Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sullivan Park Care Center during CMS and state inspections, most recent first.
A facility failed to maintain a clean, safe, and homelike environment for residents and multiple shower rooms. Surveyors observed mildew odors, water damage, broken and missing tile, peeling paint, exposed drywall and metal, sharp edges, debris, and clutter in shower rooms on several halls. Residents and staff reported the shower rooms were in poor condition, with one resident avoiding showers at the facility and staff acknowledging the rooms needed attention. Resident rooms also had exposed drywall, holes, peeling tape, scratches, and other visible damage.
Food and drinks were served at improper temperatures and were described as unpalatable by multiple residents. Surveyors observed cold items on test trays above the required 41 F limit, and the dietary manager confirmed the temperatures were out of range. Residents reported cold meals, warm beverages, melted ice cream, overcooked or tough meats, mushy vegetables, and delayed tray delivery, while food cart doors were observed left open during lunch service.
Food storage and kitchen sanitation deficiencies were identified when dry goods and refrigerated foods were found stored on the floor, uncovered, and lacking clear use-by dates. Staff reported they did not use use-by dates on food bins or prepared foods and were unsure what the dates on items meant, while multiple prepared foods and bulk items had only single dates or no dates at all. The dishwashing area, kitchen walls and floors, walk-in cooler area, and entrance/rear exit were also observed dirty or damaged, with food debris, grease, grime, exposed surfaces, and broken door components noted.
EBP was not identified for a resident with a history of MDROs in the urine and a urostomy, as no EBP sign was posted and staff provided care wearing gloves only. During urinary catheterizations for two other residents, an LPN did not consistently wear a gown, changed gloves without hand hygiene, handled urine collection items and resident care supplies, and later acknowledged not following EBP requirements.
A facility failed to ensure two residents could access their personal trust fund money after business hours and on weekends. One resident said they could not get money after 5:00 PM or on weekends, and another said they did not even try because they knew they could not get it. Staff gave inconsistent accounts of the process, with the RN unsure of after-hours access, the BOM describing limited access through a weekend supervisor, and the Administrator stating staff could call the BOM or Administrator to come retrieve funds.
A resident with dementia and Parkinson's disease was observed with a pillow wedged under the sheet at the edge of the bed, limiting bed mobility, and later in a reclined lounge chair that prevented rising. Staff said the resident had been agitated and placed there for enhanced supervision, but the record did not show an eval for medical symptoms, physician orders, or documentation of least restrictive alternatives before the restraints were used.
The facility failed to ensure Level 2 PASARR referrals were sent for two residents with positive Level 1 SMI findings. One resident had anxiety, depression, and psychotic disorder with delusions, and another had depression and PTSD; both had impaired cognition and needed help or supervision with ADLs. Staff stated referrals were handled monthly, no referrals or follow-up had been done for these residents, and some PASARRs had been completed incorrectly or remained pending for long periods.
A resident with a urostomy, dementia, and Parkinson’s disease did not have physician orders or documented nursing assessments/treatment for urostomy care after admission. The resident’s representative said they had provided urostomy care several times weekly at home, while the admission nurse and DON noted the chart lacked the expected orders for this type of care.
A resident with COPD, CHF, intact cognition, and impaired lower extremity function was found lying in bed with limited ROM and stated they wanted exercises and help maintaining mobility. The resident reported not receiving ROM exercises, and the care plan and task record showed no restorative nursing program, floor maintenance program, or individualized ROM interventions. Staff said the resident had not been identified for restorative services, therapy usually made referrals, and a prior restorative program had been discontinued without documentation explaining why.
The facility failed to fully explain the arbitration agreement, including the 30-day rescission right, to two residents. One resident had cognitive impairment and family involvement in decision making, yet the resident signed the agreement without a legal rep signature; the rep said they were unaware of the agreement. Another resident with intact cognition said they did not know what arbitration was or that they could rescind. Staff said they only summarized the document and were unaware of the full rescission requirement.
A resident admitted from the hospital with diabetes and hypothyroidism missed several ordered meds, including insulin, thyroid meds, a muscle relaxer, and an antacid, because the meds were not available when needed. The MAR and facility investigation showed missed doses on the evening shift after admission, and an LPN later confirmed the meds had not yet arrived from the pharmacy while the resident’s blood sugar was elevated and required physician notification and extra insulin.
The facility failed to provide adequate staffing to meet the needs of residents, particularly those with cognitive impairments and behavioral issues. Residents with severe cognitive impairments were observed wandering unsupervised, leading to safety risks and altercations. Additionally, care plans requiring specific staff interventions were not followed, and residents experienced long wait times for assistance. Staff interviews confirmed understaffing, particularly on the South unit, which housed many residents with cognitive and behavioral challenges.
The facility did not complete annual performance reviews for four Nursing Assistants, leading to missing evaluations in their files. Despite claims of yearly evaluations, a change in facility ownership caused a paperwork gap. This oversight placed residents at risk of receiving care from inadequately trained staff.
The facility failed to provide appetizing and palatable food, as observed during a survey. Residents reported diminished food quality, with overcooked vegetables, tough meat, and flavorless desserts. The Resident Council noted issues with variety and weekend meals. A test tray sampling confirmed the food was lukewarm and bland. The Dietary Manager acknowledged these issues, admitting the need for additional seasoning. Residents with dietary needs were affected, risking decreased nutritional intake and diminished quality of life.
The facility failed to adhere to food safety standards, with issues in food storage, labeling, and temperature monitoring. Observations revealed unlabeled and expired food items, incomplete temperature logs, and improper preparation of thickened liquids. Additionally, the facility lacked a documented cleaning schedule, indicating inadequate sanitization practices.
The facility failed to follow infection control practices during wound care for two residents, neglecting hand hygiene and enhanced barrier precautions. Additionally, staff did not implement contact precautions or notify the Infection Preventionist of a potential gastrointestinal outbreak, risking the spread of infection. These lapses highlight significant deficiencies in the facility's infection control protocols.
The facility failed to obtain appropriate consents for psychoactive medications for three residents, preventing them or their representatives from participating in care decisions. One resident, who was alert and oriented, received medications without documented consent. Another resident had medication changes without new consents, and a third resident, who was severely cognitively impaired, incorrectly signed their own consent form. Staff acknowledged these oversights.
The facility failed to implement its abuse prevention policy, leading to unreported incidents involving residents. A resident reported an altercation with another resident, while another experienced delayed call light response. Incidents of missing money and resident-to-resident altercations were not logged or reported timely. Staff interviews revealed a lack of adherence to reporting guidelines, contributing to the deficiency.
The facility failed to provide trauma-informed care to six residents with PTSD, lacking proper screening and care plans to identify and manage trauma triggers. Staff were unaware of residents' trauma histories, and the Social Services Director admitted to deficiencies in the screening process. One resident alleged being hit by staff, triggering past trauma memories, highlighting the need for improved trauma screening and care planning.
A facility failed to evaluate a resident for self-administration of medications, leading to a deficiency. The resident, with significant cognitive impairment and a history of refusing care, was left with medications unattended by a nurse without proper evaluation or documentation. The Director of Nursing confirmed that the facility's protocol requires observation unless self-administration is documented.
A facility failed to maintain a safe and homelike environment for a resident, with walls in disrepair and unsecured chemicals in a utility room. The resident's room had damaged walls and mismatched paint, while the utility room door was left ajar with a cleansing spray bottle inside. Staff acknowledged the issues, but repairs and securing of chemicals were delayed.
The facility failed to complete required PASRR Level 2 evaluations for two residents prior to admission and did not implement PASRR recommendations for another resident. A resident with serious mental illness indicators and another with delusional disorder were admitted without necessary evaluations. Additionally, a resident with borderline personality disorder did not receive timely behavioral health services as recommended. Another resident with a new depression diagnosis did not have a timely PASRR evaluation.
The facility failed to accurately complete PASRR Level I for three residents, leading to potential risks of inappropriate placement and unmet mental health care needs. One resident's PASRR omitted anxiety and depression diagnoses, another's incorrectly indicated schizophrenia, and a third's did not reflect mood or psychotic disorders despite a depression diagnosis and psychotropic medication use. The facility's policy required PASRRs to be reviewed for accuracy, but this was not effectively implemented.
The facility failed to update care plans for two residents with changing conditions. One resident, at high risk for falls, experienced multiple falls and a major injury without timely updates to their care plan. Another resident with Addison's disease did not have their care plan updated to include necessary interventions for adrenal crises, leading to concerns about staff's understanding of their condition.
The facility failed to implement the bowel management protocol for two residents, resulting in prolonged periods without bowel movements and lack of necessary medications. Additionally, the facility did not timely identify changes in a resident's skin condition, despite visible irritation and a history of psoriasis. Staff interviews revealed a lack of awareness and communication regarding these issues.
A resident with a PICC line for antibiotic therapy experienced deficiencies in care management, including missed dressing changes, omitted saline flushes, and failure to administer Cathflo Activase for an occluded line. The care plan lacked specific interventions for the PICC, and staff interviews revealed a lack of competency in managing such lines. The PICC was eventually removed, but the delay and non-compliance with protocols highlighted significant deficiencies.
The facility failed to maintain clean oxygen delivery equipment for two residents, risking respiratory complications. One resident's oxygen concentrator was unclean, and their oxygen level was set higher than prescribed. Another resident had unclean tubing with dried blood, and the concentrator filter was dusty. Staff interviews confirmed lapses in equipment maintenance and adherence to prescribed oxygen levels.
