Average — CMS composite of the measures below.
The next survey window likely opens around October 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 View Ridge Care Center during CMS and state inspections, most recent first.
Failure to explain arbitration agreement rights: The facility had 3 residents electronically sign arbitration agreements, including one resident with dementia, a BIMS score of 7/15, and a POA listed in the record. The Admissions Coordinator described the agreement as a financial document about fees, while the Administrator gave a different explanation of arbitration. In Resident Council, 3 residents said they were not told what arbitration was or what rights they had when signing.
Infection Control and Water Management Failures: A resident on contact enteric precautions was observed without proper PPE, staff entered rooms without following TBP guidance, and an LPN did not perform hand hygiene between glove changes during wound care for a resident with a chronic foot ulcer and DM. A resident with a PICC also had a dressing that remained dated for weeks despite an order for admission and weekly changes. In addition, the facility could not produce a complete Legionella water management program, including a flow diagram and risk assessment.
Resident council concerns were not followed up through the facility grievance process for multiple council meetings. Meeting minutes documented issues with call light response, shower scheduling, missing supplies, noise at shift change, and a resident's medication preference, but the grievance log showed no matching grievances. The resident council president said concerns were handled within the council, and the Activities Director stated follow-up was done with the resident who voiced the concern rather than with resident council.
A facility failed to provide residents with annual oral and written notices of resident rights. During a Resident Council meeting, 4 of 10 residents said they were not aware of their rights and reported staff had not reviewed them. The Activities Director stated resident rights had not been reviewed during Resident Council meetings and that they were unaware this was required.
MDS assessments did not accurately reflect the status of three residents. One resident with ESRD, malnutrition, and epilepsy was coded as needing supervision or touching assist to eat even though records, observations, and staff interviews showed the resident ate independently after set-up. A second resident with dementia and other neurologic conditions had a documented contracture in hospice notes, but the MDS showed no upper or lower extremity impairment. A third resident with stroke and hemiplegia was coded with adequate vision and no upper extremity impairment despite resident and staff reports of impaired vision and left-sided paralysis.
Missing Annual Staff Performance Reviews: The facility failed to complete annual performance reviews and provide education based on review outcomes for 3 of 6 sampled staff. Personnel files for two NACs and another NAC contained no documentation of a performance evaluation, and the DON stated the facility was using a new electronic review system with some reviews delayed because staff had not completed their portion electronically.
The facility failed to ensure 3 of 5 NACs received the required 12 hours of annual in-service training. Record review showed the aides had not completed the minimum training hours, and the DON stated the new electronic system did not record all training in an easy-to-read format and that the staff development coordinator had not kept training records accurately.
A resident admitted with HF, depressive disorder, anxiety disorder, and COPD had a POA listed on the EHR profile page for financial, care, and medical decisions, but no legal POA documents were found in the record. Staff stated they would not add a POA without legal documents and confirmed the family had been asked for the paperwork but it was never received.
Failure to timely report an allegation of neglect: A resident said they waited over an hour for a brief change, were left soiled with urine and feces, and developed a rash. The DON was informed, but the allegation was initially handled as a grievance and not reported to the State Agency until after a later allegation. Staff documented they did not view it as neglect at first because they believed there was no pattern.
The facility failed to develop complete care plans for two residents. One resident with edema had a care plan that did not describe the swelling or how it was managed, and another resident with stroke-related left-sided paralysis and impaired vision had no care plan or Kardex documentation for vision needs, right-side placement of items, or menu assistance.
Failure to maintain oral care assistance: A resident with developmental disability and moderate cognitive impairment was supposed to receive limited assistance with personal hygiene and oral care, but staff could not locate the resident’s toothbrush and the resident was observed with debris between the teeth and at the gumline. Staff gave conflicting accounts about oral care support, and the RCM stated residents were expected to receive oral care multiple times daily and have a toothbrush available.
Failure to Provide One-to-One Feeding Assistance: A resident with TIA, dementia, muscle weakness, and lack of coordination was care planned for one-to-one meal assistance, but was observed eating without timely help, spilling food, and later left with meals in front of them or out of reach. Staff observations and interviews showed inconsistent feeding assistance, including a meal tray removed after only a few bites and conflicting accounts about how much the resident ate.
Inconsistent splinting and restorative support for a resident with left-sided contractures. A resident with dementia, weakness, and prior intact PROM later developed worsening left hand and elbow contractures while on hospice. Hospice OT recommended a palm protector, positioning, and premedication, but facility TARs did not show the ordered devices for months, and observations found the resident without the left hand splint while the hand remained tightly fisted. The resident’s rep reported the splint placement was not consistent, and staff gave conflicting accounts about the splint schedule and the therapy carrot device.
Incomplete dialysis communication documentation was found for a resident with ESRD, malnutrition, and epilepsy who received repeated dialysis treatments. The nurse did not consistently complete the information sent with the resident to dialysis, including resident status, recent pain or anxiety meds, and signatures, and multiple return forms lacked vital signs, dialysis site assessment, bruit/thrill checks, and nurse signatures. Staff and the DON stated all portions of the dialysis communication sheet were expected to be completed.
