Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sunshine Health & Rehab during CMS and state inspections, most recent first.
Grievance forms were not readily available for anonymous use, and residents were not aware of how to file grievances or where the forms were located. A bulletin board near the nurse's station displayed grievance process information, but the form holder was empty and unlabeled, the locked complaint box was also unlabeled, and staff including an RN, LPN, IP, and DON were unsure where the forms were kept.
The facility failed to complete activity preference assessments for 6 of 7 residents reviewed, including residents with intact cognition and varying ADL assistance needs, as well as one resident with severe cognitive impairment. The Activities Assistant said the assessments were their responsibility but they were behind and did not have enough time, while the MDS Coordinator said the activity section was being marked not assessed to allow transmission and that this had been an ongoing issue. The DON stated activity assessments were expected to be completed timely as required.
Medication administration errors resulted in a 16% error rate after four errors were identified during 25 observed opportunities. An RN and an LPN failed to prime insulin pen needles before administration for multiple residents, and one LPN also did not hold the pen in place for the required time after injecting insulin. The residents involved had diabetes and other chronic conditions, and the DON stated the insulin pen process required priming and holding the pen in the skin to ensure the full prescribed dose was received.
Staff failed to follow posted contact precautions for a resident with shingles, with multiple staff entering the room without the required gown, gloves, or hand hygiene while providing care, transferring the resident, handling oxygen tubing, and performing a blood glucose check. The facility also kept expired sterile and non-sterile supplies in a treatment room, including urinary catheters, self-catheter kits, catheter tubing, and ostomy pouch supplies. The DON stated expired items were supposed to be checked weekly, and the Infection Preventionist confirmed staff should have followed the posted precautions.
Resident dignity and privacy were not maintained for two residents when medical assessments and medication discussions occurred in common areas where other residents and visitors could overhear. A nurse practitioner assessed one resident and discussed medications and a rash in the dining/common area, and an LPN loudly told another resident about MiraLAX while others were present. The DON stated medical care and related discussions should be done in a private area.
PASARR screening was not reviewed and validated correctly for a resident admitted with a spine fracture, chronic pain, depression, and anxiety. The Level I PASARR did not document SMI and showed no need for a Level II referral, but the Social Service Director later stated the depression and anxiety diagnoses should have been listed under SMI and required a Level II PASARR referral before admission; the DON stated residents with SMI diagnoses required Level II referral prior to admission.
QAPI Program Lacked Department Data and Resident Feedback: The facility’s QAPI process relied mainly on CMS reports and PIPs, while records and staff interviews showed that resident/RR feedback, formal and informal concerns, and data from departments such as Social Services, Therapy, and Infection Prevention were not consistently brought into QAPI. The DON and Administrator acknowledged the process was not being followed correctly and that the meetings did not include a thorough collection and analysis of information from all resident care departments.
The facility failed to ensure the QAA/QAPI committee met at least quarterly and included the required members. Records showed only two quarterly meetings were documented, and one meeting lacked documentation of the IP attending. The DNS and Administrator both stated the meetings were not being conducted quarterly and did not include the required members.
Laundry room conditions were found to be unsafe and unsanitary when a washer was leaking water onto the floor, wall, and foam gap material, with black sludge resembling mold noted in the puddle and foam. A second washer had a pile of rubbery black shavings underneath it, likely from a torn belt. Staff were unaware of the leak at first, and the DON/administrator later reviewed the findings and agreed the leak and possible belt issue needed attention.
A resident with severe visual impairment was not fully informed about their care and treatment in a way they could understand. The resident was given important paperwork regarding Medicare coverage termination without adequate explanation or opportunity to ask questions, and there was no documentation of attempts to involve their representative as requested.
A resident who experienced a fall was assisted back into their wheelchair by a nursing assistant before a licensed nurse could assess them for injuries, contrary to facility policy. The resident exhibited pain and swelling in the ankle and required further evaluation. The assigned nurse was on break, and although another nurse was available, the nursing assistant did not seek their help before moving the resident.
The facility submitted inaccurate direct care staffing information to CMS for a reporting quarter because census data used from MDS assessments was not current at the time of PBJ submission, resulting in reported staffing levels below mandated requirements.
The facility failed to uphold residents' rights to retain personal property as a condition of admission. Admission agreements discouraged bringing valuables, and staff interviews revealed that valuables were stored in a facility safe with limited access. Residents, including those cognitively intact and impaired, were affected by this policy, which was acknowledged by staff as potentially violating resident rights.
The facility failed to annually review infection control policies and demonstrated poor hand hygiene practices, with staff not adhering to protocols during resident care. Additionally, transmission-based precautions were improperly implemented for residents, risking infection spread.
The facility failed to ensure that the designated Infection Preventionist, who had been in the role since March 2024, met the necessary qualifications for experience, education, training, and/or certification. Interviews revealed that Staff C was still in the process of completing the required training, and no documentation was provided to confirm their qualifications. This placed all residents, staff, and visitors at risk of communicable diseases due to unmet infection control issues.
The facility failed to submit MDS data to CMS within the required timeframe for several residents, leading to late assessments. The MDS Coordinator struggled with the workload, resulting in delayed submissions confirmed by validation reports. The Administrator acknowledged the issue, expecting timely completion according to the RAI manual.
