Below average — CMS composite of the measures below.
A standard survey is most likely before around November 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 The Terraces At Skyline during CMS and state inspections, most recent first.
A resident recovering from a right clavicle fracture fell during bathing when a CNA used a shower chair that was not securely latched. The resident said she told the aide the chair felt wobbly and unstable, but the bath continued and the chair collapsed under her. The DON acknowledged the event was avoidable. After the fall, the resident had increased shoulder pain, needed oxycodone more often, and reported that the incident delayed her rehab progress for several days.
Grievance Policy Lacked Designated Grievance Official: The facility’s grievance policy did not identify a Grievance Official or include contact information, and posted grievance forms on the 7th and 8th floors also lacked that information. Residents interviewed could not identify the current grievance official, while the Administrator stated the Social Services Director held that role even though the policy did not reflect it.
RN coverage was not provided for the required eight consecutive hours on one reviewed day. The daily clinical staff posting showed no RN coverage, and the Staffing Coordinator confirmed there was no RN coverage even though RN coverage was expected. The Administrator also stated that at least eight consecutive hours of RN coverage should have been in place.
The facility failed to document use of Loeb Minimum Criteria to determine whether residents' signs and symptoms met the minimum criteria before antibiotics were started as part of its antibiotic stewardship program. Review of the Infection Control Log showed no documentation for multiple months, and the DON stated the facility had not been using the criteria to check whether antibiotic use was indicated.
Respiratory equipment was not properly labeled, dated, or stored for 3 residents. One resident with parainfluenza, acute/chronic respiratory failure with hypoxia, and CPAP/oxygen orders had an unlabeled nasal cannula and CPAP nose piece left out in the room. Another resident with pneumonia had unlabeled nebulizer equipment in the room without an order, and a third resident with OSA and viral pneumonia had uncovered, unlabeled nebulizer parts and CPAP equipment left on room surfaces instead of being stored in a clean bag.
An expired multi-dose tuberculin vial was found in the 8th Floor med room refrigerator during an observation with an RN. The vial had been opened beyond the 30-day discard timeframe, and the RN stated it should have been discarded. The DON said staff used a pharmacy sheet for expiration dates and were expected to identify and dispose of expired meds properly.
Infection control deficiencies were identified in the facility’s water management program, outbreak reporting, and PPE use. The water management plan lacked a detailed written description of the water system and did not include the IP or MD on the water management team. Four residents with respiratory illness/parainfluenza were placed on droplet precautions, but staff did not recognize or report the cluster as an outbreak to the health department. Staff also failed to wear required gowns for EBP during transfers and catheter care for one resident, and failed to use eye protection that fully covered the eyes for a resident on droplet precautions.
Advance Directive Not Obtained or Filed: The facility failed to obtain and file a copy of a resident's advance directive in the EHR. The resident stated they had a copy at home, but there was no documentation that the AD was requested, offered, or obtained during admission. The SW and DON both confirmed the record lacked the required AD documentation.
Missing Documentation of Non-Pharmacological Interventions for Antidepressant Use: A resident receiving an antidepressant for depression had no documented non-pharmacological interventions in the physician orders, care plan, or MAR. During record review and staff interviews, the RN, RCM, and DON stated the resident was not on the mental health services list, a mental health consult was not indicated, and the DON expected staff to chart non-pharmacological interventions related to antidepressant use in the MAR.
Failure to complete an SCSA MDS for a resident with a significant decline in condition. The resident had major weight loss and new functional limitation in ROM to both upper extremities, and the quarterly MDS reflected both changes. The MDS Coordinator and DON stated the resident met criteria for a significant change and should have had an SCSA completed.
The facility failed to accurately complete a resident’s MDS discharge assessment. The MDS marked the discharge as unplanned even though the care conference note showed the resident had a planned discharge to the community with transport and outside services already coordinated and scheduled. The MDS Coordinator acknowledged the MDS was inaccurate, and the DON stated the MDS was expected to be completed accurately.
Missing Discharge Care Plan: A resident had no discharge care plan documented in the comprehensive care plan. The resident said staff had not discussed the return to the ALF and seemed unsure of the discharge plan. The SW and DON both confirmed that discharge planning should have been completed during admission, but it was not.
Failure to provide consistent ADL assistance for a resident who needed extensive help with personal hygiene and 1:1 feeding. The resident had dx including pneumonitis from aspiration, dysphagia, and RA. Staff observed the resident with unkempt hair and later acknowledged grooming was not offered before the resident left the room. At lunch, a CNA left a beverage within reach and the resident drank without the required 1:1 feeding assistance, despite POC instructions for supervision and 1:1 support.
Therapeutic diet not followed and representative not educated: A resident with dysphagia and aspiration history was ordered a minced and moist diet with mildly thick liquids, but staff left thin liquids at bedside and provided crackers and other noncompliant foods, including Ritz crackers, Triscuits, and Cheetos. Staff and the resident’s representative acknowledged the diet restrictions, but the DON and RCM confirmed there was no documented risks-and-benefits education for the representative regarding not following the prescribed texture diet.
Disinfectants were found stored on a resident room bathroom sink counter with personal hygiene items, including a Lysol spray canister and Clorox wipes. Staff interviews stated that cleaning chemicals were supposed to be kept with housekeeping in a locked cart and not in resident rooms, but the items remained accessible in the room during observations.
A resident’s MRR recommendation to separate gabapentin and magnesium administration times was not implemented for 45 days. The DON stated the pharmacist sent monthly MRRs to the facility, RCMs forwarded recommendations to the provider, and after provider completion the RCMs carried them out, but the resident’s MARs showed the change was not made until much later than expected.