The facility had inaccurate weight documentation for one resident, with conflicting weights recorded in the MDS, EMR, nutrition assessment, and provider notes, including struck-out weights with no explanation for the changes. The facility also had incomplete hospice documentation for another resident with TIA, dementia, weakness, and poor coordination, as hospice records were kept in a separate EMR and were not fully present in the resident’s chart.
The facility failed to maintain sanitary conditions in its kitchen, dining rooms, and nourishment refrigerators, risking foodborne illnesses. Observations showed soiled refrigerators, broken light fixtures with insects, and a dishwashing machine not reaching required temperatures. The kitchen had dust and debris, missing flooring, and lint around vents. Staff were unclear on cleaning responsibilities.
The facility failed to ensure proper storage and expiration management of medications and biologicals, as observed in two medication carts and a medication room. An LPN found an unrefrigerated probiotic and expired glucometer solutions on Cart 4, while an RN identified an expired medication on Cart 3. In the medication room, vaccines were improperly dated and expired, with inconsistent temperature log entries confirmed by a Patient Care Coordinator/RN.
A resident placed on hospice services did not receive a timely Significant Change in Status Assessment (SCSA) within the required 14-day timeframe, as required by the RAI 3.0 User's Manual. Interviews revealed a communication breakdown among staff, with the MDS Coordinator not informed of the resident's change in condition due to the absence of the Patient Care Coordinator and a lapse in communication by the Director of Nursing.
The facility failed to accurately complete MDS assessments for two residents, leading to potential risks in care planning. One resident with Schizophrenia and Bipolar disorder frequently refused medications and exhibited behaviors, but these were not reflected in the MDS. Another resident with dental issues affecting their ability to chew had these concerns unaddressed in their care plan and MDS. The LPN/MDS Coordinator admitted to incomplete documentation review.
The facility failed to complete the federally required PASRR forms for two residents with mental health diagnoses before their admission. One resident was admitted with Major Depressive Disorder, and their PASRR incorrectly indicated no mood disorders. Another resident's PASRR was incomplete, missing required information. The clinical team did not ensure the accuracy and completion of these forms.
A resident with multiple health conditions, including vision impairment, did not have their visual needs addressed in their care plan. Despite being cognitively intact, the resident was unaware of meal options due to difficulty reading menus. Staff interviews revealed a lack of awareness about the resident's vision issues, and the MDS Coordinator could not explain why these needs were omitted from the care plan, risking unmet care needs and diminished quality of life.
A facility failed to ensure proper communication and management of anticoagulant therapy for a hospice resident. The resident, with a history of pressure ulcers and long-term anticoagulant use, had elevated INR levels without proper monitoring or documentation. Facility staff were unclear about the resident's medication management, and there was a lack of coordination with the hospice provider, leading to a deficiency in resident-centered care.
A resident under hospice care did not receive their prescribed antidepressant medication on multiple occasions due to unavailability, with no notification to the physician or pharmacy. The resident experienced sleep difficulties, and staff were unaware of the issue until later. The facility failed to follow procedures for medication unavailability, placing the resident at risk.
A facility failed to monitor and reduce unnecessary psychotropic medications for a resident with dementia. The staff did not identify or monitor target behaviors for antipsychotic medication use and did not attempt a Gradual Dose Reduction (GDR) for Risperdal, despite a pharmacy recommendation. The resident, who exhibited physical behaviors but no hallucinations or delusions, was on hospice care. A second antipsychotic was added but not administered, and there was no psychotic behavior monitoring in place. Staff acknowledged the lack of specific behavior monitoring and that dementia is not an approved diagnosis for antipsychotic use.
A facility failed to ensure residents with swallowing difficulties were fed by trained staff. An Activities Manager, without a nursing license or specialized training, assisted a resident with a swallowing problem during breakfast. The resident's care plan required assistance from one staff member and specified a minced and moist texture diet. Despite the facility's claim of not using paid feeding assistants, the Director of Nursing confirmed that non-nursing staff should not provide feeding assistance.
The facility failed to follow infection control procedures, including the use of PPE and proper storage of respiratory equipment. A nurse did not wear a gown during a dressing change for a resident on Enhanced Barrier Precautions, and respiratory equipment was improperly stored. Additionally, a Maintenance Supervisor entered a contact precaution room without proper hand hygiene or gowning, and did not disinfect equipment used in the room.
