lacked determination letters prior to admission. In some cases, sections of the PASARR were marked incorrectly, such as indicating intellectual disability when there was no supporting diagnosis in the resident's medical history. For one resident with bipolar disorder and anxiety, the PASARR indicated the need for a Level II evaluation due to serious mental illness, but no determination letter or evaluation summary was found in the record. Another resident with severe cognitive impairment and on hospice had a PASARR form with incorrect indications of intellectual disability, despite no such diagnosis in their history. Staff interviews revealed a lack of understanding regarding proper PASARR completion and the process for obtaining and documenting Level II evaluations. Additionally, the facility admitted residents without having received the required Level II PASARR determination letters, as confirmed by both the social worker and the administrator. The process described by staff involved admitting residents and then waiting for the evaluation summary or determination letter, rather than ensuring these were completed prior to admission. This resulted in residents being admitted without the necessary mental health evaluations and documentation as required by federal regulations.
Failure to Involve Residents in Care Planning Conferences
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were given the opportunity to participate in care conferences, which are meetings where a resident's care is discussed and coordinated by the interdisciplinary team. For three residents reviewed, there was no documentation that required care conferences had been completed. One resident with moderate cognitive impairment had no record of a quarterly care conference. Another resident, who was cognitively intact, reported not being informed about or involved in any care plan meetings, and there was no documentation of such meetings in their record for over a year. A third resident, with no cognitive impairment, had a care conference scheduled, but there was no documentation that it occurred, and staff confirmed the absence of records for the meeting. Interviews with staff revealed that care conferences are expected to be conducted on admission, quarterly, annually, and as needed, but staff acknowledged that these meetings were not occurring as required for many residents. The lack of documentation and missed care conferences meant that residents were not involved in discussions about their person-centered care, and staff were unable to provide evidence that residents or their representatives were offered the opportunity to participate in care planning as mandated.
Failure to Assist Resident with Advance Directive Formulation
Penalty
Summary
The facility failed to obtain or offer assistance to a resident in formulating an Advance Directive (AD), despite documentation indicating the resident wished to pursue one. Upon admission, the resident was assessed as having no cognitive impairment, and the medical record included an Advance Directive Review stating the resident wanted to formulate an AD. However, there was no further documentation showing that the resident had been provided with information or assistance regarding their right to formulate an AD. Interviews with facility staff revealed that social services are responsible for assisting residents with ADs, including providing Power of Attorney documents and information for a mobile notary. The Social Services Assistant admitted to not following up with the resident, citing the resident's independence and lack of desire for others to be involved in their care or finances. The Administrator confirmed that the process should have started immediately upon the resident's request, but acknowledged that no documentation existed to show the resident was assisted in formulating an AD.
Failure to Review and Revise Care Plans for Multiple Residents
Penalty
Summary
The facility failed to review and revise care plans for three residents as required, resulting in deficiencies in care planning. For one resident with a history of shingles and on long-term antiviral medication, the care plan only referenced the medication under skin impairment without specifying goals or interventions related to the medication use. Staff interviews confirmed that the care plan lacked necessary details and had not been updated to reflect the resident's ongoing therapy and monitoring needs. Another resident, who was dependent on bed mobility and at risk for pressure ulcers, had a care plan intervention for heel protection that was not being implemented. Observations over several days showed the resident was not using pressure-relieving boots as documented, and staff reported that the resident did not tolerate the boots and alternative interventions, such as using pillows, were being used but not reflected in the care plan. The care plan had not been updated to remove the ineffective intervention or to include the actual care being provided. A third resident with a right below-knee amputation had a prosthesis and physician orders for its use, but the care plan did not document the presence of the prosthesis or instructions for its application and removal. Staff interviews revealed that the resident only wore the prosthesis during therapy sessions, and care staff relied on the care plan and Kardex for guidance, which did not include this information. The lack of care plan updates led to inconsistencies in care and documentation for the resident's prosthesis management.
Failure to Document and Authorize Bed Placement as Restraint
Penalty
Summary
A resident with Alzheimer's Disease and on hospice care, who had severely impaired cognition, was observed in bed with a blanket over their head. The bed was positioned in the lowest setting and placed against the wall, with a scoop mattress on the floor on one side. There was no physician's order, signed consent, or care plan documentation authorizing the bed to be placed against the wall for this resident. Multiple staff interviews confirmed that the bed had always been positioned against the wall for this resident, and staff described this practice as a form of restraint used in the facility. Staff also outlined the required process for implementing restraints, which includes assessment, obtaining a physician's order, securing consent, and updating the care plan. However, for this resident, none of these steps were documented or completed regarding the bed's placement against the wall.