Missing COVID-19 Vaccine Education and Documentation: The facility failed to document COVID-19 vaccine education, including risks and benefits, and failed to record whether a CNA accepted or refused the vaccine booster. The CNA stated they refused the booster and had been informed of the risks and benefits, but the DON, Staffing Coordinator, and Administrator could not produce documentation in the employee record.
Two residents had loose, wobbly bed rails that were not tightly secured to the bed frame. One resident used bilateral grab bars/enablers for turning and repositioning in bed, and staff observed the right rail was more loose than the left. An LPN, the DFM, and the ADM all acknowledged the rails should have been secured, and one resident stated the wobbly rail worried them because it was used all the time.
A resident's unexpected death was not promptly investigated or reported according to facility policy and state guidelines. The incident was not logged on the facility's incident reporting log until 19 days after the event, and staff confirmed that both the investigation and reporting were delayed.
The facility did not submit the required direct care staffing information to CMS for the fourth quarter of 2023 on time. Despite the facility's policy requiring timely electronic submission of staffing data, Staff J was unsure if the data was submitted, and Staff A confirmed it was not. This resulted in CMS having inaccurate staffing data, potentially affecting resident care.
The facility failed to ensure a homelike dining environment by allowing LPNs to administer medications during meals in the dining room, affecting six residents. Staff admitted that medications should be given in residents' rooms, and care plans did not include dining room administration. This oversight risked diminishing residents' quality of life.
The facility failed to provide the required RN coverage for six days, as revealed by interviews and record reviews. Despite having a policy mandating sufficient staffing and a minimum of 0.55 hours of RN care per resident per day, the facility's records showed a lack of eight-hour RN coverage on specific dates. The Staffing Coordinator could not explain the lapse, and the Administrator confirmed the requirement for RN coverage, acknowledging the facility's failure to meet this expectation.
The facility failed to properly label and store medications and supplies in two medication rooms, risking compromised effectiveness. On the Seventh Floor, a tuberculin vial was expired by three days. On the Eighth Floor, expired amoxicillin and catheters were found. Staff acknowledged these items should have been discarded.
The facility failed to discard expired food items and maintain a working thermometer in the Kitchen Walk-In Refrigerator, as observed during a survey. Expired Impossible Burger patties and raw pork chops were found, and two broken thermometers were identified, preventing accurate temperature monitoring. Staff acknowledged these issues, which contravened the facility's food safety policies.
A facility failed to ensure proper hand hygiene during meal tray distribution and medication administration. A CNA did not perform hand hygiene when entering and exiting resident rooms, including those requiring Enhanced Barrier Precautions. An LPN improperly handled medications by pouring them into gloved hands and taking medication bubble cards into resident rooms, contrary to facility policy. These actions increased the risk of infection for residents, visitors, and staff.
A resident was administered an antidepressant medication without obtaining informed consent beforehand, contrary to the facility's policy. The medication was prescribed and administered in March, but consent was not signed until late May. This was confirmed by the Resident Care Manager and the Corporate Director of Health Services, who both acknowledged the lapse in procedure.
The facility failed to assess and document self-medication administration for two residents. One resident self-administered enoxaparin injections without an assessment or physician order, while another resident self-administered multiple medications without proper documentation or orders. The facility did not follow its policy requiring assessments, orders, and care plan updates for self-medication.
A facility failed to provide a written transfer notice to a resident and their representative, as required by policy. The resident was transferred to a hospital, but the facility only notified the family by phone, contrary to the policy that mandates written notification. Staff interviews confirmed this practice, which did not align with the expectations of the Corporate Director of Health Services.
A resident was transferred to the hospital without being provided a bed hold notice, as required by the facility's policy. Staff interviews confirmed the oversight, and the Corporate Director of Health Services expected the notice to be given.
A resident admitted to hospice care experienced a delay in the completion of a Significant Change in Status Assessment (SCSA) MDS, which was completed four days late. This delay was acknowledged by the MDS Coordinator and the Corporate Director of Health Services, indicating a failure to adhere to the required 14-day timeline for assessments.
A facility failed to maintain consistent communication with hospice care for a resident, resulting in outdated hospice notes from December 2023 being the most recent available. Staff interviews revealed that hospice visit notes were not readily accessible, and there was a lack of coordination in care for the resident's left heel wound. This deficiency highlighted a failure in ensuring resident-centered care and treatment according to professional standards.
A resident's pressure ulcer was not properly assessed or documented, leading to a deficiency in care. The resident's left heel showed discoloration and later developed into a blister, which was treated as a pressure injury without proper staging. Staff interviews revealed a lack of documentation and clarity regarding the ulcer's stage, contrary to facility policy. This oversight placed the resident at risk for further deterioration.
Two residents with respiratory conditions were found with improperly labeled and stored oxygen supplies, including undated nasal cannulas and humidifier bottles. Staff interviews revealed a lack of physician orders and adherence to facility policy on oxygen administration, leading to a deficiency in respiratory care.
Unlatched Shower Chair During Bathing Led to Resident Fall
Penalty
Summary
The facility failed to ensure that a shower chair was securely latched during bathing assistance for one resident who had been admitted for rehabilitation after a right clavicle fracture and was documented as cognitively intact. Facility policies stated that bathing equipment must be safe and secure, that hazards must be identified and mitigated, and that staff must use equipment in safe working order. During the incident, the resident was being assisted with bathing by a CNA when the seat of the shower chair was not properly latched and the resident fell into the well of the chair. The resident stated that she told the aide the chair felt unstable, wobbly, and like it kept moving, but the aide continued the bath process. The resident reported that the chair collapsed under her and that she was left in severe pain. The DON later acknowledged that the staff member could have checked the chair after hearing the resident report that it felt unstable and stated that the event was an avoidable accident. The resident also reported emotional distress from being seen naked by other staff during the incident. After the fall, the resident experienced increased pain in her right shoulder and required stronger pain medication. A pain assessment showed pain almost constantly over the prior five days, interference with sleep and daily activities, and severe pain on the verbal descriptor scale. The medical provider documented that since the fall the resident had been using oxycodone routinely, whereas before the fall she had weaned herself down to Tylenol. The resident and staff both stated that the fall set back her recovery for several days.