The facility failed to implement a system to evaluate staff competencies, affecting 10 out of 12 sampled staff, including both in-house and agency personnel. The deficiency involved a lack of documented training in infection control, dementia care, and administration of TPN and IV care, despite the facility's complex resident needs. Interviews revealed systemic issues in training processes, with no structured system to verify staff skills and competencies.
The facility failed to track and dispose of controlled medications for discharged residents, as found in the North Hall medication room. Unopened bottles of Morphine and Lorazepam, along with expired Dronabinol capsules, were discovered without proper documentation in the narcotic book. Staff interviews revealed that these medications were not logged or counted as required, posing a risk for drug diversion.
The facility failed to administer medications as ordered for two residents. One resident with lupus missed multiple doses of Cellcept due to pharmacy delivery issues, leading to increased pain. Another resident with atrial fibrillation received amiodarone despite low blood pressure readings, as a new LPN was unaware of the hold parameters.
The facility failed to ensure that a dietary staff member, specifically the Dietary Manager/Registered Dietician, had the required Washington State Food Worker Card. This deficiency was identified during a review of dietary staff records, where it was found that the staff member did not possess the necessary qualification. The staff member acknowledged the absence of the card and its importance in demonstrating competency in dietary operations, posing a potential risk for unsafe food handling practices.
A resident with a history of stroke and difficulty swallowing was transferred to a hospital after vomiting blood, but the facility failed to document the events leading to the transfer. The medical records lacked entries detailing the resident's decline, interventions, and notifications, and the transfer form was incomplete. Staff interviews confirmed the absence of necessary documentation, posing a risk for incomplete information sharing.
The facility failed to educate staff on the COVID-19 vaccine and did not maintain proper documentation of vaccination status. An LPN reported not receiving education or signing consent for the vaccine. The Infection Prevention RN confirmed incomplete vaccination logs, and Human Resources lacked comprehensive documentation, risking exposure to COVID-19.
A facility failed to accommodate a resident's visual impairment needs, as the resident did not have corrective lenses despite having cataracts and impaired vision. The care plan required staff to ensure the availability of glasses, but after a new prescription was issued, there was no follow-up to obtain new glasses. Staff interviews revealed a lack of awareness and follow-up regarding the resident's need for glasses, and the facility lacked a clear process for handling new prescriptions.
The facility failed to ensure accurate completion and documentation of advanced directives for three residents. A resident had conflicting code status information between POLST forms and the EMR, another had no official POA paperwork despite being listed as having one, and a severely cognitively impaired resident inappropriately signed their own advanced directive documents. These discrepancies could lead to confusion during medical emergencies.
The facility failed to adequately supervise two cognitively impaired residents, leading to multiple resident-to-resident altercations. One resident, with moderate cognitive impairment, exhibited verbal aggression and wandering, while another, with severe cognitive impairment, engaged in aggressive behaviors despite having a wanderguard. Staff acknowledged the need for increased supervision, but the facility's actions were insufficient to prevent further incidents.
The facility failed to create baseline care plans within 48 hours of admission for two residents, omitting necessary goals and interventions for managing their specific medical conditions. One resident had cardiovascular issues and vision impairment, while another had lung diseases. The Resident Care Manager acknowledged the oversight.
The facility failed to develop and implement appropriate care plans for three residents, leading to deficiencies in their care. A resident with hearing loss was observed using only one hearing aid, contrary to their care plan, which also lacked alternative communication methods. Another resident, who required two staff for interactions due to a past incident, was often attended by a single staff member, violating their care plan. A third resident, needing glasses for daily activities, had no vision needs documented in their care plan, affecting their ability to engage in activities and perform tasks safely.
The facility failed to provide timely assistance with ADLs for two residents, impacting their quality of life. One resident did not receive showers as scheduled, while another was not regularly shaved, despite needing assistance. Staff shortages and reassignments contributed to these deficiencies.
The facility failed to prevent and manage pressure ulcers in three residents, leading to the development and worsening of pressure injuries. A resident developed a deep tissue injury due to inadequate documentation and communication regarding positioning devices and mattress settings. Another resident's Stage 4 pressure injury worsened due to lack of documentation on refusals and specific mattress settings. A third resident's pressure injury deteriorated, and additional heel blisters developed due to insufficient interventions and reliance on comfort-based mattress settings.
A facility failed to secure smoking materials and monitor the use of a heating pad, leading to potential safety risks. A resident used a heating pad without physician orders or care plan documentation, while another resident kept cigarettes and a lighter accessible, contrary to their care plan. Staff were aware but did not enforce safety protocols, increasing the risk of accidents and fire.
The facility failed to maintain the ADL abilities of two residents due to a lack of appropriate RNP referrals after therapy services. One resident, admitted for therapy after an arm fracture, did not receive restorative services due to issues with therapy referrals, leading to a gap in rehabilitation. Another resident, requiring partial ADL assistance, was not placed on an RNP after therapy completion, also due to referral issues. Both residents were at risk for physical decline and decreased quality of life.
A resident with schizoaffective disorder missed doses of clozapine due to delayed pharmacy delivery, leading to increased irritability and hallucinations. The facility's staff noted the behavioral changes and administered Seroquel for agitation. Despite this, the resident's condition worsened, resulting in a hospital evaluation. The facility was in the process of switching to a local pharmacy to improve medication delivery times.
A facility failed to promptly notify a resident's representatives and medical provider after an incident where two residents with dementia were found in the same bed. The delay in notification, approximately 13 hours, limited the effectiveness of a medical exam to rule out sexual assault. The Assistant Director of Nursing acknowledged that immediate notification should have been made.
The facility failed to properly investigate an alleged resident-to-resident abuse incident involving two residents with dementia. A resident was found in another's bed, undressed, and unable to provide a statement. The involved resident was not interviewed until the next day and was transferred to the hospital over 13 hours later, after being showered and having their clothing removed, compromising evidence preservation. The Assistant DON confirmed the need for a medical exam and acknowledged the lack of communication among staff.
A resident was transferred to a hospital for psychiatric evaluation after a physical altercation, but the facility failed to provide a written transfer/discharge notice to the resident, their representative, and the Ombudsman. Staff were unaware of the requirement for written notices, and verbal notifications were made instead.
Two residents experienced harm due to inadequate pain management, resulting in hospital transfers. One resident with fractures did not receive prescribed morphine and tramadol due to prescription validity issues and pharmacy delays. Another resident, post-abdominal surgery, did not receive oxycodone due to staff disagreements over prescription validity. Both residents reported pain, but staff failed to provide timely relief, despite having medications in stock. Miscommunications and procedural gaps contributed to the deficiency.
The facility failed to provide adequate assistance to residents during meals and bathing, leading to deficiencies in care. A resident with impairments did not receive necessary meal supervision, resulting in uneaten meals. Another resident struggled with meal setup and did not receive alternatives when needed. Additionally, residents experienced significant gaps in bathing assistance, contrary to their care plans, due to insufficient staffing.
A facility failed to provide sufficient nursing staff, resulting in delayed responses to call lights and unmet care needs for several residents. One resident waited over an hour for assistance with toileting, while another did not receive required bathing and meal supervision. Staff shortages, particularly on weekends, contributed to these delays, affecting residents' quality of life and safety.
Three residents in the facility did not receive their prescribed medications upon admission due to delays in pharmacy delivery and issues with the automated medication dispensing system. This included antibiotics, insulin, and other critical medications, leading to potential health risks. Staff interviews revealed confusion about medication order processing and access to necessary systems.
Unsafe and Unhomelike Resident and Shower Room Conditions
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment for residents and shower rooms. The deficiency involved resident rooms and multiple shower rooms that had visible damage, exposed surfaces, peeling paint, broken tile, loose metal pieces, and accumulated debris. The report states this condition affected 2 of 3 residents reviewed for environment and 4 of 6 shower rooms on Halls 100, 200, 500, and 600. In the shower rooms, surveyors observed extensive deterioration and unsanitary conditions. The 500 Hall shower room had a strong mildew odor, severe water damage, exposed drywall and metal framing, peeling paint, and an unsealed loose metal top piece with sharp jagged edges. The 600 Hall shower room had duct tape on the stall edges, missing tile with sharp edges, a sink pulling away from the wall, exposed screw holes, a loose sharp-edged metal corner piece, black and brown substance around tile edges, cracked and missing tile, and deep scratches exposing drywall. The 100 Hall shower room had broken and crushed floor tiles, blackish/brown debris in grout lines, loose tile, a shower chair on its side, a blue bin overflowing with used towels and dirty clothes, and brown/yellow film on the floor. The 200 Hall shower room had cracked and peeling paint, peeled linoleum with stagnant water, discolored areas, exposed underlayment and metal mesh, a white powdery substance along the mopboard and floor joint, rust on a metal cabinet, and laundry items and incontinence briefs placed on top of the cabinet. Resident interviews and staff statements confirmed the condition of the shower rooms. One resident stated the 100 Hall shower room was moldy, had poor ventilation, and made it hard to breathe. Another resident stated they did not shower at the facility because the 500 Hall shower room was in bad condition and instead showered at a friend's home. A third resident stated the 500 Hall shower room was terrible, moldy, and had green and brown areas with a sharp lifted metal piece on the shower ledge. Staff stated they were aware of the shower room conditions, that repair requests were supposed to be entered into TELS, and that maintenance rounds were not completed on a consistent schedule. The maintenance director stated staff often failed to use TELS, that they did not conduct walking rounds consistently, and that room checks for repairs were only done twice a year. The administrator stated monthly maintenance rounds were expected and acknowledged the shower rooms needed attention. Resident rooms also showed damage and unfinished surfaces. One resident with Alzheimer's, sepsis, and hospice care had an exterior electrical outlet area with missing paint, exposed drywall, deep gouges, and an unevenly mounted wire covering with unpainted areas and scrapes. Another resident with multiple sclerosis, emphysema, and sepsis had bathroom walls with holes covered by peeling blue tape, unpainted areas behind the grab bar, peeling base trim, a scratched and discolored wood door, and deep gouges and scrapes on the wall near the bed. The resident stated the room and bathroom should be in better condition.