The facility failed to provide scheduled bathing services for two residents, leading to deficiencies in personal hygiene care. One resident, requiring substantial assistance, received only 2 out of 7 scheduled showers due to staffing shortages. Another resident, who valued regular showers, received only 2 out of 5 scheduled showers, with no refusals documented. The DON acknowledged the oversight.
The facility failed to accurately reconcile controlled drugs, including Ativan, in the Victorian Rose medication room. Observations revealed that Ativan was stored improperly and not tracked accurately, increasing the risk of drug diversion. Staff were unable to verify the Ativan count due to lack of access to the electronic medication dispensing machine, and documentation lacked sufficient detail for reconciliation.
The facility failed to maintain food safety standards, as staff did not check food temperatures before serving, leading to unsafe temperature levels for cold foods. Incomplete kitchen temperature logs and improper food storage, including uncovered and expired items, were also observed. The Dietary Services Director acknowledged these lapses in food safety protocols.
The facility failed to provide education on vaccination benefits and side effects, offer pneumococcal and influenza vaccines, and document these actions in residents' records. Three residents lacked documentation of education or offers for the 2024-2025 flu season, despite facility policies requiring such actions.
The facility failed to document the required 12-hours of annual in-service training for nursing assistants, including dementia and abuse prevention training. Despite efforts to provide training, the facility lacked records to verify compliance, with only eight out of nineteen nursing assistants attending a mandatory skills fair.
A facility failed to assess a resident for safe self-administration of medications, as required by policy. The resident, who was cognitively intact, had medications left at their bedside without a proper assessment or provider order. Staff interviews revealed a lack of awareness and adherence to the facility's process, posing potential safety issues.
A facility failed to maintain a medication error rate below five percent, with two errors occurring during 26 medication administrations, resulting in a 7.69% error rate. A resident with GERD and IBS received Metoclopramide and Pantoprazole after breakfast, contrary to the prescribed schedule. The RN responsible admitted the error, and the DON confirmed the late administration as a medication error.
The facility failed to employ a dietician with the necessary Washington State licensure, as required by state regulations. The Corporate Dietician, although nationally registered, did not possess state-specific credentials, placing residents at risk for unmet nutritional needs. The facility's policy requires tracking of professional licenses, but documentation of the dietician's state licensure was not provided when requested.
A resident was inappropriately prescribed antibiotics for a UTI without exhibiting symptoms, contrary to the facility's antibiotic stewardship policy. Despite the absence of urinary symptoms, antibiotics were administered, and subsequent urine culture results did not meet the McGeer Criteria for a UTI diagnosis. Interviews revealed that staff did not adhere to established protocols, leaving decisions to the provider without ensuring criteria were met, risking multi-drug-resistant organisms and adverse side effects.
A resident with a history of falls and COPD was at risk for tripping over their oxygen tubing, a hazard not addressed in their care plan. Despite staff observations of the resident getting tangled in the tubing, the care plan lacked interventions for this risk. The resident experienced an unwitnessed fall, resulting in fractures, highlighting the need for individualized care plans that consider unique environmental risks.
A resident with COPD and atrial fibrillation was transported from the hospital to the LTC facility without the prescribed oxygen, leading to low blood pressure and chest pain. The facility's transportation staff did not apply oxygen, assuming the resident was stable without it. The facility lacked a specific policy for hospital transport, contributing to the oversight.
Grievance forms were unavailable and residents were unaware of the grievance process
Penalty
Summary
The facility failed to ensure that residents, families, and visitors had access to grievance forms if they wanted to file a grievance anonymously, and failed to ensure that residents knew the process for filing grievances for 4 of 4 residents reviewed in Resident Council. A facility policy dated 10/2025 titled Resident/Family Grievance Policy a Procedure stated that staff would make grievance forms available to residents, family members, and friends. During a Resident Council meeting, Residents 61, 15, 66, and 51 each stated they were unaware of the grievance process, including how to file a grievance anonymously or where the forms were located. Resident 51 stated they thought they would probably call the corporate office if they had any concerns. An observation showed a bulletin board near the nurse's station with information about the grievance process, along with an empty plastic pocket intended to hold papers or forms and a locked wood box attached to the wall for completed forms; neither item was labeled or identified. Staff were unable to identify where grievance forms were located. An RN stated they were not sure where the forms were and suggested asking someone else. An LPN stated they were unsure and thought the forms might be at the nurse's station. The Infection Preventionist stated the forms were in the file cabinet at the nurse's station but could not find any and said they would get some because they kept them there. The DON observed the empty pocket and locked box and stated the pocket should be identified as the grievance form holder and the box as the receptacle for completed grievance forms.