Grievance Policy Lacked Designated Grievance Official
Penalty
Summary
The facility failed to establish a grievance policy that designated a Grievance Official to oversee the grievance process for the Seventh and Eighth Floors. Review of the facility’s policy titled, Grievances, revised on 01/01/2025, stated that residents may approach staff with complaints or recommendations, that the social worker would meet with residents as needed, and that unresolved grievances could be referred to the Administrator. However, the policy did not identify a Grievance Official or include contact information for that role. Review of grievance forms posted next to the elevators on the seventh and eighth floors showed no documentation identifying the Grievance Official or providing contact information. During a group interview, Residents 31, 16, and 23 stated that the previous Administrator had responded to resident and family group concerns, but they could not identify the current grievance official. In an interview and joint record review, the Administrator stated that the Social Services Director was the facility’s Grievance Official, while also acknowledging that the facility’s policy did not reflect that designation.
RN Coverage Not Provided for Required Hours
Penalty
Summary
The facility failed to provide the required RN coverage for 1 of 30 days reviewed for staffing, specifically on 08/03/2025, when the Daily Clinical Staff Posting did not show documentation of RN coverage for at least eight consecutive hours. During an interview and joint record review on 08/07/2025, the Staffing Coordinator stated they were responsible for the daily clinical staff posting and said they would schedule 16 hours of RN coverage a day, but the clinical staff posting for 08/03/2025 showed no RN coverage. The Staffing Coordinator further stated there was no RN coverage on that date and that there should have been. In a separate interview, the Administrator stated there should be at least eight consecutive hours a day of RN coverage and expected that level of coverage on 08/03/2025.
Failure to Use Loeb Criteria for Antibiotic Initiation
Penalty
Summary
The facility failed to ensure that infections related to the initiation of antibiotics were based on CDC-approved criteria for 6 of 6 months reviewed, covering February 2025 through July 2025, for the antibiotic stewardship program. The facility policy titled, Antibiotic Stewardship Program, revised on 01/22/2024, stated that the program was intended to optimize treatment of infections while reducing adverse events associated with antibiotic use, and that Loeb Minimum Criteria would be used to determine whether to treat an infection with antibiotics. Review of the Infection Control Log for February 2025 through July 2025 did not show documentation that Loeb's criteria were used to determine whether residents' signs and symptoms met the minimum criteria before antibiotics were prescribed. During a joint record review and interview on 08/07/2025 at 4:52 PM, Staff B, DON, stated that the infection control log did not have documentation showing that residents' signs and symptoms met the minimum criteria for antibiotic use, and stated that the facility had not been using the Loeb Minimum Criteria to check whether the criteria were met before antibiotic use.
Respiratory Equipment Not Properly Labeled or Stored
Penalty
Summary
The facility failed to ensure proper storage, dating, and labeling of respiratory equipment for 3 residents who had orders for oxygen, CPAP, and/or nebulizer treatment. The facility policy titled "Oxygen Administration" stated that oxygen nasal cannulas or masks should have the date written on a label attached to the tubing and that oxygen tubing should be changed every week with a new cannula or mask. Resident 1 had diagnoses including parainfluenza and acute and chronic respiratory failure with hypoxia, and had orders for oxygen as needed and CPAP at night. Observations showed the oxygen nasal cannula was not labeled or dated and was lying on the resident's recliner, while the CPAP tubing nose piece was lying on the nightstand and not properly stored. Resident 2 had a diagnosis including pneumonia, and although no nebulizer order was found in the record, a nebulizer machine with respiratory equipment was observed attached and placed on the bedside drawer, unlabeled and undated. Resident 3 had diagnoses including obstructive sleep apnea and human parainfluenza virus pneumonia, with orders for CPAP at bedtime and nebulizer treatment three times a day for dyspnea. Observations showed nebulizer parts, including a mouthpiece, uncovered and placed on a paper towel on top of cardboard boxes near the bedside, and the CPAP nose piece was uncovered and placed on top of the bedside drawer; staff stated the equipment should be labeled and/or stored in a clean bag.
Expired Tuberculin Vial Kept in Medication Refrigerator
Penalty
Summary
The facility failed to dispose of an expired multi-dose vial of tuberculin in the 8th Floor Medication Room Refrigerator in accordance with accepted medication storage and labeling practices. During a joint observation and interview, Staff M, RN, identified one tuberculin vial in the refrigerator with an open date that was two days past the 30-day discard timeframe for opened multi-dose vials. Staff M stated that tuberculin is good for 30 days from the date it is opened and acknowledged that the vial should have been discarded. The facility policy on medication labeling stated that nursing staff would ensure resident medications were appropriately labeled according to pharmacy recommendation, and that multi-dose vials that have been opened or accessed would be dated and discarded within 30 days unless the manufacturer specified a different timeframe. In an interview, the DON stated that staff referred to a pharmacy sheet for medication expiration dates and that it was the expectation for staff to identify and properly dispose of expired medication.