Food and drink served at improper temperatures and with poor palatability
Penalty
Summary
The facility failed to provide food and drinks at proper temperatures and with palatable taste for 5 of 8 residents reviewed for food service. A policy titled Food Safety stated cold products are to reach temperatures no greater than 41 degrees Fahrenheit, and the facility’s schedule showed breakfast, lunch, and dinner service times. During interviews, Resident 4 stated warm food was cold and cold food was warm, and Resident 97 stated drinks were warm and ice cream was melted by the time meals were received. Resident 92 stated breakfast was delayed until 9:45 AM on one occasion, was cold, and that there was no organized system for tray distribution; the resident also described dry meat, tough orange chicken, mushy vegetables, and cold breakfast items on another occasion. Resident 56 stated food was served cold, meat was thin and overcooked, and meals were repetitive and lacked taste. Resident 48 stated the food tasted terrible, was cold when it should have been hot, and included overcooked items and lukewarm soup. Surveyor observations confirmed cold food and drink temperatures above the required range. On one test tray, milk measured 48.9 F, orange juice 57.9 F, and strawberry yogurt 44.2 F; on a second test tray, milk measured 52 F, apple juice 51.3 F, and peach yogurt 60.4 F. The dietary manager stated these temperatures were not within required parameters and confirmed cold food and drinks should be held at 41 F or lower. Observations also showed the Hall 100 food cart door was left open for 14 minutes during lunch tray delivery, and the Hall 200 food cart door was left open for 13 minutes during lunch tray delivery.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure dry goods and refrigerated foods were properly stored, covered, and labeled with use-by dates for food safety tracking. During the kitchen observation, multiple items were stored on the floor, including a case of milk used to prop open a door, containers of salt, Glucerna, and Ensure, and two cases of frozen chicken breasts on the freezer floor. A cooling rack holding trays of cookies, chocolate brownies, and pecan pie was left completely uncovered in a high-traffic area where staff traveled in and out of the kitchen. The facility also failed to maintain food items with clear dates showing when they were prepared or when they should be used by. Multiple prepared foods and bulk storage items had only single dates or no dates at all, including cookie bags, juices, milk, thickened juice, salad mix, tuna, applesauce, pudding, cake, egg salad, opened lettuce bags, flour, rice, sugar, breadcrumbs, oats, and brown sugar. Staff stated they believed the markings were made dates, did not know what the dates meant, and said the facility did not place use-by dates on food bins or prepared food. Staff also stated the kitchen standard was to never use an item after it had been stored for more than three days, but direct observation showed multiple food items exceeded that threshold. The kitchen, dishwashing area, entrance, and rear exit were observed in an unclean and damaged condition. The food trap and drain under the dishwasher were filled with food and debris, the wall behind the dishwasher was coated with black dirt, grease, and grime, and the floor underneath was covered with garbage, black grease, and grime. The walk-in cooler area had damaged wall covering pulled away from the wall, exposing the underlying wall, studs, dirt, and black grime. The dish room door had deep scratches, exposed bare wood, and visible grease and grime. The entrance and rear exit area also had missing paint, exposed drill holes, an open utility access cover exposing pipes with rust, scattered garbage in the hallway, and a back door coated with grease and grime with broken weather stripping.
EBP and Hand Hygiene Not Followed During Resident Care
Penalty
Summary
The facility failed to ensure Enhanced Barrier Precautions (EBP) were identified for a resident with a history of multidrug-resistant organisms (MDROs) in the urine and a urostomy. The resident had diagnoses including dementia, Parkinson’s disease, and bladder cancer, and the admission nurse form showed the resident had been treated in the hospital for MDROs in the urine with IV antibiotics. Although the resident required EBP on admission to the facility, multiple observations of the resident’s room showed no EBP signage posted outside the room to identify the staff requirement to follow EBP. During a concurrent observation and interview, two nursing assistants assisted the resident to the restroom and emptied the urinary catheter bag while wearing gloves only. One staff member assisted the resident with changing clothes and also wore only gloves. Both staff members stated there was no EBP sign posted and no supply of gowns or other PPE placed near the resident’s room. The Director of Nursing stated the resident should have been placed on EBP upon admission and acknowledged the resident had been missed. The facility also failed to ensure EBP and hand hygiene were implemented during urinary catheterizations for two residents. One resident had diagnoses including multiple sclerosis, neuromuscular dysfunction of the bladder, and sepsis, and required assistance with ADLs. Another resident had diagnoses including benign prostatic hyperplasia with urinary retention, recurrent urinary tract infections, and a left below-the-knee amputation, and was alert and oriented and required assistance with transfers and care. During the catheterization observations, the LPN did not consistently wear a gown for residents identified as EBP, changed gloves multiple times without performing hand hygiene, handled supplies and urine collection items, rinsed a used urinal in the resident’s sink, and touched resident items while wearing or after removing contaminated gloves. The LPN stated they were supposed to use hand sanitizer each time they changed gloves or were contaminated, but did not, and stated they did not follow the EBP requirements. The Administrator stated staff should have been using PPE and sanitizing hands when necessary and required.
Residents Lacked Access to Personal Trust Funds After Hours and on Weekends
Penalty
Summary
The facility failed to ensure residents had access to their personal trust fund money outside of normal business hours, including after 5:00 PM on weekdays and during weekends, for 2 of 6 residents reviewed for personal funds. Resident 4 stated during interview that they could not access their personal money after 5:00 PM during the week or on the weekends. Resident 76 stated they did not have access to their personal money on the weekends or after administration left during the week and said, "I don't even try because I know I cannot get it." Staff interviews showed inconsistent understanding of how residents could access funds after hours. An RN stated that if the business office were open when a resident requested money, business office staff would talk with the resident, but was unsure of the process for accessing personal trust funds after hours or on weekends. The BOM stated the activities department got a list during the week of residents who wanted to go shopping or wanted money, and said the weekend supervisor had access to the cash box in the BOM's office, but was not sure of the process when that staff member was not available. The Administrator stated the weekend supervisor was in the building on weekends until 10:00 PM to distribute funds, and that after hours or after the weekend supervisor left, staff could call the BOM at home or call the Administrator to come to the facility to retrieve the money.
Physical restraints used without required evaluation or documentation
Penalty
Summary
The facility failed to ensure a resident was free from physical restraints and did not have an evaluation or documented medical symptoms to support the use of restraints for Resident 148. The resident was admitted with diagnoses including dementia and Parkinson's disease, and the comprehensive assessment showed cognitive impairment and substantial assistance needed for dressing, grooming, bathing, and mobility. During observation, Resident 148 was seen lying in bed with a pillow wedged under the sheet at the edge of the bed, creating a barrier that limited the resident's bed mobility. On another observation, the resident was in a reclined lounge chair in the common area, still in night clothes, and was unable to get up because the chair's reclined position prevented rising. Staff stated the resident had been agitated, had refused cares, and had been placed in the chair for enhanced supervision. The record did not show evaluation for medical symptoms to justify either restraint, physician notification for orders, or documentation that least restrictive alternatives had been attempted before the restrictive measures were used.
PASARR Level 2 referrals not completed for two residents
Penalty
Summary
The facility failed to review and validate PASARR Level 2 referrals for two residents who had positive Level 1 PASARR findings. Resident 14 was admitted with diagnoses including an anxiety disorder, depression, and a psychotic disorder with delusions, and the comprehensive assessment showed moderately impaired cognition and need for assistance with ADLs. The resident’s PASARR showed two mental health diagnoses marked yes under Section 1, but no referral had been sent for the required Level 2 PASARR. Resident 97 was admitted with diagnoses including depression and PTSD, and the comprehensive assessment showed moderately impaired cognition and need for supervision for ADLs. The resident’s PASARR showed two mental health diagnoses marked yes under Section 1, but no referral had been sent for the required Level 2 PASARR. During interviews, the Social Service Director stated they were responsible for ensuring Level 2 PASARR evaluations were completed, while Staff B stated referrals were only done monthly, that they had not sent referrals or followed up for these residents, and that they had been trained to treat the initial determination as an admission placeholder. Staff G also stated older PASARRs had been completed incorrectly and that some referrals remained pending for long periods without timely response from the contracted agency.
Failure to Provide Ordered Urostomy Care
Penalty
Summary
The facility failed to ensure a resident with a urostomy received treatment and services in accordance with professional standards of practice and resident-directed care. Resident 148 was admitted with diagnoses including a history of bladder cancer with a urostomy, dementia, and Parkinson’s disease. The comprehensive assessment showed the resident was cognitively impaired and required substantial assistance from staff for dressing, toileting activities, grooming, and mobility. The history and physical documented that the resident was admitted to the facility with a urostomy for urinary elimination needs. Review of the June 2026 physician orders showed no identification or treatment interventions to ensure appropriate care was provided for the urostomy. Review of progress notes from 06/13/2026 to 06/24/2026 showed no assessments or documentation that consistent licensed nursing care had been provided for 11 days after admission. The resident’s representative stated they had been providing urostomy care at least three times weekly when the resident lived at home. The admission nurse stated they could not find any physician or treatment orders for urostomy care, and the DON stated the expectation on admission for a resident with a urostomy was to ensure appropriate treatment and physician orders.