Failure to Explain Arbitration Agreement Rights
Penalty
Summary
The facility failed to explain and ensure residents understood the arbitration agreement for 3 of 3 residents reviewed for arbitration agreements. Resident 74’s arbitration agreement, dated 11/18/2025, was electronically signed by the resident. The resident’s record documented a diagnosis of dementia, a BIMS score of 7 out of 15 indicating severe impairment, and that the resident’s family member was the power of attorney. Resident 75’s arbitration agreement, dated 11/04/2025, was electronically signed by the resident, and Resident 81’s arbitration agreement, dated 11/16/2025, was also electronically signed by the resident. During an interview on 11/19/2025, the Admissions Coordinator stated they assisted residents with the arbitration agreement upon admission and reviewed it with the admission agreement, but described it as a financial agreement about fees owed to the facility. The Administrator later stated the arbitration agreement was not just a financial agreement and explained that arbitration would be used if a resident had a dispute, while also stating the arbitration was not binding and all residents had the right to sue. In a Resident Council group interview, three residents stated they were unaware of what arbitration was and were not provided explanations of their rights when signing one.
Infection Control and Water Management Failures
Penalty
Summary
The facility failed to ensure staff followed infection prevention and control practices for a resident on contact enteric precautions for C. diff. Resident 81 was cognitively intact and had a documented order for contact enteric precautions. During observation, the resident was seen in the hallway without PPE while being pushed by a COTA, and the COTA later entered the resident’s room without PPE. The COTA stated they were unsure of the precaution at first, then said they believed PPE was not needed as long as the resident’s C. diff was contained and they did not touch the resident’s brief. The COTA was also observed entering another resident’s room with gloves but no gown, then removing the gloves, washing hands, and leaving the room. Another staff member entered Resident 81’s room without PPE to deliver a water pitcher and later stated they thought PPE was not needed for that task, then acknowledged PPE should have been worn in rooms with contact precaution signs. The DON stated residents on CEP could leave the room for medical necessity if they met the 3 C’s, and the infection preventionist stated staff were expected to wear PPE before entering rooms on TBP. The facility also failed to follow hand hygiene practices during wound care for a resident with a chronic left foot ulcer and diabetes. Resident 3 was cognitively intact and had a daily dressing change order for the left lower extremity wound. During the observed dressing change, two staff members were gowned and gloved, but the LPN removed gloves and donned new gloves multiple times without performing hand hygiene between glove changes. The LPN cleansed the wound, applied treatment, skin prep, kerlix, and Coban while changing gloves repeatedly, and only performed hand hygiene after removing gloves and gown at the end of the procedure. The LPN stated they did not perform hand hygiene between glove changes because their hands were already clean and said doing so would take too long. The infection preventionist stated staff should perform hand hygiene every time they donned new gloves. The facility also failed to ensure a PICC dressing was maintained according to the ordered schedule for a resident with heart failure and osteomyelitis. Resident 78 had a PICC in the right arm, and the dressing was observed dated 11/02/2025 on multiple occasions. The MAR documented an order to change the PICC dressing 24 hours after insertion, on admission, every week, and as needed, but the record showed no documentation that the dressing had been changed since admission. The infection preventionist stated the dressing should have been changed on admission and weekly for infection control and to maintain dressing integrity. The DON stated the PICC dressing order had been transcribed incorrectly and was not visible to the nurses caring for the resident. The facility also did not provide a complete Legionella water management program. Staff were unable to produce the water management book when requested, and what was eventually provided consisted of two July 2025 testing pages only. The materials did not include a water flow diagram, a facility risk assessment for where Legionella or other opportunistic waterborne pathogens could grow or spread, or a complete water management plan. An incomplete binder was later delivered, but it still lacked the required risk assessment and flow diagram sheets.
Resident Council Concerns Not Followed Up
Penalty
Summary
The facility failed to follow up on concerns raised by the resident council related to resident care in 4 of 5 resident council meeting minutes reviewed, including June, July, August, and October 2025. The facility policy for addressing resident concerns from Resident Council stated that concerns such as missing clothing, food concerns, care concerns, and call light response time concerns required a grievance form to be completed and turned into the administrator, DON, and social services director with the resident council minutes. However, the resident council minutes documented concerns including noise at shift change, call light response time, requests for showers more than twice a week, running out of washcloths and clothing protectors, and a resident preference for medication timing. Review of the grievance log from June 2025 through August 2025 and October 2025 showed no documented grievances consistent with the concerns voiced at resident council. In interview, the resident council president stated concerns were attempted to be resolved within the council meeting without escalating them to facility administration. The Activities Director stated grievance forms were completed for concerns expressed at resident council, residents were encouraged to fill them out, and if they did not, staff would complete one; however, when asked about follow-up with resident council regarding grievances discussed there, the Activities Director stated they did not follow up with resident council and instead followed up with the resident who voiced the grievance.
Failure to Review Resident Rights at Resident Council
Penalty
Summary
The facility failed to ensure residents were provided notices of their resident rights, both orally and in writing, on an annual basis. During a Resident Council meeting, 4 of 10 residents who attended stated they were not aware of their resident rights, and when asked whether staff talk about and review resident rights in the facility, Residents 6, 8, 29, and 30 said they had not. During an interview, the Activities Director stated that resident rights had not been reviewed during Resident Council meetings and that this would be done moving forward, and also stated they were unaware that resident rights should be reviewed during those meetings.