Infection Control Program Deficiencies
Penalty
Summary
The facility failed to maintain its infection prevention and control program in several areas. Review of the water management program showed that the document did not include a detailed written description of the facility’s water system, and the water management team did not include the infection preventionist or the medical director. Staff stated that the schematic diagram was being used as the water system description, and the infection preventionist stated they were not part of the water management team, while the administrator acknowledged that the plan should have included a detailed description and the infection preventionist and medical director should have been part of the team. The facility also failed to report an outbreak involving four residents. Residents 6, 3, 1, and 22 were placed on droplet precautions after developing respiratory symptoms and/or being diagnosed with parainfluenza or possible human parainfluenza virus. The facility’s policy defined an outbreak as two or more residents or staff with similar symptoms and required notification to the local/state health department. Staff stated they did not know whether the respiratory symptoms for these residents constituted an outbreak, and the Director of Nursing stated the respiratory symptoms were not reported to the state or local health department. The facility further failed to ensure proper PPE use for residents on transmission-based precautions. For a resident on enhanced barrier precautions for PEG tube and Foley catheter care, two CNAs entered the room and performed a Hoyer lift transfer and emptied the urinary catheter bag without wearing gowns, even though the posted signage directed staff to wear gowns and gloves for high-contact care activities including transferring and catheter care. For another resident on droplet precautions for human parainfluenza virus pneumonia, staff were observed entering the room without eye protection that fully covered the eyes, and one staff member wore eyeglasses with eye protection that did not fully cover the sides of the eyes. Staff also stated that face shields were not available on the PPE cart, although the cart was expected to be stocked with PPE for staff use.
Advance Directive Not Obtained or Filed
Penalty
Summary
The facility failed to ensure that a copy of the advance directive was obtained and placed in the record for Resident 11, who had an advance directive. The facility policy titled, Advanced Directives, revised on 01/01/2025, stated that residents would be given information about advance directives during the initial assessment and that the most recent advance directive would be kept in the resident's record. Review of Resident 11's face sheet showed admission to the facility on [DATE]. Review of the resident's EHR miscellaneous tab printed on 08/05/2025 showed no copy of an advance directive and no documentation that the resident was asked to provide one or offered assistance in completing one. During interview on 08/05/2025, Resident 11 stated they had a copy of their advance directive at home and could not remember whether the facility asked for it. The Social Worker stated there was no documentation in the EHR that an advance directive was requested, offered, or obtained, and said a copy should have been requested during admission. The DON stated social services staff were responsible for requesting a copy during admission or offering to help formulate one, and that if one existed, a copy should have been in the EHR. A joint record review showed no copy or documentation of an advance directive for Resident 11.
Missing Documentation of Non-Pharmacological Interventions for Antidepressant Use
Penalty
Summary
The facility failed to ensure non-pharmacological interventions were in place for a resident receiving an antidepressant for depression. Resident 3 had a physician order for an antidepressant that began on 07/24/2025, but review of the resident’s physician orders, care plan, and August 2025 MAR did not show documentation of non-pharmacological interventions associated with the medication’s use. During interviews and joint record reviews on 08/07/2025, Staff M, RN, stated Resident 3 was not included in the list of residents receiving mental health services. Staff D, Resident Care Manager, stated a mental health consultation was not indicated for Resident 3 and was unsure whether non-pharmacological interventions associated with antidepressant use were expected to be identified and documented. Staff B, DON, stated the interdisciplinary team discussed and identified non-pharmacological interventions for residents receiving medications such as antidepressants, but the August 2025 MAR for Resident 3 did not show documentation of those interventions.
Failure to Complete Significant Change Assessment After Major Decline
Penalty
Summary
The facility failed to ensure a Significant Change in Status Assessment (SCSA) MDS was completed for one resident after a significant change in condition was identified. Review of the RAI Manual showed that an SCSA is required when the interdisciplinary team determines a resident has a significant change involving a major decline or improvement that affects more than one area of health status and requires interdisciplinary review and/or care plan revision. The resident’s admission MDS showed no weight loss and no functional limitation in range of motion to the upper extremities. A later quarterly MDS showed significant weight loss and functional limitation in range of motion to both upper extremities. A weights and vitals summary showed the resident weighed 160 pounds on 04/14/2025 and 129.4 pounds on 07/14/2024, reflecting a 19% weight loss in three months. An OTA stated the resident had limited ability to raise or bring up both arms. The MDS Coordinator stated the resident’s significant weight loss and limited range of motion met two areas of decline and that an SCSA should have been completed, and the DON stated an SCSA should have been completed related to the resident’s significant weight loss and decline in range of motion.
Inaccurate MDS Discharge Assessment
Penalty
Summary
The facility failed to accurately assess 1 of 15 residents reviewed, Resident 28, on the Minimum Data Set (MDS) related to discharge status. The discharge MDS dated [DATE] showed the resident was discharged from the facility on 06/07/2025, and Section A0310G (Type of Discharge) was marked as an unplanned discharge. A review of Resident 28’s care conference note dated 06/06/2025 showed the discharge was planned for the resident to go to the community (home) on 06/07/2025, with transport and care services outside the facility coordinated and scheduled. During an interview and joint record review on 08/07/2025, the MDS Coordinator stated the resident had a planned discharge to the community and that the MDS was inaccurate, and that the discharge type should have been marked as planned. The DON stated that the MDS was expected to be completed accurately.
Missing Discharge Care Plan
Penalty
Summary
The facility failed to develop and/or implement a discharge care plan for Resident 15. The facility policy titled, Policy and Procedure - Resident Comprehensive Assessment and Care Plan, dated 10/25/2017, stated that the care plan is person centered, involves the interdisciplinary team, identifies all resident needs according to the comprehensive assessment, documents care plan decisions, and is completed within seven days of completion of the comprehensive assessment. A face sheet printed on 08/07/2025 showed Resident 15 was admitted to the facility on [DATE]. A comprehensive care plan printed on 08/04/2025 showed Resident 15 had no care plan for discharge planning. During an interview on 08/07/2025 at 12:26 PM, Resident 15 stated they were feeling frustrated and did not understand why no one had discussed their return to the assisted living facility. Resident 15 stated they had spoken with several staff, could not recall their names, and they did not appear to know what the plan was regarding discharge. Staff C, Social Worker, stated during an interview and record review on 08/05/2025 at 2:58 PM that discharge planning was initiated during admission to ensure a smooth and safe transition back to home or another care setting after therapy, and that Resident 15 should have had a discharge plan completed during admission. Staff B, DON, also confirmed during a joint record review and interview on 08/07/2025 at 11:30 AM that Resident 15 did not have a discharge care plan and that it was the expectation that discharge care planning would be completed during admission.