Failure to Implement Restorative Nursing Services for a Resident with Limited ROM
Penalty
Summary
The facility failed to ensure restorative nursing services were implemented for one resident with limited ROM and impaired lower extremity mobility. The resident was admitted with COPD and CHF, had intact cognition, required assistance from two staff members with ADLs, and had impairment to the lower extremities. The comprehensive assessment showed no restorative nursing program in place. During multiple observations, the resident was found lying in bed and stated they wanted exercises, felt forgotten and overlooked, and wanted help with ROM exercises for the left arm and legs. The resident demonstrated limited active movement of the left arm and said they did not want to lose mobility and wanted to be able to do their hair. Review of the care plan showed no restorative nursing program, floor maintenance program, or individualized ROM interventions. The task record from January 2026 through June 2026 showed no active restorative nursing programs, floor maintenance programs, or individualized ROM interventions logged by nursing assistants. Staff stated the resident had not been identified for restorative services, that therapy typically referred residents, and that the resident had previously been on a restorative program that was discontinued without transfer documentation explaining why it stopped. The DON stated RCMs were responsible for following up on restorative program implementation after therapy discharge and that residents were to be evaluated quarterly for restorative needs.
Failure to fully explain arbitration agreement and rescission rights
Penalty
Summary
The facility failed to explain the binding arbitration agreement in its entirety, including the right to cancel the agreement within 30 calendar days, in a manner and language the resident or representative understood for 2 of 3 residents reviewed. The facility policy stated that residents or their representatives were to be informed of the agreement, understand that it waived the right to a jury trial in federal or state court, and be given 30 days to rescind the agreement. The report identified Resident 138, who was admitted with metabolic encephalopathy, sepsis, and weakness, and whose social services note stated the resident was not able to make their own decisions due to cognitive impairment and that family was involved in decision making. Resident 138’s arbitration document was electronically signed by the resident, but no legal representative signed it. Resident 138’s representative stated they were the POA and were not aware of any arbitration agreement, had not been told about it, and did not know what arbitration was or that the agreement could be rescinded. Resident 2 was admitted with left leg and arm fractures, diabetes, and high blood pressure, and had intact cognition on assessment. Resident 2’s arbitration document was electronically signed by the resident, but during interview the resident stated they did not know what arbitration was, did not know they had signed an arbitration agreement, and were unaware of the 30-day rescission option. Staff stated they summarized the agreement rather than reading it in full, and the admissions assistant stated they had not read the agreement themselves and were not aware of the 30-day rescission right. The admissions director and administrator acknowledged the 30-day rescission period and described arbitration as a process to resolve disputes outside court.
Missed Admission Medications for Resident with Diabetes and Hypothyroidism
Penalty
Summary
Pharmaceutical services were not provided to meet the needs of one resident who was admitted from the hospital with diagnoses of diabetes and hypothyroidism. The resident’s transfer orders included levothyroxine, liothyronine, Novolog insulin with meals and at bedtime, Gaviscon after meals and at bedtime, methocarbamol four times daily, losartan/hydrochlorothiazide daily, and fluoxetine daily. Review of the January 2026 MAR showed the resident did not receive all ordered medications on 01/30/2026 and 01/31/2026. The facility investigation documented that on the evening shift of 01/30/2026 the resident did not receive Novolog, levothyroxine, methocarbamol, and Gaviscon. The resident’s representative reported that nursing staff said they did not have orders or medications when the resident arrived from the hospital on a Friday evening, and expressed concern that insulin was missed while the resident’s blood sugar was very high and required intervention during the first 48 hours at the facility. An LPN later confirmed the medications had not yet arrived from the pharmacy when the resident was seen on Saturday, and that the resident’s blood sugar was elevated and required physician notification and additional insulin doses.
Inadequate Staffing Leads to Resident Safety Concerns
Penalty
Summary
The facility failed to ensure adequate staffing to meet the needs of residents, particularly those with cognitive impairments and behavioral issues. The report highlights several instances where residents with severe cognitive impairments, such as wandering and aggressive behaviors, were not adequately supervised. For example, Resident 63, who had severe cognitive impairment and a history of wandering and aggression, was observed wandering unsupervised on multiple occasions, leading to resident-to-resident altercations and potential safety risks. Similarly, Resident 89 and Resident 91, both with severe cognitive impairments and wandering behaviors, were involved in incidents of elopement and falls, indicating insufficient staff supervision and intervention. The report also details the facility's failure to adhere to care plans requiring specific staff interventions. Resident 62, who had a care plan requiring two staff members for all interactions due to previous allegations of abuse, was observed receiving care from a single staff member on multiple occasions. This non-compliance with the care plan highlights a lack of sufficient staffing to meet individualized resident needs and ensure their safety and well-being. Additionally, the report notes issues with call light response times, with residents experiencing excessively long waits for assistance. Resident 42 reported waiting over an hour for their call light to be answered after an incontinence episode, and similar delays were observed during the survey. Staff interviews revealed that the South unit, which housed many residents with cognitive impairments and behavioral issues, was understaffed, leading to difficulties in managing resident care and completing necessary tasks. The facility's reliance on minimum staffing levels and the use of agency staff further contributed to the inadequate staffing situation.
Failure to Conduct Annual Staff Performance Reviews
Penalty
Summary
The facility failed to complete annual staff performance reviews as required, affecting four out of six sampled staff members, specifically Nursing Assistants Staff I, BB, N, and UU. These staff members did not have documentation of performance evaluations in their personnel files, despite being employed for several years. Interviews with the Human Resources staff and the Director of Nursing revealed that while evaluations were reportedly completed yearly, a change in facility ownership led to a gap in paperwork, resulting in missing evaluations. The Administrator confirmed the expectation for yearly performance evaluations, which were not met, placing residents at risk of receiving care from inadequately trained or underqualified staff.
Facility Fails to Provide Palatable and Appetizing Food
Penalty
Summary
The facility failed to provide appetizing and palatable food for several residents, as observed during a survey. Residents reported that the food quality had diminished, with complaints about overcooked vegetables, tough meat, and desserts lacking flavor. Specific examples included Resident 35, who found the meat too tough to chew and the vegetables mushy, and Resident 211, who described their meal as overcooked and unappetizing. These issues were corroborated by observations of meals that appeared unappealing and were not consumed by the residents. The Resident Council also expressed dissatisfaction, stating that the food was only good a couple of days a week, with particular issues on weekends. The council noted a lack of variety and overcooked vegetables. During a test tray sampling by the survey team, the food was found to be lukewarm and bland, with the main entree lacking expected flavors. The Dietary Manager, Staff Z, acknowledged these issues, admitting that the lemon fish almondine lacked lemon flavor and required additional seasoning. Residents with specific dietary needs, such as those with malnutrition or diabetes, were affected by the poor food quality. Resident 46, who was on a therapeutic diet, expressed dissatisfaction with both the regular and alternate menu options. The facility's failure to provide appetizing and palatable food placed residents at risk for decreased nutritional intake and a diminished quality of life, as they often resorted to alternative food sources or skipped meals altogether.
Deficiencies in Food Safety and Preparation Standards
Penalty
Summary
The facility failed to adhere to professional standards for food safety, as evidenced by multiple observations of improper food storage and labeling. During a kitchen inspection, it was noted that a tossed salad in the reach-in refrigerator was unlabeled, and several opened bags of cereal in the dry storage room were past their expiration dates. Additionally, various items in the walk-in refrigerator and freezer were found to be opened and unlabeled, including precooked sausage patties, sliced turkey meat, and several gallons of condiments. The north nourishment refrigerator was overcrowded with resident food items that were opened and unlabeled, posing a risk for bacterial contamination. The facility also failed to monitor and record food temperatures as required. During a tray line service observation, the dietary staff did not check the temperatures of food items on the steam table, and a fruit parfait was found to be above the safe temperature for cold foods. Despite being prompted by the surveyor, the staff did not consistently check or record the temperatures of the food items, which is crucial for preventing foodborne illnesses. The kitchen temperature logs were incomplete, missing final cooking and holding temperatures for several dates. Furthermore, the facility did not ensure the accuracy of thickened liquids preparation, which is essential for residents with dysphagia. An observation revealed that a dietary aide incorrectly prepared thickened lemonade, using fewer pumps of thickener than required. The facility did not conduct regular IDDSI Flow Tests to verify the consistency of thickened liquids, and there was a lack of training for dietary staff on this matter. Additionally, the facility lacked a documented cleaning schedule, and the sanitizer bucket was not readily available in the kitchen, indicating inadequate cleaning and sanitization practices.
Infection Control Deficiencies in Wound Care and Outbreak Management
Penalty
Summary
The facility failed to adhere to proper infection control practices during wound care for two residents, Residents 101 and 105, who were being treated for pressure ulcers. Staff T, an LPN, did not perform hand hygiene at critical points during the dressing change for Resident 101, such as after removing soiled gloves and before donning new ones. This lapse in protocol occurred multiple times during the procedure, including when handling the resident's gastrostomy tube. Similarly, during wound care for Resident 105, the Infection Preventionist and other staff did not use enhanced barrier precautions, such as wearing gowns, despite the presence of an indwelling catheter and a moist wound that required dressing. The facility also failed to implement contact precautions and notify the Infection Preventionist of a potential gastrointestinal outbreak in one of the units. Residents 74 and 20 exhibited symptoms such as nausea, vomiting, and diarrhea, yet there were no contact precaution signs on their doors, and staff did not take necessary precautions to prevent the spread of infection. Staff M, a Registered Nurse, acknowledged the need for contact precautions but had not informed the Infection Preventionist, which is crucial for preventing the spread of germs. Additionally, the facility did not consistently follow enhanced barrier precautions for residents with wounds or indwelling medical devices. For instance, Resident 102, who had a stage 3 pressure ulcer, did not receive care with the required precautions, as staff only used enhanced barrier precautions when they anticipated contact with the resident's legs. Furthermore, there were multiple instances where staff failed to wear gowns or perform hand hygiene when entering rooms with contact precaution signage, indicating a broader issue with compliance and awareness of infection control protocols.