MDS assessments did not match resident functional status
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected resident status for 3 of 14 sampled residents. For Resident 8, who had ESRD, malnutrition, and epilepsy, the Quarterly MDS dated 10/09/2025 coded the resident as requiring supervision or touching assist to eat meals. However, the resident’s Kardex and care plan stated the resident ate independently after set-up assistance, and two observations showed the resident eating breakfast independently without staff present. Staff interviews also confirmed Resident 8 was independent with eating, while the MDS nurse stated the eating section was completed from progress notes and the DON stated the coding meant set-up assist, not independent eating. For Resident 58, who had a history of TIA, dementia, muscle weakness, and lack of coordination, a hospice progress note dated 01/27/2025 documented a contracture of the left elbow and hand. Despite this, the Quarterly MDS dated 05/02/2025 and the Significant Change MDS dated 06/27/2025 documented no functional impairment to the upper or lower extremities. The MDS nurse stated a contracture should be coded on the MDS under functional impairment and acknowledged that hospice notes were only glanced at during data collection. For Resident 80, who had stroke with hemiplegia, the 5-Day MDS dated 11/03/2025 coded moderately impaired cognition, adequate vision, and no impairment of both upper extremities. The resident stated they could not read regular-sized print, had limited left-side vision from the stroke, and could not move the left arm and leg. Staff also stated the resident had impaired vision, needed help reading the menu, and had left-sided paralysis. The MDS nurse stated vision was assessed by asking residents to read menu or activity papers and said the coding issue in Section GG was an oversight.
Missing Annual Staff Performance Reviews
Penalty
Summary
The facility failed to complete annual staff performance reviews yearly and failed to provide education based on the outcomes of those reviews for 3 of 6 sampled staff reviewed for performance reviews. Review of the personnel files for Staff R, Staff S, and Staff T showed no documentation of a performance evaluation. Staff R's NAC personnel file showed an original hire date of 06/20/2023, another Staff R NAC personnel file showed an original hire date of 09/27/2023, and Staff T's NAC personnel file showed an original hire date of 04/30/2024. During interview, the DON stated the facility had a new electronically coordinated system for annual reviews and that some reviews were not completed because the staff member needed to complete their portion electronically.
Nurse Aides Lacked Required Annual In-Service Training
Penalty
Summary
The facility failed to ensure that 3 of 5 nurse aides, identified as Staff S, T, and W, received the required 12 hours of annual in-service training. A review of the NAC training hours showed that these staff members had not completed the minimum 12 hours of training within the year. During an interview on 11/19/2025 at 10:30 AM, the DON stated the facility had a new electronic system that did not record all training completed in an easy-to-read format, and the staff development coordinator had not kept staff training records accurately. The deficiency was cited under WAC 388-97-1680(2)(a-c).
Missing POA Documentation in Resident Record
Penalty
Summary
The facility failed to ensure that power of attorney (POA) legal documents were in the medical record for Resident 5, who was admitted with diagnoses including heart failure, depressive disorder, anxiety disorder, and COPD. The resident’s electronic health record showed a POA listed on the profile page indicating authority for financial, care, and medical decisions, but no legal POA documents were found or provided in the record. Staff U stated they would not add a POA to a resident’s EHR without legal documents and verified that the profile page showed a POA without supporting documentation. Staff F stated they would not document a POA without the documents and would instead document a point of contact person. Staff D stated they had asked the resident’s family for the POA documents and never received them, and verified that the profile page listed a POA without a copy of the legal document.
Failure to Timely Report Allegation of Neglect
Penalty
Summary
The facility failed to ensure timely reporting of an allegation of neglect to the State Agency for one resident. The facility policy on abuse and neglect required allegations to be handled according to nursing home guidelines in the Purple Book, which states a report must be made when there is reasonable cause to believe abuse, neglect, abandonment, mistreatment, injuries of unknown source, personal or financial exploitation, or misappropriation of resident property has occurred. Neglect was defined in the Purple Book as either a pattern of conduct or inaction by an individual or entity with a duty of care for nursing home residents, or a one-time act or omission by such an individual or entity. A resident stated they had waited over an hour for a brief change, had been soiled with feces and urine, and developed a rash when left unchanged. The Director of Nursing Services was informed of the allegation and stated they would follow the facility process. The resident later stated they had been fully soaked in urine, had used the call light several times during the night, and did not receive assistance for a brief change. The DON later stated the allegation was reported to the state reporting agency, but the incident report from the initial allegation had not been logged and had been placed on a grievance instead, and was not called in until the resident made an additional allegation of neglect. A Social Services Director documented that they met with the resident and determined it was not a pattern, and staff documented they had followed the Purple Book guidance and did not consider it neglect at the time because there was no pattern.