Failure to Provide Consistent ADL Assistance
Penalty
Summary
The facility failed to ensure Activities of Daily Living assistance was consistently provided for a resident who required extensive help with personal hygiene and 1:1 feeding assistance. The resident was readmitted with diagnoses including pneumonitis due to inhalation of food and vomit, dysphagia, and rheumatoid arthritis. The care plan showed the resident needed extensive assistance from one to two staff for personal hygiene, and the facility policy stated ADL assistance was intended to help residents achieve maximum function and improve quality of life. During observation, the resident was seen with hair worn down and unkempt while seated in a wheelchair outside the room, and staff later acknowledged the resident’s hair had not been brushed and should have been brushed before leaving the room. Staff also stated they did not offer the resident the opportunity to brush the hair before assisting the resident out of the room. For nourishment, the resident had an order for 1:1 feeding related to aspiration precautions, but during lunch a CNA placed a beverage within easy reach and left to attend to other residents, and the resident drank independently without 1:1 assistance. Record review and staff interviews showed the point-of-care instructions listed both supervision for all meals and 1:1 feeding assistance, and staff stated the care plan needed to be updated to reflect the resident’s needs.
Therapeutic Diet Not Followed and Representative Not Educated
Penalty
Summary
The facility failed to follow Resident 2’s prescribed therapeutic diet and failed to provide education to the resident’s representative regarding the risks of not following that diet. Resident 2 was readmitted with diagnoses including pneumonitis due to aspiration of food and vomit and dysphagia. A physician order dated 07/25/2025 prescribed a minced and moist diet with mildly thick liquids. On 08/05/2025, speech therapy documented that thin liquids were at the bedside and that nursing and CNA staff were educated on the resident’s thickened liquid precautions. Observations showed Resident 2 had three non-thickened drinks within reach at the bedside and had Triscuit crackers and a can of Cheetos stored on room furniture. During a meal observation, a CNA gave Resident 2 a small bag of Ritz crackers with cheese, and the CNA stated they typically gave those as a snack because the resident did not appear to have difficulty with them. The resident’s representative stated they knew of the prescribed texture diet and that Resident 2 had aspirated twice, but also stated the facility had not provided education about the current diet texture change. Staff interviews confirmed crackers were not included in the prescribed diet texture and that risks and benefits education had not been provided to the representative, and the electronic health record did not show documentation of such education.
Disinfectants Stored in Resident Bathroom Sink Area
Penalty
Summary
The facility failed to ensure disinfectants were stored properly in one resident room, room [ROOM NUMBER], during review of accident hazards. The facility policy titled, Storage of Chemicals, revised on 01/01/2025, stated that all chemicals, including cleaning supplies and disinfectants, must be stored in a secure, labeled, and well-ventilated area to prevent unauthorized access by residents, staff, or visitors. Resident 3 was readmitted to the facility on 04/29/2025 and was assigned to room [ROOM NUMBER]. On 08/04/2025 at 10:46 AM, an observation showed a metal canister with liquid disinfectant and compressed gas (Lysol) and a plastic canister with pre-moistened disinfecting wipes (Clorox) stored on the bathroom sink counter in room [ROOM NUMBER]. The same observation also showed an uncovered used toothbrush, an uncovered water floss pick, and uncovered towels on the bathroom sink with the disinfectants. A later observation on 08/05/2025 at 8:27 AM again showed a canister of Lysol spray and a canister of Clorox wipes stored on the bathroom sink of room [ROOM NUMBER] along with personal hygiene products. Staff interviews stated that disinfecting supplies were normally kept with housekeeping in a locked cart and that chemicals should not be stored in a resident room, but the disinfectants remained in the resident's bathroom sink area during the observations.
Delayed Implementation of MRR Recommendation
Penalty
Summary
The facility failed to ensure a Medication Regimen Review was completed for Resident 20, who was reviewed for unnecessary medications. The facility’s policy titled Medication Regimen Review, revised 07/01/2024, stated that recommendations are acted upon and documented by facility staff and/or the prescriber. The resident’s MRR included a recommendation dated 04/11/2025 to change the administration times for gabapentin and magnesium so they would be spaced two hours apart because gabapentin efficacy may be decreased, resulting in breakthrough symptoms. Record review showed the pharmacy recommendation was not completed until 05/26/2025, 45 days later. During an interview and joint record review on 08/07/2025, the DON stated the pharmacist sent the monthly review to the facility, the RCMs gave the recommendations to the provider, and after the provider completed them, the RCMs carried them out. Review of the April 2025 MRR and the April and May 2025 MARs showed the recommendation for Resident 20 was not implemented until 05/26/2025. The DON stated the expectation was for the 04/11/2025 MRR recommendations to be implemented within 24-48 hours of receipt and not a month and a half later.