Failure to Obtain Informed Consent for Psychoactive Medications
Penalty
Summary
The facility failed to obtain appropriate consents prior to administering psychoactive medications to three residents, which prevented them or their representatives from participating in decisions regarding their care and treatment. For Resident 411, the facility's policy required informed consent before administering psychoactive medications, but the medical record lacked documentation of such consent. Despite being alert and oriented, Resident 411 was administered several psychoactive medications without a documented review of the risks and benefits. Staff acknowledged the oversight, noting that consent evaluations should have been completed upon admission. Resident 102, who was cognitively intact, had changes in their psychotropic medication regimen without obtaining new consents. Although initial consents were obtained for medications upon transfer from a hospital, subsequent changes, including the addition of escitalopram, were not consented to as required. Staff admitted that new consents should have been obtained with medication changes. For Resident 91, who was severely cognitively impaired, an informed consent form was incorrectly signed by the resident themselves, despite their inability to make decisions regarding their care. The Director of Nursing acknowledged this error.
Failure to Implement Abuse Prevention Policy
Penalty
Summary
The facility failed to implement its abuse prevention policy effectively, which included the identification of potential allegations, timely reporting to the State Survey Agency, thorough investigation of allegations, and monitoring residents for potential psychosocial harm. This deficiency was observed in six out of ten sampled residents, placing them at risk of potential abuse, neglect, and misappropriation of property. The facility's policy required all potential allegations to be identified, reported within required timeframes, investigated, and residents protected from potential harm during the investigation process. Resident 20, who was cognitively intact, reported an incident where another resident entered their room and yelled at them. The incident was not documented in the February 2025 incident log, and the State Survey Agency was not notified as required. Similarly, Resident 42 reported a delay in call light response, which was not initially reported to the administration or the State Survey Agency. Resident 62 alleged being hit in the head by a staff member, but the incident was reported over 24 hours later, and there was a delay in monitoring for potential psychosocial harm. Additionally, Resident 35 and Resident 311 reported missing money, but these incidents were not logged or investigated as potential allegations of misappropriation. Resident 63, who had severe cognitive impairment, was involved in multiple resident-to-resident altercations, but these incidents were not reported to the State Survey Agency within the required timeframe. Staff interviews revealed a lack of understanding and adherence to the facility's abuse prevention policy, contributing to the failure to report and investigate these incidents appropriately.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care to six residents diagnosed with PTSD. The facility did not adequately screen, assess, or identify potential trauma triggers for these residents, nor did it develop and implement Trauma Informed Care Plans. This lack of action placed the residents at risk for re-traumatization and diminished quality of life. For instance, Resident 6, who had a history of PTSD and significant traumatic events, did not have a care plan in place, and staff were unaware of the resident's trauma history. Staff interviews revealed a lack of communication and awareness regarding the residents' trauma histories. Nursing assistants and LPNs on the 200 and 300 Halls were not informed about the residents' PTSD diagnoses or potential triggers. The Social Services Director admitted to being unaware of Resident 6's PTSD history and acknowledged that the facility's screening process did not trigger the development of Trauma Informed Care Plans for residents who answered 'Not sure' to significant life events. Additionally, Resident 62, who had anxiety and depression, was not properly screened for trauma. The resident alleged being hit by a staff member, which triggered memories of past trauma. The facility's trauma screening process was inadequate, as it did not directly ask residents if they had experienced trauma. Staff interviews confirmed a lack of awareness about Resident 62's trauma history, and the Social Services Director acknowledged the need for a more effective screening process to identify potential trauma triggers.
Failure to Evaluate Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure a resident was evaluated for their ability to self-administer medications, which led to a deficiency. Resident 20, who had diagnoses including diabetes, heart failure, and aphasia, was observed during medication administration without an evaluation or provider order in their medical record to self-administer medications. The resident had a Brief Interview for Mental Status (BIMS) score of 00, indicating significant cognitive impairment, and their care plan noted episodes of refusing care. Despite this, a registered nurse left the resident's medications unattended on a table in front of them without observing the resident take the pills. The nurse, Staff M, acknowledged that they should have watched the resident take the medications, as there was no documentation authorizing the resident to self-administer. The Director of Nursing, Staff B, confirmed that the facility's expectation was for nurses to observe residents taking their medications unless there was specific documentation allowing self-administration. The lack of evaluation and documentation for Resident 20's ability to self-administer medications resulted in a failure to comply with the facility's medication administration protocols.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, safe, and homelike environment for Resident 20, as observed through multiple instances of disrepair in the resident's room. The walls in Resident 20's room had multiple patches of drywall, black scrapes, gouges, and a hole near the floor. The bathroom had mismatched paint colors due to a raised paper towel dispenser. Resident 20 expressed dissatisfaction with the environment, stating it did not feel homelike. Staff L, the Maintenance Director, acknowledged the need for repairs and the importance of a homelike environment, but repairs were not completed in a timely manner. Additionally, the facility failed to secure chemicals properly in the soiled utility room on the 600 hall. The door to the utility room was observed ajar and not latched, with a large cleansing spray bottle inside. Staff WW and Staff K acknowledged the issue, noting the door had been ajar for at least a month, and the chemicals needed to be secured. Despite being aware of the problem, the facility delayed contacting fire door repair companies, resulting in prolonged exposure to unsecured chemicals. Staff L admitted uncertainty about the chemicals stored in the room and did not provide a solution for securing them until the door could be fixed.
Failure to Complete and Implement PASRR Evaluations
Penalty
Summary
The facility failed to ensure the completion of required Pre-Admission Screening and Resident Review (PASRR) Level 2 evaluations for two residents prior to their admission. Resident 6 was admitted with serious mental illness indicators, including depression, anxiety disorder, and post-traumatic stress disorder, but the facility did not complete the necessary PASRR Level 2 evaluation before admission. Similarly, Resident 102, who had diagnoses of delusional disorder and major depressive disorder, required a Level 2 evaluation due to their history of delusions and psychotic disorder, but the facility did not have this evaluation completed at the time of admission. Additionally, the facility failed to implement the PASRR Level 2 recommendations for Resident 52, who had borderline personality disorder and depression. Although a Level 2 evaluation was completed prior to admission, which recommended specialized behavioral health services, the facility did not ensure that Resident 52 received these services in a timely manner. The resident expressed suicidal ideation and was agreeable to a behavioral health consultation, but no progress notes from a behavioral health provider were available. Furthermore, Resident 91, who had diagnoses including stroke, aphasia, and dementia, was admitted without a timely Level 1 PASRR. A new diagnosis of depression and subsequent antidepressant medication order did not prompt a new Level 1 PASRR or a Level 2 referral. The Social Services Director acknowledged the oversight and the importance of completing PASRR evaluations to ensure appropriate state program evaluations.
Inaccurate PASRR Completion for Residents
Penalty
Summary
The facility failed to ensure accurate completion of Preadmission Screening and Resident Review Level I (PASRR) for three residents, which is crucial for identifying serious mental illness, intellectual or developmental disabilities, or related conditions. Resident 6 was admitted with diagnoses of anxiety disorder, depression, and PTSD, but the PASRR Level I only identified PTSD, omitting the other conditions. Resident 411's PASRR Level I did not mention PTSD and incorrectly indicated schizophrenia, which was not diagnosed in the medical record. Resident 63 was admitted with a diagnosis of depression and was on psychotropic medications, but the PASRR did not reflect any mood or psychotic disorders, and a Level II evaluation was not indicated. The facility's policy required PASRR Level I to be included in admission paperwork and reviewed for accuracy. However, the PASRRs for these residents were not accurately completed or reviewed, leading to potential risks of inappropriate placement and unmet mental health care needs. Staff Q, the Social Services Director, acknowledged the inaccuracies and the need for double-checking PASRRs upon admission. The facility's administrator expected social services to review and correct PASRRs as needed, but this was not effectively implemented, resulting in the deficiencies noted.
Failure to Update Care Plans for Residents with Changing Conditions
Penalty
Summary
The facility failed to update the care plan for Resident 44 after a significant change in their condition. Resident 44, who was severely cognitively impaired and at high risk for falls, fell and fractured their femur. Despite this major injury, the care plan was not updated until several months later. During this period, the resident experienced multiple additional falls, some resulting in injuries, yet the care plan remained unchanged for an extended time. Interviews with staff revealed that there was a lapse in documentation during a transition of facility ownership, which contributed to the delay in updating the care plan. Resident 35, who was diagnosed with Addison's disease, did not have their care plan updated to include disease-specific interventions. The resident experienced multiple adrenal crises, during which they required hydrocortisone injections. However, the care plan lacked documentation on how to manage these crises, and the nursing staff appeared to be inadequately informed about the necessary interventions. The resident expressed concerns about the staff's understanding of their condition, which was not addressed in the care plan. The deficiencies in updating and revising care plans for both residents put them at risk for unmet care needs and unintended health consequences. The facility's failure to promptly revise care plans in response to significant changes in residents' conditions highlights a gap in ensuring that care plans are reflective of current needs and interventions. This oversight was evident in both the management of fall risks for Resident 44 and the management of Addison's disease for Resident 35.