Incomplete Care Plans for Edema, Stroke, and Impaired Vision
Penalty
Summary
The facility failed to develop comprehensive care plans that reflected the current medical status and nursing services for Resident 19 and Resident 80. Resident 19 was admitted with developmental disability and localized edema, and the admission and quarterly nursing assessment documented swelling to both lower legs. However, the care plan dated 10/29/2025 only noted pain related to edema and potential for skin issues related to edema, without describing the edema, how it manifested, or how it was to be managed. Resident 80 was admitted with a stroke that caused paralysis and had moderately impaired cognition on the 5-day MDS. The resident stated they were paralyzed on the left side, had limited left-sided vision, could not read regular-size print, and needed help reading the menu. Review of the care plan and Kardex showed no documentation of impaired vision, no interventions addressing the resident’s need to have items placed on the right side due to left-sided paralysis, and no mention of assistance with menu selection.
Failure to Maintain Oral Care Assistance
Penalty
Summary
The facility failed to provide services to ensure that a resident’s abilities in activities of daily living did not diminish without a medical reason. Resident 19 was admitted with diagnoses including developmental disability and need for assistance with personal care, and a BIMS score of 8 out of 15 documented moderate cognitive impairment. The care plan dated 10/29/2025 stated the resident required limited assistance from one staff member with personal hygiene and oral care. During observation and interview, Resident 19 stated they did not know where their toothbrush was and thought it might be in the bedside table, but no toothbrush was found in the bedside table or bathroom. The resident had gray and white matter between the teeth and at the gumline, and later was again observed with debris between the teeth and at the gumline. Staff M stated residents were assisted with oral care after breakfast and that Resident 19 required assistance with oral care, while Staff P stated they provided Resident 19 with a toothbrush and toothpaste to brush their teeth. The Resident Care Manager stated staff were expected to provide oral care two to three times daily and that all residents were to have a toothbrush, but was unaware Resident 19 did not have one.
Failure to Provide One-to-One Feeding Assistance
Penalty
Summary
The facility failed to provide assistance with activities of daily living for 1 of 2 sampled dependent residents, Resident 58, who was care planned for one-to-one assistance with meals. Resident 58 was admitted with diagnoses including TIA, dementia, muscle weakness, and lack of coordination. The care plan dated 09/23/2024 and revised on 08/27/2025 documented the need for one-to-one assistance to eat meals. During observation on 11/20/2025, Resident 58 was seen in the common area with lunch on an overbed table, not wearing a clothing protector, and eating with their right hand while spilling food on their blanket. Staff P did not assist until 12:16 PM, when the staff member asked if help was needed and then assisted after the resident said yes. On 11/21/2025, Resident 58 was observed in bed with breakfast in front of them, head hanging down toward their chest, with a full tray that included juice, milk, oatmeal, eggs, French toast, and an unopened health shake. Staff Q removed the tray and clothing protector, and the resident was not offered anything else to eat or drink; Staff Q stated the resident had only two bites of eggs and said they usually help feed the resident. Later that day, Resident 58’s lunch tray was observed out of reach and then later partially eaten, while Staff Q stated the resident ate all of lunch around the normal noon time. The DON stated Resident 58 had been in the common area at lunch, was offered lunch, and then taken back to bed after declining to eat.
Inconsistent splinting and restorative support for a resident with left-sided contractures
Penalty
Summary
The facility failed to provide consistent equipment and assistance to maintain a resident’s mobility and range of motion. Resident 58 was admitted with diagnoses including TIA, dementia, muscle weakness, and lack of coordination. A provider note documented good upper and lower extremity motor strength and intact PROM, and the restorative care plan identified a program to maintain current ROM and prevent contractures with PROM exercises to the shoulders, elbows, wrists, fingers, hips, knees, ankles, and shoulder/hip abduction and adduction six times a week as tolerated. Hospice records showed the resident was admitted to hospice for end stage dementia and failure to thrive, later evaluated by hospice OT for stiffening of the left side, and then developed worsening left hand and elbow contractures. Hospice notes documented staff reports that the left hand was getting stiffer and causing discomfort, that the left arm/hand was becoming contracted, and that the resident developed a contracture to the left elbow and hand. Hospice OT recommended a left palm protector, positioning with a pillow to the left side after ROM, and premedication prior to the restorative nursing program, and the resident’s representative reported the therapy services were not being received. Facility records and observations showed the ordered equipment was not consistently available or in use. The resident’s TAR for January through September 2025 showed no orders for a splint, therapy carrot, or palm protector despite OT documentation of contracture management devices. During observations in November 2025, the resident was seen in bed and in a wheelchair with no left hand splint, and the left hand was balled into a fist with the thumb pressed against the pointer finger. The resident’s representative stated splint placement was not consistent, and staff interviews reflected confusion about the splint schedule and use of the therapy carrot, with one staff member stating the resident needed the splint on all the time and another stating the device was sometimes hard to locate.