Incomplete Activity Preference Assessments
Penalty
Summary
The facility failed to ensure accurate activity assessments were completed for 6 of 7 residents reviewed, including Residents 44, 7, 64, 61, 20, and 49. The report states that the activity preference section of the comprehensive assessments was not assessed for these residents, despite several of them having intact cognition and needing varying levels of assistance with activities of daily living. Resident 44 was cognitively intact and required substantial assistance with transfers, lower body dressing, and mobility; Resident 64 had intact cognition and could make needs known; Resident 61 had intact cognition and required set-up/moderate assistance for ADLs; Resident 20 had intact cognition and required moderate assistance for ADLs; and Resident 49 had intact cognition and required assistance from one staff member for ADLs. Resident 7 had severe cognitive impairment, but the activity preferences were also not assessed. During interview, the Activities Assistant stated they were responsible for completing activity assessments for newly admitted residents and that the assessments included resident preferences and a plan to accommodate them, but they were not always able to complete them because they did not have enough time and were behind. The MDS Coordinator stated the activity portion of the assessment was being marked as not assessed so it could be transmitted, and that incomplete activity assessments had been an ongoing issue that had improved for a while but worsened again. The DON stated resident activity assessments were expected to be completed timely as required and that the issue would be revisited because it had been a previous concern.
Medication Administration Errors with Insulin Pens
Penalty
Summary
The facility failed to ensure a medication error rate of less than five percent. During 25 observed medication administration opportunities, four medication errors were identified for 3 of 8 residents, resulting in an error rate of 16%. The errors involved insulin administration and were identified during observation, interview, and record review. Resident 31 had diagnoses including diabetes, COPD, and hypertension, and the comprehensive assessment showed intact cognition. The resident had multiple insulin orders, including sliding scale and scheduled doses. During one observation, an RN prepared insulin pens by cleaning the tops, attaching disposable needles, and dialing doses, but did not prime either pen before administration. During another observation, an LPN prepared two insulin pens for a total ordered dose, swabbed the pen tops, dialed each pen to two units and pressed the plunger before attaching the needles, then administered the insulin in two injections. The LPN did not prime the needles before administration. Resident 61 had diagnoses including diabetes, kidney disease, and hypertension, and required set-up/moderate assistance with ADLs with intact cognition. The resident had insulin orders including a sliding scale dose and a scheduled mealtime dose. During observation, the RN swabbed the insulin pen top, attached a disposable needle, dialed the pen to 13 units, and administered it to the resident’s abdomen without priming the needle. Resident 75 had diagnoses including diabetes, kidney disease, and COPD, and had impaired cognition. During observation, the LPN prepared the insulin pen without priming the needle, then administered the dose and immediately removed the pen from the resident’s abdomen without holding it in place and counting to five seconds. The DON stated the insulin pen process required priming the needle and holding it in the skin for the required time to ensure the full prescribed dose was received.
Infection Control Failures With Contact Precautions and Expired Clinical Supplies
Penalty
Summary
The facility failed to ensure staff followed infection control measures for a resident room on contact precautions for shingles. A posted contact precaution sign instructed staff to perform hand hygiene and don a gown and gloves before entering the room, but multiple staff members did not follow those instructions during observations. Staff L entered the room and obtained vital signs without a gown or gloves, and later stated they should have worn them. Staff M stated the resident had shingles but said a gown was not required, only a mask and gloves. Staff N entered the room, handled the resident’s gait belt and oxygen tubing, and stated they did not know why the sign was posted. Staff O and Staff P entered without hand hygiene or gowns and assisted the resident and roommate with transfers and toileting. Staff Q entered the room without gown or gloves, adjusted the resident’s wheelchair brakes, moved the bedside table, handled oxygen tubing, and placed the call light on the bed. Staff K entered the room without gown or gloves and performed a blood glucose fingerstick after obtaining supplies from the medication cart. The Infection Preventionist stated the contact precautions sign was dedicated for the room and staff should have followed the posted instructions. The facility also failed to maintain medical supplies in a manner to prevent healthcare-associated infections in a treatment supply room on Lilac Hallway. During inspection, expired sterile and non-sterile clinical supplies were found in the room, including four sterile 22 Fr urinary catheters, one sterile 18 Fr urinary catheter, two self-catheter kits, one 18-inch catheter extension tube expired in 09/2016, and ostomy pouch care supplies with expiration dates in 01/2021 and 10/2023. The expired items remained stored with current supplies in the treatment room at the time of review. The DON stated Central Supply Assistants were expected to check for expired items weekly, and that the current assistant was a new employee who was unaware of the task and needed additional training. The report also cited CDC guidance stating that use of an expired catheter constitutes a breach of aseptic technique because the manufacturer’s expiration date is the final date for which sterility and material integrity are guaranteed.
Resident medical information discussed in common areas
Penalty
Summary
The facility failed to maintain resident dignity and privacy for 2 of 3 residents reviewed for resident rights. Resident 32 had diagnoses including Parkinson's disease and dementia, and the comprehensive assessment showed the resident was cognitively intact and required substantial assistance with dressing, toileting, and transfers. During an observation, Resident 32 was sitting in the common area waiting for lunch with two visitors and two other residents at the table, while additional residents were seated nearby. A nurse practitioner approached the resident in the common area, placed a stethoscope on the resident's chest and back to listen to the lungs and heart, and discussed the resident's medications, medical care, and a body rash with possible causative factors in a way that could be overheard by visitors and other residents. Resident 58 had diagnoses including pancreatitis and dementia, and the care plan showed the resident required substantial assistance with dressing, toileting, and transfers. During an observation, an LPN stood at the medication cart across the room from Resident 58, who was seated in the common room with other residents. In a loud voice, the LPN told the resident, "I've got your MiraLAX, it should help." Six other residents and one visitor were present in the common area and could overhear the conversation about the resident's bowel medication. The DON stated that staff were expected to respect resident privacy and dignity and that medical care or discussions related to medical care should be done in a private area such as the resident room.