Failure to Implement Bowel Protocol and Identify Skin Changes
Penalty
Summary
The facility failed to implement the bowel management protocol for two residents, leading to prolonged periods without bowel movements. Resident 18, who required substantial assistance for daily activities, had multiple instances of three to five days without a bowel movement, yet did not receive the prescribed laxatives or suppositories as per the bowel protocol. Similarly, Resident 71 experienced three-day periods without bowel movements and also did not receive the necessary bowel medications. Interviews with staff confirmed that the bowel protocol was not followed, which should have included administering medications and notifying the provider. Additionally, the facility did not timely identify changes in the skin condition of Resident 15, who had a history of Alzheimer's Disease and required significant assistance with personal hygiene. Observations revealed red, irritated patches on the resident's scalp, with blood and flakes, which were not documented or addressed in the care plan. Despite the family member's intervention with personal psoriasis cream, there were no provider orders or documentation of the skin condition in the resident's records. Interviews with staff indicated a lack of awareness and communication regarding Resident 15's skin issues, which were not reported to the nurse as required. The failure to monitor and document the resident's skin condition and to follow the bowel management protocol placed residents at risk for complications and diminished quality of life.
Deficient Management of PICC Line in Resident
Penalty
Summary
The facility failed to maintain a resident's peripherally inserted central catheter (PICC) according to established standards, placing the resident at risk for complications. The resident, who was cognitively intact and had diagnoses including fractured ribs and empyema, was receiving antibiotics through a PICC line. However, the care plan did not include goals or interventions for managing the PICC line. Provider orders included regular saline flushes, dressing changes, and monitoring for complications, but these were not consistently followed. The resident's medication and treatment administration records showed that the last dose of antibiotics was administered on February 20, 2025, but the PICC dressing changes were missed on February 16 and March 2, 2025. Additionally, saline flushes were omitted from February 25 to March 1, 2025, and the ordered Cathflo Activase for an occluded PICC was not administered due to unavailability. There were no progress notes documenting attempts to restore the PICC's patency or assessing the continued need for the PICC line. Observations revealed that the PICC dressing was not changed as required, and the resident reported that the PICC line was no longer functional. Staff interviews indicated a lack of awareness and competency in managing PICC lines, with no documented competencies for nursing staff. The PICC line was eventually removed without difficulty, but the delay in addressing the occlusion and the lack of adherence to protocols highlighted deficiencies in the facility's management of the resident's PICC line.
Failure to Maintain Clean Oxygen Equipment
Penalty
Summary
The facility failed to maintain oxygen delivery equipment in a clean manner for two residents, leading to potential risks of respiratory complications and infection. Resident 74, diagnosed with chronic obstructive lung disease and respiratory failure, was observed using an oxygen concentrator that was unclean with thick dust debris. The resident's oxygen was set at 4 liters per minute, contrary to the physician's order of 3 liters per minute. Despite the facility's policy requiring weekly cleaning of concentrator filters, observations over several days showed the filter remained unclean until the resident cleaned it themselves. Staff interviews revealed a lack of adherence to the prescribed oxygen levels and maintenance schedule. Resident 35, with chronic respiratory failure, was also affected by the facility's failure to maintain clean oxygen equipment. The resident reported requesting a new nasal cannula due to visible blood and dirt, but the tubing was not changed promptly. Observations confirmed the presence of dried blood on the tubing, which was dated several months prior, and the concentrator filter was unclean with dust debris. Staff interviews confirmed there was no documentation of the tubing and cannula being changed, highlighting a lapse in infection control practices.
Deficiency in Staff Competency Evaluation and Training
Penalty
Summary
The facility failed to develop and implement a system to evaluate staff competencies in skills and techniques necessary to provide care tailored to each resident's individualized needs. This deficiency was identified for 10 out of 12 sampled staff members, including both in-house and agency staff. The facility's assessment indicated an average daily census of 120 residents, many of whom were acutely ill with multiple co-morbidities, requiring specialized care such as total parental nutrition, respiratory care, intravenous medications, and wound care. Despite this, the facility did not ensure that staff had the necessary training and competency documentation, particularly in infection control and prevention, dementia care, and the administration of TPN and IV care. The report highlighted specific staff members who lacked documented training and competency in critical areas. For instance, several nursing assistants, including Staff N, UU, I, and BB, had no training or competency documentation on infection control and prevention. Staff RR, a Licensed Practical Nurse, lacked training in administering TPN, IV care, and infection control. Similarly, Staff LL, a Registered Nurse, had no documented training for caring for cognitively impaired residents or administering TPN and IV care. Agency staff also showed significant gaps in training, with some having only minimal or outdated training records. Interviews with facility personnel revealed systemic issues in the training and orientation processes for both in-house and agency staff. Staff AA, from Human Resources, acknowledged the absence of a process to train or orient agency staff and confirmed that the facility was working on developing such a process. The Staffing Coordinator, Staff NN, admitted that there was no process to verify agency staff skills and competencies. Staff C, responsible for staff development, was still in the process of developing a system to verify staff skills and competencies, despite having taken over the role several months prior. The Director of Nursing and the Administrator both expressed expectations that staff should have the appropriate skills and competencies, yet the facility lacked a structured system to ensure this was the case.
Failure to Track and Dispose of Controlled Medications for Discharged Residents
Penalty
Summary
The facility failed to ensure proper tracking and disposal of controlled medications for discharged residents, as observed in the North Hall medication room. During an inspection, it was found that controlled medications belonging to two discharged residents were still present in the locked narcotic box in the refrigerator. These medications included unopened bottles of liquid Morphine and Lorazepam, as well as expired Dronabinol capsules. The medications were not entered into the narcotic book, and the corresponding page numbers were missing, indicating a lack of proper documentation and tracking. Interviews with staff revealed that the medications should have been counted every shift and entered into the narcotic book upon receipt. However, the medications for the discharged residents were not logged, and the staff responsible for receiving and storing the medications did not follow the required procedures. The Director of Nursing admitted that the facility had not been checking the narcotic box for medications belonging to discharged residents, especially if they were not recorded in the medication book, which posed a risk for drug diversion.
Medication Administration Errors for Two Residents
Penalty
Summary
The facility failed to ensure medications were administered according to the provider's order for two residents. Resident 95, who had lupus and drug-induced suppression of the immune system, did not receive multiple doses of Cellcept, a medication to treat lupus, on several occasions in January and February 2025. The medication was unavailable due to issues with pharmacy delivery and prior authorization requirements. This omission was documented in the medication administration records and progress notes, and Resident 95 reported experiencing increased pain due to the missed doses. Resident 102, diagnosed with rapid atrial fibrillation and stroke, was prescribed amiodarone to control heart rate. The medication was to be held if the systolic blood pressure was below 110, but it was administered despite low blood pressure readings on multiple occasions in February 2025. Staff P, a newly employed LPN, was unaware of the hold parameters and did not notify the provider of the low readings. This oversight was attributed to frequent interruptions during medication administration.
Dietary Staff Lacked Required Food Worker Card
Penalty
Summary
The facility failed to ensure that all dietary staff had the required qualifications, specifically the current Washington State Food Worker Cards, for safe and effective food handling. This deficiency was identified for one of the fourteen dietary staff members, specifically the Dietary Manager/Registered Dietician, referred to as Staff Z. During a review of dietary staff records, it was found that Staff Z did not possess a valid Food Worker Card as required by state regulations. Staff Z acknowledged the absence of the card and confirmed the necessity of obtaining it to demonstrate competency and knowledge in dietary operations. This oversight posed a potential risk for unsafe food handling practices, which could lead to foodborne illnesses among residents.
Incomplete Medical Record Documentation for Hospital Transfer
Penalty
Summary
The facility failed to ensure complete and accurate documentation of medical records for a resident who was transferred to a hospital for urgent treatment. The resident, who had a history of stroke and difficulty swallowing, required substantial assistance with daily activities and was capable of making decisions about their care. On the day of the incident, the resident was observed to be absent from their room, and staff reported that the resident had vomited blood and was sent to the hospital. However, the medical records lacked documentation of the events leading to the resident's decline, any interventions attempted, notifications made to providers, or information provided to the hospital. The deficiency was identified when a review of the resident's records revealed no entries from the last physician visit until the hospital transfer, leaving a gap in the documentation of the resident's condition and care. The eINTERACT transfer form was incomplete, with the reason for transfer left blank. Staff interviews confirmed the absence of documentation regarding the resident's symptoms and the decision to transfer them to the hospital. This lack of documentation posed a risk for incomplete sharing of vital information with caregivers across different levels of care.
Inadequate COVID-19 Vaccine Education and Documentation
Penalty
Summary
The facility failed to ensure that staff were adequately educated about the risks and benefits of the COVID-19 vaccine and did not maintain proper documentation of staff vaccination status. Specifically, Staff P, an LPN who had been employed for about two weeks, reported that they were offered the COVID-19 vaccine during orientation but did not receive any education on it and had not signed any consent or declination form. This lack of education and documentation was confirmed during an interview with Staff D, the Infection Prevention RN, who acknowledged that a comprehensive log of staff COVID vaccinations was not yet completed. Further investigation revealed that Staff P's employment file, reviewed with Staff AA from Human Resources, only contained records of tuberculosis screening and respirator mask fit test results. Staff AA stated that health-related documents were kept in separate health folders and that a spreadsheet was maintained for any documents received, but it was not a comprehensive list of required documents. This deficiency in maintaining proper documentation and providing necessary education placed both staff and residents at risk of exposure to COVID-19.