Missing COVID-19 Vaccine Education and Documentation
Penalty
Summary
The facility failed to ensure that staff were provided education about COVID-19 vaccination, including the risks, benefits, and potential side effects, and failed to document whether the vaccine was accepted or refused in the employee record for one staff member, Staff O, a CNA hired on 06/11/2010. The facility policy titled, COVID-19 Prevention, Response and Reporting, stated that the facility would offer resources and counseling to healthcare personnel, residents, and visitors on the importance of receiving the COVID-19 vaccine and staying up to date with recommended doses. During interview, Staff O stated that they refused the COVID-19 vaccine booster and had been informed of the risks and benefits last year and signed a paper. Staff E, the Staffing Coordinator, stated that staff were provided information regarding COVID-19 vaccine risks and benefits, but did not provide documentation for Staff O. Staff B, the DON, stated they were going to look for documentation for Staff O's COVID-19 vaccine education and/or risks and benefits, and Staff A, the Administrator, stated that they were not able to find documentation showing Staff O was provided risks and benefits related to COVID-19 vaccination.
Loose Bed Rails Not Secured for Two Residents
Penalty
Summary
The facility failed to ensure bed rails were properly secured and maintained for safety for 2 residents who used bed enablers. The facility policy titled, Bed Rail, stated nursing staff would inspect rails each shift for secure attachment and defects, check resident positioning and skin integrity, and monitor for signs of distress, agitation, or injury. The deficiency was identified during observation, interview, and record review related to accident hazards. Resident 9’s care plan showed bilateral grab bars/enablers were used to maximize independence with turning and repositioning in bed. During observations, the resident’s right bed rail was not tightly secured and could be moved from side to side. Staff LPN observed the same condition and stated the rail was more loose than the left rail and should not have been loose. The Director of Facilities stated maintenance checked rooms monthly and would fix bed rail issues, and then stated the resident’s bed rails would be replaced. Resident 29’s record showed admission to the facility, and multiple observations showed the resident’s right bed rail was loose, wobbly, and not tightly secured. The resident stated the rail worried them because it was wobbly and used all the time. Staff also observed the rail was loose and should not have been.
Failure to Timely Investigate and Report Unexpected Resident Death
Penalty
Summary
The facility failed to ensure that an incident involving the unexpected death of a resident was investigated and reported in a timely manner. According to the facility's policy and the Washington State Guidelines Purple Book, an immediate investigation and prompt logging of such incidents are required. However, review of records showed that the resident's unexpected death was not logged on the incident reporting log until 19 days after the event, and the investigation was not initiated promptly. The online incident report was completed six days after the resident's death, and the incident was not included in the April incident log, only appearing in the May log after a significant delay. Interviews with facility staff, including the Director of Health Services and the Interim DON, confirmed that the incident was neither investigated nor reported in accordance with required timelines. Staff acknowledged that the reporting and investigation were not completed in a timely manner, and the incident was logged late. These actions were not consistent with both facility policy and state guidelines, which require immediate response and documentation for unexpected deaths, especially those that are suspicious or not clearly related to abuse or neglect.
Failure to Submit Timely Staffing Data to CMS
Penalty
Summary
The facility failed to ensure timely submission of direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) for the fourth quarter of the fiscal year 2023. This deficiency was identified during an interview and record review, which revealed that the Payroll Based Journal (PBJ) data, mandatory for reporting staffing information based on payroll data, was not submitted on time. The facility's policy, revised on July 1, 2024, mandates the electronic submission of complete and accurate staffing information, including agency and contract staff, in a uniform format as specified by CMS. However, Staff J, the Staffing/Central Supply Coordinator, was uncertain if the data for the fourth quarter of 2023 was submitted, and Staff A, the Administrator, confirmed that it was not submitted promptly. This failure resulted in CMS having inaccurate data related to nursing home staffing levels, potentially impacting resident care and services.
Medication Administration During Meals in Dining Room
Penalty
Summary
The facility failed to provide a homelike dining environment by allowing the administration of medications during meals in the dining room, which was observed during two of three dining observations involving six residents. Licensed nurses were seen administering oral medications to residents in the dining room during breakfast and lunch meals, contrary to the facility's policy that medications should be administered in residents' rooms. Staff F, an LPN, was observed giving medications to two residents during breakfast, and later admitted that medications should not have been administered in the dining room. Similarly, Staff E, another LPN, was observed administering medications to four residents during breakfast and lunch, and acknowledged that due to short-staffing, they sometimes administered medications in the dining room. Interviews with facility staff, including the Resident Care Manager and the Corporate Health Services Director, confirmed that the expectation was for medications to be administered in residents' rooms unless specifically included in the care plan. However, a review of the comprehensive care plans for the involved residents did not indicate that medication administration in the dining room was part of their care plans. This oversight placed the residents at risk for a diminished quality of life, as the dining room environment was not intended for medication administration.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the required Registered Nurse (RN) coverage for six specific days, as identified in the report. This deficiency was discovered through interviews and record reviews, which revealed that the facility did not have RN coverage for eight hours on the dates of 10/07/2023, 10/08/2023, 10/15/2023, 10/21/2023, 10/22/2023, and 11/04/2023. The facility's policy, revised on 04/01/2024, mandates that staffing must be sufficient to ensure accurate direct care staffing information and that a minimum of 0.55 hours of direct nursing care per resident per day must be provided by RNs. Despite this policy, the Daily Nursing Staff Posting records confirmed the absence of the required RN coverage on the specified dates. During a joint record review and interview, the Staffing Coordinator acknowledged the lack of RN coverage on the identified dates but was unable to explain the reason for this lapse, despite stating that there was no staff shortage. The Administrator also confirmed the regulatory requirement for RN coverage and expressed the expectation that the facility should meet this requirement. The absence of RN coverage on these days placed residents at risk for inadequate assessments, delays in care services, unmet care needs, and a diminished quality of life, as per the findings of the report.
