Below average — CMS composite of the measures below.
The next survey window likely opens 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 Washington Care Center during CMS and state inspections, most recent first.
Failure to Complete Transfer Notices, Bed-Hold Offers, and LTCO Notifications: Staff did not complete required transfer paperwork and notifications for multiple residents who were sent to the hospital. Records showed no bed-hold offers for several residents, no written transfer notices for residents or their representatives, and delayed LTCO notification for some transfers. The affected residents included individuals with conditions such as infection, anemia, mental status changes, dialysis needs, respiratory disease, and low oxygen levels, and several had DPOAs in place.
Incomplete Arbitration Agreement Process: The facility failed to ensure residents and/or their representatives were informed of the nature and implications of a binding arbitration agreement and their right to refuse. Two residents with intact cognition signed agreements without indicating acceptance or decline, and later stated they did not remember signing or know what the agreement was for. A third resident with severe memory impairment had an agreement that was not signed by the resident or representative and was left incomplete.
A facility failed to honor resident rights by not obtaining proper consent before giving immunizations and an antipsychotic medication to a resident with dementia, and by using wander/elopement devices for two other residents without complete consent documentation. One resident had declined flu and COVID vaccines, another repeatedly refused a wander device and said they felt trapped, and a third had an elopement device applied before consent was documented and later had the device attached to a wheelchair instead of worn.
Failure to Document AD Information: The facility did not ensure two residents received and had documented information about their right to accept or refuse treatment and establish an AD. One resident had severe memory impairment and a POA on file, but the facility communicated with a family member who was not the appointed POA. Another resident with no memory impairment said they were not offered AD information, and the record lacked documentation that staff helped explain or implement an AD or contacted the resident’s brother, who was listed as the primary emergency contact.
A facility failed to keep several resident rooms safe, clean, and homelike. Observations found soiled privacy curtains, a large hole in a wall, a bent heater bracket protruding into a room, a dirty baseboard heater, and one resident room with no personal belongings, pictures, or decorations. The DON and Maintenance Director acknowledged the environmental concerns, and one resident reported repeatedly bumping into the heater bracket and having told a nurse about it earlier.
Inaccurate PASRR Screenings for Residents With Mental Health Diagnoses: The facility failed to keep PASRR Level 1 screenings accurate for four residents with documented MH conditions and psychotropic medication use. Records showed schizophrenia, depression, anxiety, and dementia with psychotic disturbances, but the PASRRs did not reflect the residents’ current mental status or indicate Level 2 evaluation when needed; the SS director acknowledged the screenings were not accurate.
Care plans were not updated to match current resident needs for four residents. One resident on hospice had repeated refusals of wound care and skin checks, but the skin care plan did not address those refusals. Two residents who were dependent on staff for repositioning were observed lying on their backs without the expected turning and positioning interventions, and one of those residents was also observed with the bed raised and the door closed despite fall-risk and isolation-related care plan directions. Another resident with cognitive impairment and full ADL dependence had a fall from bed with injury, but the care plan was not updated to reflect the fall or the use of a concave mattress.
Physician orders were not followed for several residents. A resident with kidney failure, chronic pain, and impaired mobility received O2 at a higher flow than ordered, pain meds were given outside ordered pain parameters, and a bowel program was not followed after multiple days without a BM. Another resident had an unclear PRN pain order with no documentation showing whether doses were for pain or fever, and a wander guard was applied without a provider order. A third resident’s pain record lacked documentation of nonpharmacological interventions.
Failure to provide and reoffer ADL assistance for two dependent residents. One resident with urinary and bowel incontinence, dependence for bathing, dressing, oral hygiene, and mechanical-lift transfers had repeated bath refusals documented, including one missed scheduled bath, and was observed in bed unclothed with unbrushed hair. Another resident with similar ADL dependence and incontinence was observed in bed in a gown with messy hair and stated staff did not offer help with hygiene, dressing, or getting out of bed.
Unsecured chemicals and sharps were found in multiple utility and linen rooms. A soiled utility room door was left unlocked with cleaning chemicals inside, a clean linen room had no lock and contained drug disposal gel with medications, and a clean utility room door would not lock even though it stored razors and nail clippers. Staff stated these items should have been behind locked doors for resident safety, and the DON said chemicals and sharps were expected to be secured.
Staff failed to follow EBP PPE requirements for two residents with EBP signage posted outside their rooms. One CNA entered a room without hand hygiene and assisted with transfers, dressing, hygiene, and urinary catheter care without gowns, while an RN applied medicated skin cream to another resident’s leg without a gown, despite the signs directing staff to wear gloves and gowns for high-contact care activities.
Failure to Monitor ABO Use: The facility failed to implement its ABO stewardship program for two residents reviewed for unnecessary antibiotics. One resident received ABOs for a UTI and an upper respiratory infection, and another resident received an ABO for fever only. The Infection Preventionist stated the ABOs were not tracked on the stewardship line listing and did not have McGeers assessments or ABO time outs completed, despite the facility policy requiring those reviews.
A resident who required total assistance for transfers, including the use of a mechanical lift with two-person support, was transferred by a CNA without a second staff member present. This failure to follow the care plan led to the resident falling from the lift and sustaining a traumatic brain injury, multiple brain bleeds, a neck fracture, and facial fractures. The incident was attributed to the CNA not reviewing or following the Kardex instructions, placing other residents needing similar assistance at risk.
A resident with significant mobility and medical needs was injured after being repositioned by a single CNA, despite care plan instructions requiring two-person assistance. The resident fell from bed and sustained multiple fractures, and records showed that not all CNAs had completed required training on care protocols.