Incomplete Dialysis Communication Documentation
Penalty
Summary
The facility failed to ensure that dialysis communication documents were completed before and after a resident’s dialysis appointments for one resident reviewed for dialysis services. The resident was admitted with end stage renal disease, malnutrition, and epilepsy and received repeated dialysis treatments during August, September, and October 2025. Review of the dialysis communication documents showed multiple instances where the portion sent with the resident to dialysis did not include resident status, recent pain or anxiety medication, or a nurse signature, and multiple return portions lacked documentation of vital signs, assessment of the dialysis site, whether a bruit or thrill was detected, and a nurse signature. During interview, the resident stated they thought the facility and dialysis clinic should have better communication. Staff stated nurses were expected to complete the dialysis communication sheet, provide it with the resident to dialysis, document any change in status or medication changes, and complete the return portion after the resident came back, including assessment of the dialysis site and vital signs. The Director of Nursing stated it was the expectation that all portions of the dialysis communication document be filled out before the document was uploaded into the resident’s electronic health record.
Inaccurate Weight Documentation and Incomplete Hospice Records
Penalty
Summary
The facility failed to maintain accurate medical records for Resident 81 by documenting conflicting weights across the chart. The resident was cognitively intact on the admission MDS, which listed a weight of 179 pounds, while the resident stated during interview that they had just been weighed at 248 pounds and had not weighed less than 200 pounds. The EMR showed October 2025 weights that were later struck out as incorrect documentation, but there were no progress notes explaining why those weights were crossed out. The record also contained multiple different weights in the nutrition assessment and provider progress notes, including 179.4 pounds in earlier notes and 250 pounds in later notes, without any explanation for the large discrepancy. The hospital discharge summary listed the resident’s weight as 279.4 pounds, which differed substantially from the facility’s admit weight and the weight entered on the MDS. The facility also failed to maintain complete hospice documentation for Resident 58, who had diagnoses including TIA, dementia, muscle weakness, and lack of coordination and had been admitted to hospice services. Review of the EMR showed inconsistent hospice documentation and did not include all dates when hospice saw the resident. Staff stated hospice records were kept in a separate EMR not linked to the facility’s EMR and that the hospice documentation should have been in the resident’s facility record. Additional hospice records were later added to the EMR, covering dates from October 2024 through March 2025.
Sanitation Deficiencies in Kitchen and Dining Areas
Penalty
Summary
The facility failed to maintain sanitary conditions in its kitchen, dining rooms, and nourishment refrigerators, which placed residents at risk for foodborne illnesses. Observations revealed that the 2nd floor nourishment room refrigerator and freezer had sticky residue, scattered food debris, and a significant buildup of ice. Similarly, the 1st floor nourishment room refrigerator and freezer were soiled with food residue, and the refrigerator had a layer of frozen water. Additionally, the overhead light fixture in the nourishment room was broken and contained many dead insects. Interviews with staff indicated that housekeeping was responsible for cleaning these areas, but the cleaning was not adequately performed. The dishwashing machine consistently failed to maintain the required minimum wash cycle temperature of 120 degrees Fahrenheit, with recorded temperatures ranging from 103 to 119 degrees Fahrenheit on multiple occasions. The kitchen ceiling in the food preparation area had lint blowing from the air conditioner, and the flooring in front of the dishwashing area was missing linoleum. The food preparation shelving and coffee maker were covered in dust and debris, and several overhead light fixtures contained dead insects. The first-floor dining room ceiling had a buildup of lint and dust around the vents. Staff interviews revealed uncertainty about responsibilities for cleaning these areas, and there were plans to replace the kitchen flooring and potentially the dishwashing machine.
Medication Storage and Expiration Deficiencies
Penalty
Summary
The facility failed to ensure that medications and biologicals were properly stored and unexpired, as observed in two medication carts and one medication room. On Medication Cart 4, an opened bottle of acidophilus probiotic was found, which should have been refrigerated according to the label, and expired glucometer control solutions were present. Staff M, an LPN, confirmed that the probiotic was not stored in the refrigerator and acknowledged the expiration of the glucometer solutions. On Medication Cart 3, an expired bottle of calcium polycarbophil was found, and Staff K, an RN, confirmed its expiration and intended to remove it. In the first-floor medication room, the refrigerator contained several vaccines, including a multidose vial of Flucelvax quad vaccine and a vial of tubersol, both of which were open but not dated. The Flucelvax quad vaccine was also expired. Temperature logs for the refrigerator showed numerous missing entries for both July and August, indicating that temperatures were not consistently recorded twice a day as required. Staff J, a Patient Care Coordinator/RN, confirmed the absence of open dates on the vials and the failure to check refrigerator temperatures twice daily.