Improper Labeling and Storage of Medications and Supplies
Penalty
Summary
The facility failed to properly label and store medications and medical supplies in two medication rooms, which could compromise the effectiveness of these items. On the Seventh Floor, a multidose vial of tuberculin was found in the refrigerator with an open date that exceeded the 30-day usage period, indicating it was expired by three days. Staff C, the Resident Care Manager, acknowledged that the tuberculin should have been discarded as it was past its expiration date. On the Eighth Floor, a bottle of amoxicillin with an expiration date that had already passed was found in the medication room's refrigerator. Additionally, expired medical supplies, including two intermittent catheters and one Foley catheter, were discovered. Staff N, a Registered Nurse, confirmed that these items were expired and should have been discarded. Staff D, another Resident Care Manager, and Staff B, the Corporate Director of Health Services, both stated that the expired medications and supplies should have been removed from the medication rooms.
Expired Food and Broken Thermometers Found in Kitchen
Penalty
Summary
The facility failed to adhere to its food safety policies by not discarding expired food items and not maintaining a working thermometer in the Kitchen Walk-In Refrigerator. During an observation, a tray of Impossible Burger patties with a past use-by date and a tray of raw pork chops with an expired prep date were found in the refrigerator. Staff U, the Sous Chef, acknowledged the presence of these expired items and stated they would remove them. This indicates a lapse in the facility's policy that requires expired food to be removed immediately to prevent foodborne illness. Additionally, the facility did not ensure the proper monitoring of refrigerator temperatures as required by their policy. During the inspection, two thermometers in the Kitchen Walk-In Refrigerator were found to be broken, rendering them unable to provide accurate temperature readings. Staff U confirmed the malfunctioning state of the thermometers. The facility's policy mandates that temperatures in refrigeration units be checked daily and recorded to ensure food safety. The Administrator, Staff A, admitted that the expectation was to have a functioning thermometer inside the refrigerator and acknowledged the oversight in discarding expired foods promptly.
Infection Control Deficiencies in Hand Hygiene and Medication Administration
Penalty
Summary
The facility failed to ensure proper hand hygiene practices during meal tray distribution, as observed with Staff L, a Certified Nursing Assistant. Staff L was seen setting up meal trays for residents without performing hand hygiene before or after entering and exiting multiple resident rooms, including a room requiring Enhanced Barrier Precautions (EBP). Despite acknowledging the requirement to wash hands when entering and exiting EBP rooms, Staff L did not adhere to these protocols, as confirmed during interviews with the Resident Care Manager/Infection Preventionist and the Corporate Director of Health Services. Additionally, the facility did not follow infection control practices during medication administration for three residents. Staff E, an LPN, was observed preparing and administering medications by pouring them into their gloved hand before placing them in medication cups. This practice was repeated for Residents 6, 235, and 18, despite handling medication carts, bottles, and bubble cards with the same gloves. Staff E also took medication bubble cards into resident rooms, contrary to the facility's policy, which was confirmed by the Resident Care Manager and the Corporate Director of Health Services. The deficiencies in hand hygiene and medication administration practices placed residents, visitors, and staff at an increased risk of infection. The facility's policies on handwashing and medication administration were not followed, as evidenced by the actions of Staff L and Staff E. These lapses were identified through observations and interviews, highlighting a need for adherence to established infection control protocols to prevent contamination and infection.
Failure to Obtain Informed Consent for Antidepressant Medication
Penalty
Summary
The facility failed to ensure informed consent was obtained for an antidepressant medication before administration to a resident. The facility's policy on psychotropic drug use requires that residents or their responsible parties make an informed choice regarding the use of such medications, with potential risks and benefits explained beforehand. However, a review of the resident's records revealed that the antidepressant medication was prescribed on 03/19/2024 and administered starting 03/20/2024, but the consent was not signed until 05/28/2024. This oversight was confirmed during a joint record review and interview with the Resident Care Manager, who acknowledged that consent should have been obtained prior to the medication's administration. The Corporate Director of Health Services also stated that the expectation was for consent to be completed before the resident began taking the medication.
Failure to Assess and Document Self-Medication Administration
Penalty
Summary
The facility failed to ensure that residents were properly evaluated and assessed for self-administration of medications, and did not obtain necessary physician orders for two residents. Resident 235, who had been self-administering enoxaparin injections since before their admission, continued to do so without an assessment, physician order, or care plan in place. Despite the resident's preference and history of self-administration, the facility staff did not conduct the required evaluations or update the care plan to reflect this practice. Similarly, Resident 20 was self-administering multiple medications, including Fluticasone Nasal Spray and Ponaris Nasal Solution, without the necessary physician orders or inclusion in their comprehensive care plan. The facility's records did not show a self-administration order for these medications, and the resident's care plan lacked documentation for self-medication administration. Observations revealed that medications were left at the resident's bedside for unsupervised use, further indicating a lack of proper oversight and documentation. The facility's policy required an interdisciplinary team assessment, physician orders, and care plan updates for residents who self-administer medications. However, these procedures were not followed for Residents 235 and 20, leading to a deficiency in ensuring safe and accurate medication administration. The lack of assessments and orders placed the residents at risk for potential medication errors and adverse effects.
Failure to Provide Written Transfer Notice
Penalty
Summary
The facility failed to provide a written transfer or discharge notice to a resident and their representative, as required by their policy and regulatory standards. This deficiency was identified during a review of the case of a resident who was transferred to a hospital for further evaluation. The facility's policy, revised in April 2024, mandates that residents be notified in writing of the reasons for a transfer in a language and manner they can understand, and that this notice be documented in the resident's record by the facility and the physician. However, the review of the clinical health record, both electronic and paper, revealed no documentation of such a written notice being provided to the resident or their representative. Interviews with facility staff, including a Licensed Practical Nurse and the Resident Care Manager, confirmed that the standard practice was to notify family or representatives of hospital transfers by phone, rather than in writing. This practice was contrary to the facility's policy and the expectations stated by the Corporate Director of Health Services, who emphasized the requirement for written notification. The lack of written notice placed the resident and their representative at risk of not having the opportunity to make informed decisions regarding the transfer or discharge.