PASARR Screening Not Validated for Resident With Depression and Anxiety
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not reviewed and validated correctly for one resident. The resident was admitted with diagnoses including a fracture of the lower spine, long term pain, depression, and anxiety. The resident’s comprehensive assessment dated 01/16/2026 showed cognition was intact and the resident was able to make needs known. The facility’s Level I PASARR assessment, dated 01/12/2025, showed no SMI documented and indicated that a Level II PASARR referral was not required. During interview, the Social Service Director stated the facility received Level I PASARR assessments before admission and reviewed them for accuracy, but after reviewing this resident’s PASARR, stated the depression and anxiety diagnoses were not documented under the SMI section and that a Level II PASARR referral was required. The DON stated that all residents with SMI diagnoses required a PASARR Level II referral prior to admission, and the resident’s PASARR was not accurate or sent for a Level II referral before admission.
QAPI Program Did Not Include Department Data or Resident Feedback
Penalty
Summary
The facility failed to establish and implement an effective QAPI program that included information from all resident care departments and resident or resident representative feedback. The facility’s QAPI policy stated the program was intended to use a systematic, interdisciplinary, data-driven approach and to collect information from several areas, including trends, staff and resident input, critical incidents, and citations. However, the policy did not describe systems for obtaining resident or resident representative feedback, how that information would be used to identify high-risk or problem-prone areas, or how data from all departments would be identified, collected, and used. Record review of the QAPI meeting documents from December 2024 through January 2026 showed meetings were held in March 2025 and November 2025. The records showed discussion of current and completed PIPs and CMS facility resident reports, but they did not document data or information brought in from all departments, staff attending the meeting, resident or resident representative grievances or feedback, or how any of that information was used to identify problem areas or opportunities for improvement. The facility’s QAA-QAPI Plan also referenced CMS reports, rehospitalization reports, resident medical records, and formal grievances, but did not show how resident or resident representative input outside of formal grievances was included or how information from departments such as infection control, pharmacy, or nursing was used. Interviews with staff showed that department leaders attended QAPI meetings but generally did not bring in data from their departments. The Social Service Director stated that resident concerns were sometimes handled quickly without being documented as formal grievances and that no grievance information had been brought to QAPI because there had been no grievances since July 2025. The Therapy Director stated daily care meeting information, including some resident and family concerns, was not brought into QAPI unless it related to the PIP being reviewed. The Infection Preventionist stated infection control data, antibiotic trends, and surveillance information were not brought into QAPI. The DON and Administrator acknowledged that the facility was not following the correct QAPI process and that the meetings did not incorporate a thorough collection and analysis of resident data and information from all departments.
QAA Committee Failed to Meet Quarterly and Include Required Members
Penalty
Summary
The facility failed to ensure its Quality Assessment and Assurance (QAA) committee included the required members and met at least quarterly. Facility policy stated the QAA committee would collect and review data from areas such as staff and resident input and critical incidents, and that the committee would meet at least quarterly. Another facility policy stated the committee should include the Administrator, DNS, a physician, three other staff members, and the Infection Preventionist (IP). Record review showed quarterly QAA/QAPI meetings were documented only for 03/24/2025 and 11/03/2025 during the review period, leaving 2 of 4 quarters without documented meetings. The 03/24/2025 meeting included the Administrator, Medical Director, DNS, and at least three other staff members, but there was no documentation that the IP attended. During interviews, the DNS stated they coordinated the quarterly meetings, while the Administrator stated the DNS handled the meetings and documentation. The DNS later stated the facility was supposed to hold QAA/QAPI meetings quarterly with the Administrator, Medical Director, IP, other staff, and a governing body representative, but only two quarterly meeting sign-in sheets were available and no additional documentation could be produced. Both the DNS and Administrator acknowledged the committee meetings were not being conducted quarterly and did not include the required members.
Laundry Room Water Leak and Debris
Penalty
Summary
The laundry room was observed to have an unsafe and unsanitary condition involving washing machine number one. During the observation, a one-foot by one-half-foot puddle of water was found behind the machine on the concrete floor, with the water coming from a metal plate attached to the bottom of the machine and dripping from inside the washer. The bottom of the nearby drywall showed brown discoloration and cracking from prior water exposure, and the water was in contact with foam gap-filling material between the drywall and the concrete floor. The foam was wet to the touch, and water was seen seeping through it. The puddle contained black sludge resembling mold, and similar black material was also noted within the wet foam at the base of the wall. Washing machine number two had a one-foot by one-half-foot by three-inch-tall pile of rubbery black shavings underneath it, which staff identified as likely coming from a torn rubber belt used during operation. Staff stated they were unaware of the leak behind washing machine number one, acknowledged that the wall and foam were wet, and said the leak needed to be fixed and cleaned up. The administrator later reviewed photographic documentation and agreed that the water leak and possible broken washer belt needed to be fixed.