Failure to Complete Timely Significant Change Assessment for Hospice Resident
Penalty
Summary
The facility failed to identify a significant change in condition and complete a timely Significant Change in Status Assessment (SCSA) within the required 14-day timeframe for a resident who was reviewed for Hospice Services. The Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual requires that an SCSA be completed no later than 14 days from the determination date of a significant change in status, which includes when a terminally ill resident enrolls in a hospice program. In this case, the resident was placed on hospice services, but no significant change assessment was completed, placing the resident at risk for unmet care needs, decreased quality of care, and diminished quality of life. Interviews with facility staff revealed a breakdown in communication and responsibility. Staff O, the Licensed Practical Nurse/MDS Coordinator, stated that they rely on communication from the nurse manager during morning clinical meetings to identify residents with a change in condition. However, Staff J, the Registered Nurse/Patient Care Coordinator, was on vacation during the first two weeks the resident was on hospice services and was unsure who was responsible in their absence. Staff B, the Director of Nursing Services, acknowledged that they were aware of the coverage for Staff J but failed to communicate the resident's change in condition to the MDS coordinator, resulting in the missed assessment.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate completion of Minimum Data Set (MDS) assessments for two residents, leading to potential risks in care planning and quality of care. Resident 14, who was admitted with diagnoses including Schizophrenia and Bipolar disorder, frequently refused medications and exhibited behaviors such as yelling and cursing, as documented in progress notes. However, the MDS assessments inaccurately reported no behaviors or refusals of care. The Licensed Practical Nurse (LPN)/MDS Coordinator admitted to signing off on these sections without reviewing all relevant documentation, relying instead on incomplete nursing assistant records. Resident 6, admitted with conditions such as Congestive Heart Failure and Diabetes Mellitus Type 2, expressed interest in obtaining dentures due to missing teeth and cavities, which affected their ability to chew. Despite these issues being noted in a dietician's progress note, the MDS assessment inaccurately indicated no dental issues, and the care plan failed to address these concerns. The LPN/MDS Coordinator was unable to explain the discrepancy, indicating a lack of thorough assessment during the admission process.
Incomplete PASRR Forms for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure the completion of the Pre-Admission Screening and Resident Review (PASRR) forms for two residents, which is a federally required screening process for individuals with Intellectual Disabilities or serious mental illnesses prior to admission to a Medicaid-certified nursing facility. For Resident 5, who was admitted with a diagnosis of Major Depressive Disorder and was on Sertraline, the Level 1 PASRR indicated no mood disorders on preadmission, which was incorrect. The Director of Nursing acknowledged the error, and it was revealed that a revision was started but not completed. Resident 47 was admitted with a diagnosis of depression, and their admission Minimum Data Set (MDS) assessment showed intact cognition and prescription of an antidepressant. However, the Level 1 PASRR for Resident 47 was incomplete, with a required section left blank. Staff O confirmed that the clinical team, which includes the unit nurse manager, admission coordinator, Director of Nursing Services, and themselves, failed to ensure the PASRR was completed and accurate prior to admission.
Failure to Address Vision Impairment in Resident Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with multiple diagnoses, including congestive heart failure, chronic obstructive pulmonary disease, diabetes mellitus type 2, cataracts, and displacement of intraocular lens. Despite the resident being cognitively intact, the care plan did not address their vision issues, which were documented in the Care Area Assessment (CAA) as requiring large print documents or having information read aloud. This oversight was evident when the resident expressed difficulty in reading the menu due to limited vision and was unaware of meal options available to them. Interviews with staff revealed a lack of awareness regarding the resident's visual impairment. A Licensed Practical Nurse (LPN) admitted to not knowing about the resident's limited vision and stated that accommodations would have been made if they had been informed. The Dietary Staff was observed reading the menu to the resident, allowing them to choose their meals. The MDS Coordinator acknowledged that the care plan should have included the resident's vision impairment, as it was documented in the CAA, but could not explain why it was omitted. This failure to incorporate the resident's visual needs into their care plan placed them at risk for unmet care needs and diminished quality of life.
Deficiency in Communication and Anticoagulant Management for Hospice Resident
Penalty
Summary
The facility failed to ensure resident-centered care and treatment 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 involved the management of a high-risk medication, an anticoagulant, which required regular monitoring of blood clotting levels through PT/INR tests. The facility did not have an order to monitor these levels, and there was a lack of documentation and communication between the facility and the hospice provider regarding the management and monitoring of the anticoagulant. Resident 29, who was on hospice services, had a history of pressure ulcers, long-term use of anticoagulants, and osteomyelitis. The resident's care plan was not updated to reflect their goals and choices for end-of-life care, and the anticoagulant medication was not managed properly. Despite having elevated INR levels, there was no clear documentation or communication between the facility and hospice provider about the necessary adjustments or monitoring of the medication. The facility's staff were unclear about the reasons for the resident's continued use of the anticoagulant and the lack of monitoring orders. Interviews with facility staff and hospice providers revealed a breakdown in communication and coordination of care. The hospice nurse had not documented care in the facility's electronic medical record, and there was confusion about who was responsible for managing the resident's anticoagulant therapy. The facility's Director of Nursing Services was unaware of the communication issues and expected that the hospice provider would document care within 24 hours of each visit. The deficiency was not identified until a significant delay had occurred, leaving the resident at risk for adverse effects from the anticoagulant therapy.