Significant Medication Error: Insulin Administered Outside Blood Sugar Parameters
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors related to the administration of insulin. The resident, who had a diagnosis of Type 2 Diabetes Mellitus and intact cognition, had physician orders specifying that Insulin Glargine should be held if blood sugar (BS) was below a certain threshold. Despite these orders, documentation showed that the resident received 25 units of Insulin Glargine on multiple occasions when their BS was below the ordered parameter, and in several instances, there was no BS recorded at all prior to administration. Review of the Medication Administration Record (MAR) revealed that insulin was administered on numerous dates when the resident's BS was less than the ordered threshold, with specific BS values documented as low as 65. Additionally, there were several days where insulin was given without any BS being recorded on the MAR or in progress notes. Staff interviews confirmed that the process was to check BS before administering insulin and to hold the dose if BS was low, but the records indicated this was not consistently followed. Further interviews with nursing staff and management revealed inconsistencies in documentation and a lack of clarity regarding the medication administration process. One nurse stated they may have mistakenly documented administration due to unfamiliarity with the electronic charting system, but injection sites and BS values outside parameters were still recorded. The resident's care team, including the advanced registered nurse practitioner, was not informed that insulin had been administered outside the ordered parameters.
Failure to Coordinate Timely Denture Services
Penalty
Summary
The facility failed to ensure that a resident received timely assistance in coordinating appropriate denture services. The resident, who had a history of pneumonia and vascular dementia and was assessed as having moderate cognitive impairment, was documented as having upper and lower dentures. Despite documentation indicating no issues with broken or loose dentures and no reported mouth pain or difficulty chewing, interviews and observations revealed that the resident's lower denture was broken and missing a tooth following a fall. The resident reported discomfort when eating, and both a collateral contact and a nursing assistant confirmed the dentures were old and missing a tooth. A review of the resident's medical record showed no documentation of a scheduled dental appointment. Multiple staff members, including LPNs and a care manager, were either unaware of the broken denture or had not initiated a dental referral. The process for scheduling dental appointments was described, but there was no evidence that it had been followed for this resident until after the issue was identified during the survey. The deficiency was identified through interviews, record review, and direct observation.
Failure to Follow Enhanced Barrier Precautions During High-Contact Care Activities
Penalty
Summary
Facility staff failed to use personal protective equipment (PPE) in accordance with CDC guidelines for residents on enhanced barrier precautions (EBP). For one resident with an open wound and stage 4 pressure ulcer, a nursing assistant did not wear a gown while transferring the resident from bed to wheelchair, despite EBP signage and care plan instructions indicating that gowns were required for high-contact activities such as transferring. The staff member acknowledged awareness of the signage but did not follow the required protocol. In another instance, two staff members assisted a resident with venous ulcers in transferring, repositioning, and dressing after a shower without wearing gowns, only donning gloves. Both staff members misunderstood the EBP signage, believing gowns were only necessary for nurses performing wound care, not for high-contact activities like transferring. The resident's care plan and physician orders specified EBP with gown and glove use for such activities, but these instructions were not followed.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to comprehensively assess the increased risk for skin breakdown, follow written policy and procedures, and develop and implement timely interventions necessary to prevent the development of avoidable pressure ulcers (PUs) for four residents. Resident 1 admitted with a Stage 2 PU, which deteriorated into an unstageable PU with osteomyelitis, requiring debridement and hospital treatment. The facility did not implement recommended interventions such as an air mattress in a timely manner, leading to the worsening of the resident's condition. Documentation and communication lapses were evident, as the care plan was not updated with new interventions, and the air mattress was not provided until 43 days after it was recommended by the wound care specialist. The resident's condition deteriorated significantly, resulting in a Stage 4 PU and osteomyelitis, necessitating hospital transfer and treatment. The facility's failure to follow through with timely interventions and proper documentation contributed to the resident's harm and deterioration. Resident 2 admitted without PUs, developed a DTPI on the right heel, which was not properly documented or measured initially. Observations revealed that the resident was not provided with pressure-relieving devices as required by their care plan. Further assessments identified additional wounds, indicating a lack of consistent and thorough skin inspections. The facility's failure to implement and monitor appropriate interventions led to the development and worsening of pressure ulcers in this resident. Resident 3, who was cognitively intact, developed a DTPI on the right heel, which was not documented accurately in subsequent skin inspections. The resident's family discovered the wound, and the facility staff failed to provide appropriate pressure-relieving devices. The care plan was not updated promptly, and the resident experienced pain during dressing changes. The facility's lack of timely and accurate documentation, along with the failure to provide necessary interventions, resulted in the resident's harm. Resident 4, admitted without PUs, developed a Stage 3 PU on the right heel. Observations showed that the resident was not consistently provided with pressure-relieving devices, and the care plan was not followed. The facility staff failed to place protective boots on the resident, despite the care plan's requirements. The facility's failure to adhere to care plan interventions and provide consistent pressure relief led to the development and worsening of pressure ulcers in this resident.