Failure to Accommodate Resident's Visual Needs
Penalty
Summary
The facility failed to accommodate the visual impairment needs of a resident, identified as Resident 46, who had cataracts and impaired vision. Despite being cognitively intact and able to verbalize their needs, Resident 46 did not have corrective lenses as per their care plan. The care plan indicated that Resident 46's vision was within normal limits with glasses, and staff were instructed to arrange eye appointments and ensure the glasses were clean and available. However, after a vision exam in January 2025, where a new prescription was provided, there was no documentation of follow-up actions to obtain new glasses for the resident. Interviews with staff revealed a lack of awareness and follow-up regarding Resident 46's need for glasses. Staff members, including a Nursing Assistant, Registered Nurse, and Resident Care Manager, were either unaware of the resident's vision issues or the status of their glasses. The Director of Nursing acknowledged the importance of the resident having functional glasses, but there was no clear process in place for tracking or replacing glasses. The Administrator was also unsure of the facility's process for handling new prescriptions for glasses, indicating a systemic issue in addressing the resident's visual needs.
Inaccurate Advanced Directives and Documentation Errors
Penalty
Summary
The facility failed to ensure that advanced directive documents were completed accurately and that the correct information was entered into the medical records for three residents. Resident 102 had conflicting information regarding their code status, with discrepancies between the POLST forms and the electronic medical record (EMR). The POLST form in the binder indicated a Do Not Resuscitate (DNR) status, while the EMR and a provider order indicated full CPR. Staff interviews revealed that there was a lack of awareness about these discrepancies, which could lead to confusion during medical emergencies. Resident 63, who had severe cognitive impairment, was admitted with a diagnosis of progressive neurological conditions and dementia. The medical record indicated that Resident 63 had a Power of Attorney (POA), but there was no documentation of POA paperwork on file. Interviews with the identified POA and the resident's child confirmed that no official POA paperwork existed. Staff acknowledged the importance of having accurate resident representative information in the medical record, but this was not ensured in Resident 63's case. Resident 91, who was severely cognitively impaired due to stroke, aphasia, and dementia, had signed their own advanced directive documents, including the Admission Agreement and POLST form. This was inappropriate given their cognitive status, and staff acknowledged that the resident should not have signed the form. These failures in handling advanced directives created potential for confusion during medical emergencies and for resident decision-makers to be uninformed of a resident's care.
Inadequate Supervision of Cognitively Impaired Residents Leads to Altercations
Penalty
Summary
The facility failed to consistently supervise and monitor cognitively impaired residents, leading to resident-to-resident altercations. Resident 89, with moderate cognitive impairment, exhibited verbal aggression, hallucinations, and delusions. Despite having a care plan that instructed staff to monitor and redirect the resident, incidents of wandering into other residents' rooms and aggressive behavior were documented. An altercation occurred on February 5, 2025, when Resident 89 entered another resident's room, leading to a confrontation. The incident was not properly documented in the facility's incident log, indicating a lapse in reporting and monitoring. Resident 63, with severe cognitive impairment, also exhibited wandering and aggressive behaviors. The resident was involved in multiple altercations, including hitting a peer with a hairbrush and pulling another resident's hair. Despite being identified as a risk for wandering and having a wanderguard in place, Resident 63 continued to wander unsupervised, intruding on the privacy of other residents and engaging in aggressive behavior. The facility's care plan for Resident 63 included administering medications and providing supervision, but these measures were insufficient to prevent further incidents. Interviews with staff and residents revealed that both Resident 89 and Resident 63 frequently wandered and exhibited disruptive behaviors. Staff acknowledged the need for increased supervision and intervention, but the facility's actions were inadequate to ensure the safety of all residents. The lack of consistent monitoring and failure to document incidents properly contributed to the ongoing risk of resident-to-resident altercations and potential abuse.
Failure to Develop Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for two residents, which documented resident-specific goals and treatment plans. Resident 6 was admitted with conditions including heart failure, high blood pressure, atrial fibrillation, and legal blindness. However, the baseline care plan lacked goals or interventions for managing these cardiovascular diagnoses and vision impairment. Similarly, Resident 411, who was admitted with chronic obstructive pulmonary disease and asthma, had a baseline care plan that did not include goals or interventions for managing these lung diseases. This oversight was acknowledged by Staff G, the Resident Care Manager, who confirmed that the baseline care plans did not identify the necessary nursing needs, interventions, or goals related to the residents' active or treated diagnoses.
Inadequate Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement appropriate care plans for three residents, leading to deficiencies in their care. Resident 78, who had medically complex conditions and significant hearing loss, was observed using only one hearing aid, contrary to the care plan that indicated the use of hearing aids in both ears. The care plan also failed to include alternative communication methods such as sign language, lip reading, or written communication, which were necessary for effective interaction with the resident. Staff members were unaware of the resident's actual hearing aid usage and communication needs, resulting in inadequate care planning. Resident 62, diagnosed with anxiety and depression, reported an incident where they were allegedly hit by a staff member. As a result, their care plan was updated to require two staff members for all interactions. However, observations showed that staff frequently entered the resident's room alone, failing to adhere to the care plan. Staff interviews confirmed that the care plan's requirements were not consistently followed, leading to potential safety concerns for the resident. Resident 41, who had a history of stroke and heart failure, required glasses for daily activities and reading, which were important to them. Despite this, their care plan lacked documentation regarding their vision needs. Observations revealed that the resident often did not wear their glasses, and when they did, the glasses were sometimes incomplete or misplaced. Staff interviews acknowledged the oversight in the care plan, which failed to address the resident's vision needs, impacting their ability to engage in activities of interest and perform daily tasks safely.
Failure to Provide Timely ADL Assistance
Penalty
Summary
The facility failed to provide timely assistance with activities of daily living (ADLs) for two residents, leading to a decreased quality of life. Resident 52, who was cognitively intact and required substantial assistance for showering, did not receive showers according to their preference and schedule. Despite being at risk for skin breakdown due to incontinence, the resident's shower schedule was inconsistent, with significant gaps between shower dates. Interviews with staff revealed that shower aides were often reassigned to other duties, resulting in missed showers for residents scheduled during evening shifts. Resident 41, who had moderate cognitive impairment and required assistance with personal hygiene, was not shaved regularly, despite expressing a preference for being clean-shaven. Observations showed that the resident often had noticeable facial hair, indicating a lack of grooming. Staff interviews confirmed that shaving was supposed to occur on shower days and as needed, but this was not consistently done. The failure to provide regular shaving was acknowledged by staff, who recognized the importance of maintaining the resident's dignity.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to ensure proper communication and implementation of interventions for pressure ulcer prevention and care, leading to the development and worsening of pressure injuries in three residents. Resident 101, who was admitted without pressure ulcers, developed a deep tissue injury (DTI) due to inadequate documentation and communication regarding the use of positioning devices and specialty mattress settings. The staff did not document or address the resident's refusals to turn or reposition, which contributed to the development of the pressure ulcer. Resident 1, who had a history of malnutrition and multiple sclerosis, developed a Stage 4 pressure injury that was not present on admission. The facility failed to document the resident's refusals to adhere to skin integrity interventions and did not provide specific settings for the air mattress used. Despite being care planned for quarterly discussions on the risks and benefits of refusals, there was no documentation of these discussions, and the resident's pressure injury worsened. Resident 105, admitted with a Stage 1 pressure injury, experienced a deterioration to a DTI and developed additional heel blisters. The facility did not provide specific settings for the air mattress or implement timely interventions for the heel blisters. The resident's spouse reported that the wound worsened at the facility, and observations confirmed the presence of unstageable wounds and blisters. The staff's reliance on resident comfort to adjust air mattress settings, rather than specific medical orders, contributed to the inadequate care provided.
Failure to Secure Smoking Materials and Monitor Heating Pad Use
Penalty
Summary
The facility failed to ensure the safe use of a heating pad for a resident with medically complex conditions, intact cognition, and vision and hearing impairments. The resident's family brought in the heating pad, which the resident used without any physician orders or documentation in the care plan regarding its purpose or safe use. Staff were aware of the heating pad but did not take appropriate actions to ensure its safe use, such as monitoring the temperature or checking the resident's ability to manage it. The heating pad was observed in use multiple times without proper oversight, posing a risk of burns or thermal injury. Additionally, the facility did not secure smoking materials as care planned for a resident with a history of stroke, hemiplegia, and diabetes, who was able to make decisions regarding their care. The resident kept cigarettes and a lighter in a cup attached to their wheelchair, contrary to the care plan that required these items to be locked in the medication cart. The unsecured smoking materials were accessible to wandering residents, one of whom was observed taking items from other residents' rooms. Staff acknowledged the risk posed by the unsecured smoking materials, especially with a roommate on oxygen, but did not enforce the care plan. These deficiencies placed residents at risk for potentially avoidable accidents and increased the facility's risk of fire. Staff interviews revealed a lack of awareness and enforcement of safety protocols regarding the use of electrical appliances and the securing of smoking materials, highlighting a need for improved supervision and adherence to care plans.
Failure to Provide Restorative Nursing Program Referrals
Penalty
Summary
The facility failed to ensure that two residents maintained their abilities in activities of daily living (ADLs) due to a lack of appropriate restorative nursing program (RNP) referrals following the completion of therapy services. Resident 1, admitted for therapy services after an arm fracture, was discharged from physical therapy without meeting most of their therapy goals and was supposed to be referred to an RNP. However, due to a problem with receiving therapy referrals after a change in the facility's electronic medical record system, Resident 1 did not receive the necessary restorative services, leading to a gap in their rehabilitation process. Similarly, Resident 3, who required partial assistance with ADLs and was receiving therapy services, was not placed on an RNP after completing occupational and physical therapy. Despite meeting some therapy goals, Resident 3 was not referred to an RNP due to the same issue with therapy referrals. This oversight resulted in a failure to maintain the resident's functional abilities as intended. Both residents were at risk for physical decline and decreased quality of life due to these deficiencies.