Failure to Provide Necessary Pharmaceutical Services
Penalty
Summary
The facility failed to provide necessary pharmaceutical services for Resident 29, who was under hospice care and had diagnoses including major depressive disorder and insomnia. The resident's physician had prescribed Trazadone HCL, an antidepressant, to be administered at bedtime. However, the medication was not available on multiple occasions throughout August 2024, specifically on the 11th, 12th, 14th, 20th, 21st, 25th, and 26th. Documentation indicated that the medication was not given due to unavailability, and there was no evidence that the physician or pharmacy was notified, nor was there any assessment of the resident's condition due to the missed medication. Interviews with the resident and staff revealed a lack of communication and follow-up regarding the unavailability of the medication. The resident expressed difficulty sleeping due to not receiving their medication. Staff members, including the Physician Assistant, Hospice RN, and Patient Care Coordinator, were unaware of the issue until it was brought to their attention later in the month. The Director of Nursing Services confirmed that the medication was not in the automated dispensing system and acknowledged the lack of action to resolve the issue. This deficiency in pharmaceutical services placed the resident at risk for adverse events related to missed medications.
Failure to Monitor and Reduce Unnecessary Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications. Specifically, the staff did not identify or monitor target behaviors for the use of antipsychotic medication and did not attempt a Gradual Dose Reduction (GDR) for the antipsychotic medication Risperdal, despite a recommendation from the pharmacy. The resident, who was readmitted with dementia and was rarely understood due to severely impaired cognition, exhibited physical behaviors such as grabbing and hitting. Despite these behaviors, there was no documentation of hallucinations or delusions, and the resident was placed on hospice care with a focus on comfort. The resident's physician's orders included Risperdal for dementia with behavior issues, and a second antipsychotic, Quetiapine Fumarate, was added for anxiety/agitation. However, the Quetiapine order had not been administered, and there was no psychotic behavior monitoring in place. Interviews with staff revealed a lack of specific behavior monitoring related to psychosis and an acknowledgment that dementia is not an approved diagnosis for antipsychotic medications. The facility's Director of Nursing Services and Social Services staff noted that the resident's behaviors were likely involuntary responses during care, and the goal was to discontinue antipsychotics.
Untrained Staff Providing Feeding Assistance
Penalty
Summary
The facility failed to ensure that residents with physical impairments and/or swallowing difficulties were fed by staff who were properly trained. This deficiency was observed when Staff L, an Activities Manager without a nursing license or specialized training, provided feeding assistance to Resident 22 during breakfast. Resident 22's care plan indicated the need for assistance from one staff member for eating, due to a swallowing problem, and specified a minced and moist texture diet. Despite the facility's assertion that they did not employ paid feeding assistants, Staff L was observed feeding Resident 22, which was confirmed by Staff B, the Director of Nursing Services. Staff B stated that non-nursing staff should not provide feeding assistance, although they could pass trays and hand items to residents. The lack of proper training and supervision for Staff L in providing feeding assistance posed a risk to Resident 22, who required specialized care due to their swallowing difficulties.
Infection Control and Equipment Storage Deficiencies
Penalty
Summary
The facility failed to ensure staff adhered to procedures for preventing the spread of disease, particularly in the context of Transmission Based Precautions (TBP) and the sanitary storage of respiratory equipment. In one instance, a Registered Nurse, identified as Staff P, entered a room with Enhanced Barrier Precautions (EBP) without wearing a gown, despite the presence of a sign indicating the need for such precautions. This oversight occurred during a dressing change for Resident 252, who was on EBP. Staff P later admitted to being unaware of the resident's precautionary status, highlighting a gap in communication or training. Additionally, the facility did not maintain respiratory equipment in sanitary conditions for Resident 252. Observations revealed that the resident's breathing treatment equipment, including a facemask, medication cup, and tubing, was left uncovered on a bedside table. This equipment was stored alongside personal items in a gray basin, contrary to the facility's policy, which required the equipment to be washed, air-dried, and stored in a labeled plastic bag. Staff K, an LPN, confirmed the correct procedure but noted the failure to adhere to it. Another deficiency was observed with Staff I, the Maintenance Supervisor, who entered a room under contact precautions without performing hand hygiene or wearing a gown. Despite applying an N95 respirator and gloves, Staff I failed to follow proper protocol by not disinfecting a metal cart used in the room and by handling items without appropriate hand hygiene. Staff I admitted to not realizing the room required such precautions, indicating a lack of awareness or training regarding infection control measures.
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.
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What surveyors actually found near you
We read the 775 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Everett
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Madison Post Acute | 1.7 mi | ★★★★★ | 1 | 0 |
| Everett Transitional Care Services | 1.9 mi | ★★★★★ | 8 | 0 |
| Bethany At Pacific | 3 mi | ★★★★★ | 0 | 0 |
| Everett Center | 4 mi | ★★★★★ | 15 | 0 |
| Bethany At Silver Lake | 4.4 mi | ★★★★★ | 10 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.