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to consistently implement care plan interventions related to bed height and mattress type to prevent accidents and falls for a resident reviewed for falls and accident hazards. The resident experienced harm when they fell out of bed and sustained a left hip fracture, pain, and required hospitalization. The care plan for the resident included keeping the bed in a safe position for transfers and using a perimeter mattress, but these interventions were not consistently followed or updated after the fall incident. The facility's incident reporting log documented that the resident sustained an unwitnessed fall in their room, resulting in a fracture. The investigation revealed that the bed was in a high position at the time of the fall, and the resident was found lying on the floor. Staff interviews and observations confirmed that a standard mattress was in place instead of the required perimeter mattress, and the bed was not consistently kept in the low position as per the care plan. Additionally, the Kardex did not reflect the correct fall interventions, and staff were unsure of the specific interventions required for the resident. Further interviews with staff indicated a lack of awareness and adherence to the resident's fall intervention plan. The maintenance department did not maintain a log for perimeter mattresses, and there was no clear communication regarding the need for such mattresses. The facility's failure to implement and monitor the prescribed interventions placed the resident at risk for falls and injuries, as evidenced by the repeated observations of non-compliance with the care plan requirements.
Failure to Conduct Thorough Fall Investigation
Penalty
Summary
The facility failed to conduct a thorough investigation for a resident who experienced a fall. The resident, who had severe cognitive impairment and required extensive assistance with mobility and personal care, sustained a fall in their room, resulting in a left femur fracture. The investigation into the fall was incomplete, lacking statements from all staff involved, contributing factors, and a root cause analysis. This failure to thoroughly investigate the incident left the facility unable to rule out abuse or neglect. Interviews with facility staff revealed that the expected protocol for unwitnessed falls was not followed. The Director of Nursing and the Regional Nurse Consultant both confirmed that the investigation should have included witness statements and a comprehensive assessment of the environment and circumstances leading to the fall. Additionally, the nurse on duty did not call 911 immediately when the resident complained of pain and was unable to move their leg, which was against the expected procedure. This is a repeat citation from previous surveys.
Failure to Update and Implement Care Plan for Fall Prevention
Penalty
Summary
The facility failed to ensure timely review and revision of the care plan for Resident 7, who was admitted with diagnoses including vascular dementia with behavioral disturbances and major depressive disorder, and later re-admitted with a left femur fracture. The care plan, dated 06/20/2022, included interventions for impaired mobility and fall risk, such as keeping the bed in a safe position and using a perimeter mattress. However, observations revealed inconsistencies in the implementation of these interventions, with the resident's bed often lacking the prescribed perimeter mattress and the fall mat not consistently in place. Staff interviews indicated a lack of awareness and reliance on outdated or incorrect information in the Kardex, leading to inconsistent care practices for Resident 7's fall prevention needs. Multiple observations between 04/10/2024 and 05/01/2024 showed that the resident's bed was frequently not in the low position, and the fall mat was not always present. Staff members, including CNAs and RNs, demonstrated uncertainty about the correct fall interventions and admitted to relying on common sense or outdated Kardex information. The RN/Regional Nurse Consultant confirmed that the care plan included a perimeter mattress as of 11/18/2023, but it was not present on the resident's bed during the survey period. This inconsistency in care plan implementation and staff awareness placed Resident 7 at risk for unmet care needs and potential harm. This issue was noted as a repeat citation from a previous survey dated 03/24/2024.
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What surveyors actually found near you
We read the 755 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Snohomish
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Madison Post Acute | 5.2 mi | ★★★★★ | 1 | 0 |
| Bethany At Silver Lake | 5.6 mi | ★★★★★ | 10 | 0 |
| View Ridge Care Center | 6.7 mi | ★★★★★ | 16 | 0 |
| Bethany At Pacific | 6.8 mi | ★★★★★ | 0 | 0 |
| Regency Care Center At Monroe | 6.9 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.