Medication Management Failure Leads to Resident's Behavioral Crisis
Penalty
Summary
The facility failed to ensure that pharmacy services were provided to meet the needs of a resident diagnosed with schizoaffective disorder, bipolar type. The resident missed doses of clozapine on two consecutive days, 11/11/2024 and 11/12/2024, due to the medication not being available. This lapse in medication administration was attributed to a delay in delivery from the pharmacy, which was not realized until just before the scheduled administration time on 11/11/2024, a holiday. The medication was reordered but did not arrive until 11/13/2024, missing the cutoff time for next-day delivery. The resident exhibited increased irritability, distressing hallucinations, and aggressive behavior, including kicking a staff member, following the missed doses. The facility's staff, including a Physician Assistant and a Licensed Practical Nurse, noted these behavioral changes and communicated with the medical provider. A one-time dose of Seroquel was administered to manage the resident's agitation. Despite this intervention, the resident continued to display erratic behavior, including tearfulness, aggression, and talking to themselves, leading to a family-requested hospital evaluation on 11/15/2024. The Director of Nursing and the facility Administrator acknowledged the issue with the pharmacy's delivery times and were in the process of switching to a local pharmacy to ensure timely medication delivery. However, this transition was not completed until after the incident. The hospital records indicated that the resident's worsening condition was likely due to a combination of missed medications and a suspected neurocognitive disorder related to alcohol abuse.
Delayed Notification of Incident Involving Residents with Dementia
Penalty
Summary
The facility failed to ensure timely notification of an incident involving Resident 8, who was found in another resident's bed. Both residents had dementia, and the incident occurred at 9:40 PM. Resident 8 reported that the other resident brought them into the room, encouraged them into bed, attempted to remove their clothes, and laid down next to them. The facility's investigation report indicated that notifications to Resident 8's representatives and medical provider were made, but it lacked specific details on the timing of these notifications. A representative for Resident 8 stated they were not informed of the incident until the following morning, approximately 13 hours later. This delay in notification resulted in Resident 8 receiving care that limited the outcome of a subsequent medical exam to rule out sexual assault. Staff B, the Assistant Director of Nursing, acknowledged that the nurse responsible at the time should have immediately notified the resident's representative, medical provider, and local law enforcement.
Failure to Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of resident-to-resident abuse involving two residents with dementia. Resident 8 was found in Resident 1's bed, with Resident 1 undressed and unable to provide a statement due to cognitive deficits. Despite the potential for sexual assault, Resident 8 was not interviewed until the following morning and was transferred to the hospital for examination over 13 hours after the incident. During this time, Resident 8 was showered and their clothing was removed, which compromised the preservation of potential evidence. The Assistant Director of Nursing confirmed that a medical exam was recommended due to the potential for sexual assault and acknowledged that Resident 8 should have been transferred to the hospital in their original clothing and without a prior shower. The incident was not properly communicated among facility staff, leading to the shower aide being unaware of the need to preserve evidence. This lack of communication and failure to follow proper procedures placed Resident 8 at risk of unidentified abuse.
Failure to Provide Written Transfer/Discharge Notice
Penalty
Summary
The facility failed to provide a written transfer or discharge notice to a resident, their representative, and the State Long-Term Care Ombudsman, as required by their policy. This deficiency was identified for one of the five sampled residents, who was involved in a physical altercation and subsequently transferred to a hospital for psychiatric evaluation. The facility's policy, adopted on 08/01/2024, mandates that a written notice be given to the resident and their representative, and a copy sent to the Ombudsman, especially in cases of emergency transfers. However, a review of the resident's electronic health record showed no documentation of such a notice being provided. Interviews with facility staff revealed that while verbal notifications were made to the resident's representative and medical provider, there was a lack of awareness regarding the requirement for written notices. Staff C, responsible for notifying the Ombudsman, admitted to not being aware of any forms required for such notifications and did not believe the Ombudsman had been informed of the transfer. The Assistant Director of Nursing also confirmed the absence of written notices, and the Administrator incorrectly believed that safety-related discharges exempted the facility from providing a 30-day notice.
Failure in Pain Management Leads to Hospital Transfers
Penalty
Summary
The facility failed to provide necessary pain management for two residents, resulting in harm and hospital transfers. Resident 3, who had fractures from a fall, was admitted with orders for morphine and tramadol for pain management. However, these medications were not administered due to issues with the prescription's validity and delays in pharmacy processing. Despite the resident's repeated requests for pain relief, staff offered only a muscle relaxer, which was insufficient. The resident eventually called emergency services for hospital transfer due to uncontrolled pain. Resident 4, who had undergone multiple abdominal surgeries, was admitted with orders for oxycodone and acetaminophen for pain management. The facility failed to enter the acetaminophen order and did not administer the oxycodone due to staff disagreements over the prescription's validity. The resident reported pain multiple times, but staff delayed addressing it, leading to a decision to send the resident back to the hospital. Observations revealed that the facility had the necessary medications in stock, but access was restricted due to pharmacy authorization issues. Interviews with staff highlighted procedural gaps and miscommunications regarding medication orders and access. Staff were unsure about weekend pharmacy submission times, and there was reluctance from the facility's medical providers to authorize prescriptions without seeing the residents. Additionally, there were misunderstandings about the availability of medications in the automated dispensing system, contributing to the failure to manage the residents' pain effectively.
Deficiencies in Meal Assistance and Bathing Care
Penalty
Summary
The facility failed to provide necessary assistance to residents during meal times and bathing, leading to deficiencies in care. Resident 8, who had impairments in both upper and lower extremities, was observed not receiving the required supervision and verbal cues during meals, as outlined in their care plan. On multiple occasions, Resident 8 was left without assistance, resulting in uneaten meals and inadequate dietary intake. Additionally, the resident did not receive the prescribed twice-weekly bathing assistance, with records showing a significant gap in bathing documentation. Resident 12, with mobility impairments in one arm, also did not receive the necessary meal setup assistance. Staff failed to provide supervision and verbal cues, and the resident struggled to cut their meal, leading to inadequate food consumption. The resident expressed concerns about their nutritional intake, particularly protein, due to a wound, but no staff were available to offer assistance or alternatives. This lack of support during meals was consistent with observations of staff being unable to monitor residents adequately. Residents 1 and 5 also experienced deficiencies in bathing assistance. Resident 1, who was severely cognitively impaired, had significant gaps between showers, contrary to their care plan. The documentation did not reflect the resident's care needs or refusals accurately. Resident 5, with paralysis in both legs, did not receive any documented showers or bed baths for 19 days since admission, despite having skin impairments. Staff attributed these failures to insufficient staffing, impacting the facility's ability to meet residents' care needs effectively.
Staffing Shortages Lead to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff were available to respond to call lights timely and meet the care needs of several residents. Observations and interviews revealed that Resident 13 experienced significant delays in receiving assistance for transferring and toileting, waiting over an hour despite having activated the call light. The resident expressed frustration and discomfort due to gastrointestinal symptoms while waiting for help. Staff interviews confirmed that staffing shortages, particularly on weekends, contributed to these delays, with only two nursing assistants available for a hall where multiple residents required assistance from two staff members. Resident 8's care plan required supervision and verbal cues during meals and assistance from two staff for bathing. However, records indicated that the resident did not receive showers twice weekly as required, and observations showed a lack of supervision during meals. Staff interviews highlighted concerns about insufficient staffing to monitor residents closely, especially those needing extensive care. Similar issues were noted for Resident 3, who reported feeling unsafe due to delayed staff responses to call lights, and Resident 4, who also experienced long wait times for assistance, sometimes resorting to calling the facility for help. Resident 5, who was dependent on staff for activities of daily living, did not receive documented bathing assistance for 19 days since admission. Staff attributed this to staffing shortages, with shower aides unavailable and nursing assistants responsible for showers. Resident 12, requiring assistance with meal setup due to mobility impairments, was observed eating less than 25% of their meal without supervision or cues. Staff interviews confirmed the need for more staff to manage residents with complex medical needs requiring close supervision and assistance.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that significant medications were administered as ordered for three residents, leading to potential risks for their health conditions. Resident 3 was admitted with orders for multiple medications, including an oral antibiotic and medications for neurological disorders and pain. However, none of these medications were administered due to a delay in processing the orders and receiving them from the pharmacy. The resident was informed that medications would not be available until the following Monday, which was not acceptable given the resident's immediate needs. Resident 4 also experienced a failure in medication administration upon admission. The resident had orders for an oral antibiotic and regular insulin, crucial for managing a peritoneal abscess and diabetes. Despite these needs, no medications were administered, and the facility did not receive the necessary records from the hospital. The delay in medication delivery was attributed to the pharmacy's slow response, and the resident's dependency on insulin made this delay particularly concerning. Resident 5 was admitted with orders for multiple antibiotics and medications for blood pressure and thyroid management. However, no medications were administered on the day of admission, and only insulin was given the following day. The delay in medication delivery extended to the third day of the resident's stay, with no documentation of the missed doses or communication with the medical provider. This lack of timely medication administration was due to delays in pharmacy delivery and issues with accessing the automated medication dispensing system.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 243 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Spokane
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aurora Valley Care | 2.3 mi | ★★★★★ | 3 | 0 |
| Sunshine Health & Rehab | 2.8 mi | ★★★★★ | 13 | 0 |
| Spokane Valley Health And Rehabilitation Of Cascad | 2.9 mi | ★★★★★ | 26 | 0 |
| Alderwood Manor | 7 mi | ★★★★★ | 25 | 0 |
| Touchmark On South Hill Nursing | 8.1 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 October 2026) and official state health department websites.