Failure to Inform Visually Impaired Resident of Care in Understandable Manner
Penalty
Summary
Facility staff failed to ensure that a resident with severe visual impairment was fully informed about their care and treatment in a manner they could understand. The resident, who had a left eye prosthetic and was legally blind in the right eye, was given a Notice of Medicare Non-Coverage (NOMNC) to sign. The NOMNC included important information about the termination of skilled nursing facility services and instructions for appeal, which required timely action. Despite the resident's blindness, staff did not adequately explain the paperwork or allow the resident to ask questions, as reported by the resident during an interview. The resident ultimately had to rely on a family member to communicate with staff about their lack of understanding regarding the NOMNC. Staff E from Social Services stated that they typically reviewed such paperwork with visually impaired residents and would involve a representative if requested. In this case, Staff E attempted to reach the resident's representative but was unsuccessful, after which the resident agreed to proceed without their representative. However, there was no documentation in the progress notes of any attempts to contact the representative on or before the date the NOMNC was served. This lack of appropriate communication and documentation resulted in the resident not being fully informed in a manner they could understand.
Failure to Ensure Timely Nursing Assessment After Resident Fall
Penalty
Summary
The facility failed to ensure that nursing assessments following a resident fall were conducted in accordance with professional standards and facility policy. Specifically, after a resident experienced a fall in their bathroom, a nursing assistant assisted the resident back into their wheelchair before a licensed nurse assessed the resident for injuries. The progress notes indicated that the resident had pain and swelling to their ankle and required ice and further diagnostics to determine the extent of the injury. According to facility policy, nursing staff are required to complete fall risk assessments and assess the level of injury before moving a resident after a fall. Interviews revealed that the assigned nurse was on a lunch break at the time of the fall, and although another nurse was available in a different hallway, the nursing assistant did not request their assistance and proceeded to move the resident. The Director of Nursing confirmed that the nursing assistant had been employed at the facility for four years and was aware of the policy requiring a nurse to assess a resident before they are moved after a fall. This lapse in following established protocols resulted in the resident being moved prior to a proper nursing assessment.
Inaccurate PBJ Staffing Data Submission Due to Outdated Census Information
Penalty
Summary
The facility failed to ensure that direct care staffing information submitted to the Centers for Medicare and Medicaid Services (CMS) for Quarter 3 of 2024 was accurate. Specifically, the Payroll Based Journal (PBJ) submission included staffing data that was reported at a level lower than required by mandated staffing levels. This occurred because resident census data, which was used to calculate staffing levels, was pulled from Minimum Data Set (MDS) assessments that were not current at the time of the PBJ submission. Staff responsible for payroll verified that the census data error was present during the initial submission, resulting in inaccurate staffing information being reported to CMS.
Violation of Resident Rights to Personal Property
Penalty
Summary
The facility failed to uphold residents' rights to retain personal property, including items of value, as a condition of admission. This deficiency was identified through interviews and record reviews for four residents. The facility's policy on resident rights, revised in February 2018, stated that residents have the right to keep and use their personal belongings as long as it does not interfere with others' rights, health, or safety. However, the admission agreements for Residents 23, 76, 184, and 185 included a clause that discouraged bringing valuables such as jewelry, money, and credit cards into the facility, which was signed by the residents or their representatives. Resident 23, who was cognitively intact, expressed that they were told not to bring money or personal items into the facility due to safety concerns, which led them to rely on their child for financial needs. Staff interviews revealed that while residents were allowed to bring personal items, valuables were inventoried and stored in a facility safe, which was not easily accessible after hours. Staff members, including the Social Service Director and Admission RNs, acknowledged that the admission agreement's wording appeared to restrict residents' rights to have personal possessions. Resident 184, also cognitively intact, had no items of value listed on their personal effect inventory sheet, and their spouse signed the agreement. Resident 185, with severe cognitive impairment, was unable to sign the agreement, yet it was electronically signed in their name. Resident 76, who was cognitively intact, had no personal effect inventory sheet found in their records. The Director of Nursing reviewed the admission agreement and acknowledged that the verbiage seemed to violate residents' rights to bring personal belongings into the facility.
Infection Control Deficiencies in Policy Review and Hand Hygiene
Penalty
Summary
The facility failed to review and update its infection prevention and control policies annually as required. Key policies, including those related to vaccinations, antibiotic stewardship, and COVID-19, had not been reviewed since their last revisions, some dating back several years. Interviews with staff, including the Charge Nurse, Infection Preventionist, and Director of Nursing, revealed uncertainty about the process and documentation for policy reviews, indicating a systemic issue in maintaining up-to-date infection control protocols. The facility also demonstrated significant lapses in hand hygiene practices. Observations showed staff failing to perform hand hygiene at critical times, such as before and after resident contact, after glove removal, and before administering medications. Specific instances included a Nursing Assistant not washing hands after handling soiled items and a Registered Nurse administering injections without gloves or hand hygiene. Interviews with staff confirmed a lack of understanding and adherence to hand hygiene protocols, which are essential for preventing the spread of infections. Additionally, the facility did not properly implement and discontinue transmission-based precautions for residents with specific needs. For example, Resident 135, who had a multidrug-resistant organism (MDRO) infection, was not consistently managed under contact precautions, as staff and visitors entered the room without appropriate personal protective equipment. Similarly, Resident 23 was unnecessarily placed under enhanced barrier precautions without a current medical justification. These failures in implementing appropriate precautions put residents, staff, and visitors at risk of infection transmission.