Failure to Provide Bed Hold Notice During Hospital Transfer
Penalty
Summary
The facility failed to provide a bed hold notice to a resident or their representative during a transfer to the hospital, as required by their policy. The policy, revised in January 2024, mandates that written information regarding bed hold policies be given prior to a resident's transfer to the hospital or when they go on therapeutic leave. However, a review of the clinical health records for the resident, who was transferred to the hospital on May 28, 2024, showed no documentation of a bed hold notice being offered. Interviews with facility staff, including a Licensed Practical Nurse and the Resident Care Manager, confirmed that the bed hold notice was not provided to the resident or their representative. Both staff members acknowledged that the notice should have been given. Additionally, the Corporate Director of Health Services stated that it was their expectation for the facility to provide the bed hold notice, indicating a lapse in following the established protocol.
Delayed Completion of SCSA MDS for Resident in Hospice Care
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) in a timely manner for a resident who experienced a significant change in condition. According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, an SCSA is required to be completed within 14 days of a significant change in a resident's status. In this case, the resident was admitted to hospice care, which is considered a significant change requiring an SCSA. However, the assessment was completed four days late, placing the resident at risk for unmet care needs and a diminished quality of life. The report details that the resident was admitted to hospice care on September 22, 2023, and the SCSA MDS with an Assessment Reference Date (ARD) of September 27, 2023, was not completed until October 10, 2024. This delay was confirmed during an interview with the MDS Coordinator, who acknowledged that the assessment was completed late according to the RAI manual. The Corporate Director of Health Services also stated that they expected the SCSA MDS to be completed in a timely manner, indicating a lapse in adherence to the required timeline for assessments.
Failure in Communication with Hospice Services
Penalty
Summary
The facility failed to ensure resident-centered care and treatment were provided in accordance with professional standards of practice by not maintaining consistent communication and collaboration with hospice care for a resident receiving hospice services. The deficiency was identified for a resident who was admitted to hospice care in September 2023, but the most recent hospice notes available in the facility's records were from December 2023. This lack of updated documentation indicated a failure in communication between the facility and hospice care, which is essential for coordinating care and ensuring the resident's needs are met. During interviews, staff members acknowledged the absence of recent hospice notes in the resident's records. A Licensed Practical Nurse was unable to find any hospice visit notes related to the resident's left heel wound in the Electronic Health Record (EHR) or paper chart. The Resident Care Manager admitted that they did not expect hospice notes to be readily available but could request them if needed. The Corporate Director of Health Services expressed that there should be both verbal and written communication to coordinate care and that hospice notes should be readily available in the facility after a hospice visit. The lack of recent hospice documentation placed the resident at risk of not receiving necessary comfort care services and unmet care needs.
Failure to Properly Assess and Document Pressure Ulcer
Penalty
Summary
The facility failed to properly assess and document a pressure ulcer for a resident, identified as Resident 9, which led to a deficiency in care. Initially, the resident's left heel showed discoloration, but it was not identified or documented as a pressure ulcer. Despite the presence of a blister that opened and was treated as a pressure injury, the facility did not stage the wound as required. Interviews with staff revealed a lack of clarity and documentation regarding the staging of the pressure ulcer, which was expected to be done once the blister opened. Further observations and interviews indicated that the pressure ulcer was unstageable with parts classified as Stage 2, yet this was not documented in the facility's records. The facility's policy required thorough assessment and documentation of pressure ulcers, including staging, which was not adhered to in this case. The lack of proper documentation and assessment placed the resident at risk for deterioration of their pressure ulcer and a diminished quality of life.
Improper Oxygen Supply Management for Residents
Penalty
Summary
The facility failed to maintain, label, date, and properly store oxygen tubing and supplies for two residents, leading to a deficiency in respiratory care. Resident 23, who was admitted with pulmonary fibrosis, was observed using an oxygen concentrator and a portable oxygen device without proper labeling or storage of the nasal cannula and humidifier bottle. The nasal cannula was found uncovered on the concentrator and the tubing from the portable device was on the floor, both undated. Staff interviews revealed that there were no physician orders for oxygen or protocols for changing the tubing and humidifier bottle, despite documentation indicating the need for oxygen since May 2024. Resident 20, diagnosed with chronic respiratory failure, was also found with improperly labeled and stored oxygen equipment. The nasal cannula connected to the oxygen concentrator and the portable oxygen tank were not labeled or dated. Interviews with staff indicated that Resident 20 managed their own oxygen and requested tubing changes as needed, but there were no physician orders for oxygen therapy prior to August 2024. The facility's policy required oxygen supplies to be dated and stored correctly, which was not adhered to in these cases. The deficiency was identified through observations, interviews, and record reviews, highlighting the facility's failure to follow its own policy on oxygen administration. Staff acknowledged the lack of proper documentation and storage practices, which placed the residents at risk for unmet care needs and potential respiratory complications. The absence of physician orders and proper labeling and storage of oxygen supplies were central to the deficiency identified by the surveyors.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Seattle
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mirabella | 0.8 mi | ★★★★★ | 2 | 0 |
| Seattle Medical Post Acute Care | 0.9 mi | ★★★★★ | 71 | 0 |
| Transitional Care Of Seattle | 1.6 mi | ★★★★★ | 49 | 0 |
| Bailey-boushay House | 1.8 mi | ★★★★★ | 0 | 0 |
| Washington Care Center | 2.7 mi | ★★★★★ | 30 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.