Inadequate Qualifications for Infection Preventionist Role
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist met the necessary qualifications for experience, education, training, and/or certification required for the role. This deficiency was identified during interviews and record reviews, where it was found that Staff C, who was appointed as the facility's Infection Preventionist, had not completed the specialized infection prevention and control training. Despite being in the role since March 2024, Staff C was still in the process of completing the required training as of October 2024. Interviews with various staff members, including the Administrator, Director of Nursing, and Admissions Registered Nurse, confirmed that Staff C was the sole infection prevention and control staff member at the facility. Staff C themselves acknowledged being new to the role and still learning. The lack of documentation proving the completion of the necessary training for Staff C was noted, and the Administrator expressed an expectation for the Infection Preventionist to have sufficient training to perform their duties effectively.
Delayed MDS Data Submission
Penalty
Summary
The facility failed to encode and transmit resident assessment data to the Centers for Medicare & Medicaid Services (CMS) within the required timeframe for seven sampled residents. This deficiency was identified through interviews and record reviews, which revealed that the Minimum Data Set (MDS) assessments for these residents were not completed and submitted within the mandated 7-day period following the assessment observation end date. The residents affected by this delay were discharged from the facility between August and September 2024, but their assessments were not completed until late October 2024. The report highlights specific cases where the MDS assessments were completed significantly later than required. For instance, Resident 6 was discharged on August 15, 2024, but the assessment was not completed until October 23, 2024. Similarly, Resident 7 was discharged on August 30, 2024, with the assessment completed on October 22, 2024. Other residents, including Residents 8, 25, 48, 50, and 53, also experienced similar delays in the completion and submission of their assessments, with some assessments not being completed as of late October 2024. Interviews with facility staff, including the MDS Coordinator and the Administrator, revealed that the MDS Coordinator struggled to manage the workload, leading to late submissions. The facility's MDS batch report and iQIES MDS validation report confirmed the late submissions, with multiple warning messages indicating that assessments were completed more than 14 days after the assessment reference date. The Administrator acknowledged the issue, stating that MDSs were expected to be completed within the required timeframes according to the RAI manual.
Failure to Provide Scheduled Bathing Services
Penalty
Summary
The facility failed to consistently provide scheduled bathing services for two residents, leading to deficiencies in personal hygiene care. Resident 28, who was cognitively intact and required substantial assistance for bathing due to conditions such as heart failure and malnutrition, was scheduled to receive showers twice a week. However, records indicated that Resident 28 only received 2 out of 7 scheduled showers over a three-week period, with numerous instances marked as 'N/A' due to staffing shortages. Interviews with Resident 28 and staff confirmed the missed showers and the lack of reattempts to provide the service. Similarly, Resident 234, who required assistance with transfers and valued regular showers, was also affected by the facility's failure to adhere to the bathing schedule. Despite being scheduled for showers twice weekly, Resident 234 only received 2 out of 5 scheduled showers, with no documentation of refusals or alternative bathing options offered. Interviews revealed that the facility did not staff a bathing aide for the evening shift, contributing to the missed showers. The Director of Nursing acknowledged the oversight and confirmed that Resident 234 should have received the scheduled showers.
Deficiency in Controlled Drug Reconciliation
Penalty
Summary
The facility failed to implement a detailed system for accurately reconciling all controlled drugs, including the emergency medication supply, in the Victorian Rose medication room. The facility's policy required controlled substances to be stored in double-locked compartments and inventoried by two licensed nurses at each shift change. However, during observations and interviews, it was found that the Ativan, a controlled substance, was stored in a clear removable box within the refrigerator, not in a permanently affixed compartment. Staff members, including RNs and the Director of Nursing, were unsure of the frequency of pharmacy checks and tracking of the Ativan, and they acknowledged that the current storage and tracking system did not allow for accurate reconciliation or detection of potential drug diversion. The report highlighted that the Ativan was part of the facility's emergency medication supply and was supposed to be tracked in the electronic medication dispensing machine. However, staff were unable to verify the Ativan count or balance due to lack of access to the machine. The Director of Nursing and the pharmacist admitted that the current system allowed staff to access both insulin and Ativan without proper tracking, increasing the risk of drug diversion. Documentation provided by the facility, including activity transaction reports and inventory replenishment reports, lacked sufficient detail to accurately reconcile the emergency Ativan supply, further indicating a deficiency in the facility's medication management system.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food safety in their kitchen, as observed during a survey. Staff members did not check the temperatures of food items before serving them, which is a critical step in ensuring food safety. During a tray line service, dietary staff were observed serving meals without verifying the temperatures of hot and cold food items. When prompted by the surveyor, staff members were unsure of the required temperature ranges and had to seek assistance from another staff member. The temperatures of several food items, including salads and fruit cups, were found to be above the safe temperature threshold for cold foods, which should be kept at or below 41 degrees Fahrenheit. Additionally, the facility's kitchen temperature logs were incomplete, lacking documentation of temperature checks before tray line service or mid-service. This lack of documentation indicates a failure to consistently monitor food temperatures throughout the meal service process. The Registered Dietician and Dietary Services Director confirmed that food temperatures should be checked at multiple points during meal preparation and service to ensure safety and palatability. However, the logs only showed final cooking and holding temperatures, with no records of checks during the tray line or mid-service. The facility also failed to properly store food items in the kitchen. During observations, a pan of cooked bacon was found uncovered and undated in the walk-in refrigerator, and several expired food items were discovered in the walk-in freezer. These included a package of frozen shrimp and resealable bags of chicken wings, chicken strips, and potato wedges, all past their expiration dates. The Dietary Services Director acknowledged that these items should have been discarded according to food safety regulations.
Deficiency in Vaccination Education and Documentation
Penalty
Summary
The facility failed to provide routine education on the benefits and potential side effects of vaccinations, offer pneumococcal and influenza vaccinations when indicated, and document these actions in the residents' medical records. This deficiency was identified in three out of five sampled residents. The facility's policies, revised in 2012 and 2014, required that all residents be offered vaccinations and provided with pertinent information, with documentation of education and any refusals in the residents' medical records. However, the review of records for Residents 4, 52, and 78 showed a lack of documentation regarding education, offers, or administration of the influenza vaccine for the 2024-2025 flu season, and a lack of documentation of education for the pneumococcal vaccine for Resident 4. Resident 4, who was cognitively intact and had a diagnosis of respiratory failure, was not documented as having been educated or offered the influenza vaccine for the 2024-2025 flu season, despite having refused the pneumococcal vaccine. Resident 78, also cognitively intact, had received the influenza vaccine outside the facility but had no documentation of education or offer for the current flu season. Resident 52's records similarly lacked documentation of education or offer of the influenza vaccine. Interviews with facility staff confirmed the absence of documentation regarding education on the risks and benefits of vaccinations when offered or refused, which was contrary to the facility's stated policies.
Deficiency in Nursing Assistant Training Documentation
Penalty
Summary
The facility failed to provide documented evidence of the required annual 12-hours of in-service training for nursing assistants, which included dementia training and abuse prevention. This deficiency was identified for five nursing assistants reviewed for continuing education, with two of them lacking documentation for abuse prevention training. The facility's assessment tool and employee handbook both stipulated the necessity of these trainings, yet the facility did not maintain adequate records to verify compliance. During interviews, the Director of Nursing admitted that while they attempted to provide individual training for those who missed mandatory sessions, these efforts were not documented. The Skills Fair itinerary reviewed did not include dementia management as a topic, and the attendance sheet showed that only eight out of nineteen nursing assistants attended the mandatory event. Staff B, the Director of Nursing, acknowledged the lack of verification for the required 12 hours of continuing education for nursing assistants. Despite efforts to remind staff of mandatory trainings through various communication methods, the facility could not ensure that all nursing assistants received the necessary training, placing residents at risk of being cared for by inadequately trained staff.
Failure to Assess Resident for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that Resident 23 was evaluated and assessed by the interdisciplinary team (IDT) for the safe self-administration of medications, as required by the facility's policy. The policy mandates that residents who wish to self-administer medications must be assessed for cognitive, physical, and visual abilities, and a provider's order must be obtained. However, there was no documentation indicating that Resident 23 underwent such an evaluation or that a provider's order was obtained. Despite being cognitively intact and having no impairments that would prevent self-administration, Resident 23's records lacked any assessment or care plan related to self-administration of medications. During an observation, Resident 23 was found with a cup containing nine pills on their bedside table, which they stated were left by staff for them to take slowly with yogurt. This practice was not in line with the facility's policy, as medications should not be left at the bedside without a proper assessment and provider order. Interviews with staff, including a Nursing Assistant, a Registered Nurse, the Director of Nursing, and the Administrator, revealed a lack of awareness and adherence to the facility's process for self-administration of medications. Staff acknowledged that medications should not be left unattended at the bedside without following the appropriate procedures, highlighting a gap in compliance with the facility's policy and potential safety issues for residents.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, as evidenced by two medication errors identified during 26 medication administration opportunities, resulting in an error rate of 7.69%. This deficiency was observed during the administration of medications to a resident who was admitted with diagnoses including Gastroesophageal Reflux Disease (GERD) and Irritable Bowel Syndrome (IBS). The resident was alert and capable of communicating their needs. On the morning of the observation, a registered nurse, Staff N, administered Metoclopramide and Pantoprazole to the resident after they had already eaten breakfast, despite the medications being scheduled for administration before meals. The resident's Medication Administration Record (MAR) indicated that Pantoprazole should be taken on an empty stomach, and Metoclopramide was to be given before meals. Staff N acknowledged the error, admitting the medications were given late. The Director of Nursing, Staff B, confirmed that these late administrations constituted medication errors.
Dietician Lacks State Licensure
Penalty
Summary
The facility failed to employ a dietician with the necessary licensure and certification to practice as a Registered Dietician in Washington State, as required by state regulations. This deficiency was identified during a review of the facility's staff credentials, which revealed that the Corporate Dietician, referred to as Staff U, did not possess a Washington State license or certification. Although Staff U was registered nationally with the Commission on Dietetics Registration, they acknowledged during an interview that they lacked the state-specific credentials needed to practice in Washington. The facility's policy on professional licenses mandates that all professional licenses be tracked using an online human resources management system, and employees with lapsed licenses are to be removed from the schedule until the issue is resolved. Despite this policy, the facility did not provide documentation of Staff U's Washington State Dietician licensure when requested by the State Survey Agency. This oversight placed all residents at risk for unmet nutritional needs and diminished quality of life, as the dietician responsible for their care was not properly credentialed according to state requirements.
Inadequate Antibiotic Stewardship Leads to Inappropriate Prescriptions
Penalty
Summary
The facility failed to implement antibiotic protocols effectively, leading to inappropriate antibiotic prescription for a resident. The facility's policy on antibiotic stewardship, revised in July 2016, required that all clinical infections treated with antibiotics undergo review by the infection preventionist or designee within 48 hours of antibiotic initiation to determine if continued therapy was justified. However, this protocol was not followed for a resident who was prescribed antibiotics for a urinary tract infection (UTI) without exhibiting any signs or symptoms of a UTI, as per the McGeer Criteria. The resident, who was cognitively intact and able to communicate their needs, was admitted to the facility with a surgical incision and an abdominal drain. Despite the absence of urinary symptoms, the resident was started on antibiotics for UTI prevention, and the facility's antibiotic stewardship surveillance spreadsheet marked the McGeer criteria as not applicable. Subsequent urine culture results did not meet the McGeer Criteria for a positive UTI diagnosis, as they showed less than 10,000 colony-forming units of mixed urogenital flora, which is insufficient to justify antibiotic use according to the criteria. Interviews with facility staff revealed a lack of adherence to the established antibiotic stewardship protocols. The charge nurse stated that the decision to prescribe antibiotics was left to the provider, and they did not review antibiotics to ensure they met the criteria for appropriate usage. The infection preventionist and director of nursing acknowledged that the provider did not always follow the McGeer criteria, and there was no documentation to show that the criteria were considered when prescribing antibiotics. This oversight placed residents at risk of developing multi-drug-resistant organisms and experiencing adverse side effects.
Failure to Address Oxygen Tubing Hazard in Resident's Care Plan
Penalty
Summary
The facility failed to develop an individualized care plan for a resident with unique environmental fall risk concerns. The resident, who had a history of falls and wore oxygen, was at risk for tripping over their lengthy oxygen tubing. This risk was not identified or included in their fall prevention care plan, despite the facility's protocol requiring hazard identification and individualized interventions to reduce fall risk. The resident had a history of falls and was cognitively intact but forgetful at times. They required partial/moderate assistance for transfers and wore oxygen due to chronic obstructive pulmonary disease (COPD). On one occasion, the resident experienced an unwitnessed fall while attempting to transfer from their wheelchair to their bed without assistance, resulting in a fractured left hip and elbow. The fall investigation noted that the resident's oxygen tubing was a potential environmental tripping hazard, but this was not addressed in the care plan. Staff interviews revealed that the resident frequently self-transferred without using their call light and had poor safety awareness. Staff had observed the resident getting tangled in their oxygen tubing on multiple occasions. Despite these observations, the care plan was not updated to include interventions related to the oxygen tubing hazard, and the Director of Nursing was unaware of the tubing being a potential contributor to the resident's fall.
Failure to Implement Oxygen Orders During Resident Transport
Penalty
Summary
The facility failed to implement the prescribed oxygen orders for a resident during transportation from the hospital to the facility, leading to a health deficiency. The resident, who had a history of COPD and atrial fibrillation, was transported without oxygen despite hospital discharge instructions indicating the need for continuous oxygen at 2 liters via nasal cannula. Upon arrival at the facility, the resident experienced low blood pressure and chest pain, necessitating a return to the emergency department for evaluation. Interviews and record reviews revealed that the facility's transportation staff did not apply oxygen to the resident during the transfer. The staff relied on hospital personnel to attach the oxygen to the facility's portable tank, but in this instance, the resident was not wearing oxygen when picked up. The transportation staff assumed the resident was stable for transport without oxygen, as they were not permitted to apply it themselves. The admission nurse, responsible for reviewing hospital records, acknowledged difficulties in determining oxygen needs from discharge instructions, which contributed to the oversight. The facility lacked a specific policy for transporting residents from the hospital, which may have contributed to the miscommunication and oversight. The Director of Nursing and other staff members recognized the need for complete discharge orders and better coordination with the hospital to ensure residents' needs are met during transport. The deficiency was identified as a failure to provide appropriate treatment and care according to orders, resident preferences, and goals, as required by regulations.
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 285 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 | 0.6 mi | ★★★★★ | 48 | 0 |
| Sullivan Park Care Center | 2.8 mi | ★★★★★ | 0 | 0 |
| Alderwood Manor | 4.2 mi | ★★★★★ | 24 | 0 |
| Touchmark On South Hill Nursing | 5.3 mi | — | 0 | 0 |
| Spokane Valley Health And Rehabilitation Of Cascad | 5.6 mi | ★★★★★ | 26 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Sunshine Health & Rehab.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.