The facility failed to maintain effective infection control practices, with inadequate PPE availability for staff caring for residents requiring Enhanced Barrier Precautions. Observations showed isolation carts were not stocked, and staff reported inconsistency in PPE supply and accessibility. Additionally, hand sanitizer dispensers were malfunctioning in several rooms, and residents noted staff did not consistently wear protective gear during care.
The facility failed to obtain informed consent for medications for three residents, including those with depression and anxiety. One resident received an antidepressant for insomnia without consent, another with depression and suicidal ideation received medications without consent, and a third had outdated and incomplete consent forms. The Regional Director of Clinical Operations confirmed these deficiencies.
The facility failed to maintain a homelike environment, with issues such as dirty and damaged walls, misaligned doors, hanging ceiling tiles, and dusty fans in resident rooms. Additionally, broken floor tiles, worn closets, and stained privacy curtains were observed. The facility entrance had broken cement tiles, posing a risk of injury. Staff X confirmed these issues and stated they should have been addressed promptly.
The facility failed to provide required written notices to residents and their representatives during transfers to hospitals. This deficiency affected five residents, as confirmed by interviews and record reviews. The Social Services Director admitted to not completing written notices for hospital transfers, citing a lack of awareness of the requirement.
The facility failed to complete PASRR Level II evaluations for three residents identified as needing them. A resident with anxiety disorder and mood swings was not referred for evaluation, while another with anxiety, depression, and bipolar disorder had no Level II evaluation completed. A third resident with complex conditions and on antipsychotic medications also lacked a necessary evaluation. Staff confirmed these oversights.
The facility failed to ensure accurate PASRR assessments for three residents, leading to potential risks in their care. A resident with depression and PTSD was not identified with SMI indicators, another resident's psychosis diagnosis was omitted, and a third resident's need for a Level II evaluation was not documented. The Social Services Director acknowledged these inaccuracies.
The facility failed to maintain accurate and updated care plans for several residents, leading to unmet care needs. A resident had conflicting care plans regarding bladder continence, while another's care plan included outdated interventions for discontinued medication. Observations showed a resident struggling with eating, yet their care plan lacked specific assistance instructions. Another resident's care plan did not include necessary tube feeding precautions. Significant weight loss in a resident was not documented in their care plan, and another's care plan lacked instructions for antibiotic use. Additionally, a resident's care plan did not include instructions for compression hose application despite a physician's order.
Several residents in a LTC facility were not provided adequate assistance with ADLs, leading to poor personal hygiene and grooming. Residents dependent on staff for tasks like bathing and dressing were observed with long fingernails, greasy hair, and strong odors. Staff interviews revealed a lack of assigned shower aides and inconsistent care practices, contributing to the deficiency.
A resident with decreased bed mobility developed pressure ulcers due to the facility's failure to conduct weekly skin assessments, adjust air mattress settings according to the resident's weight, and follow care plans. The resident refused certain interventions due to discomfort, and staff were unaware of how to adjust the air mattress. The resident's wounds deteriorated as a result.
The facility failed to ensure proper supervision and storage of smoking materials for several residents, contrary to its policy. Residents were found with cigarettes and lighters in their possession, and some refused safety measures like smoking aprons. Additionally, chemicals and sharps were left unsecured in utility rooms, posing safety risks. Staff interviews confirmed these lapses, highlighting a failure to maintain a hazard-free environment.
The facility failed to maintain infection control practices, including hand hygiene, use of PPE, and Enhanced Barrier Precautions. Staff did not perform hand hygiene during resident care and dining services, and failed to use PPE for residents under Transmission Based Precautions. Additionally, Enhanced Barrier Precautions were not initiated for residents with specific health conditions, and staff were observed wearing contaminated gloves in hallways.
The facility failed to provide written notification of its bed-hold policy to residents or their representatives during hospital transfers, affecting four residents. Interviews revealed inconsistencies in documentation processes, with staff providing conflicting accounts of departmental responsibilities. Records for the affected residents showed no documentation of bed-hold notifications, indicating a systemic issue in the facility's process.
The facility failed to follow Physician's Orders for several residents, including inconsistent flushing of a feeding tube, improper application and removal of a pain patch, and lack of compression stockings. Orders were not clarified for a resident on dialysis, leading to potential medication errors. Additionally, a resident received narcotic medication outside prescribed parameters, and tube feeding supplies were unlabeled.
Two residents in an LTC facility were not provided with individualized activity programs, leading to potential boredom and diminished quality of life. One resident, with anxiety and depression, had minimal documented activities and lacked control over their television. Another resident, with complex medical conditions, was observed not participating in activities despite having preferences for outdoor and religious activities. The facility's activity program policy was not adequately implemented for these residents.
The facility failed to provide adequate care for two residents, including pain management for a resident with a venous skin ulcer, proper monitoring and documentation of frequent diarrhea, and adherence to physician orders for compression stockings to manage edema. Despite recommendations and orders, the facility's records and observations showed lapses in care, with staff interviews revealing a breakdown in communication and execution of care plans.
The facility failed to provide adequate bowel and bladder care for two residents, leading to deficiencies. One resident, with impaired memory, was found in a room with a strong urine odor and wet clothes, with no completed bladder assessment or nighttime assistance. Another resident, requiring assistance for mobility, reported frustration due to lack of staff response to toileting requests, leading to the use of briefs. The facility did not complete necessary assessments to address the residents' incontinence needs.
The facility failed to properly store, label, and dispose of medications and supplies, with expired items found in medication carts and rooms. An opened vial of a Tuberculosis agent was over 30 days old, and a medication fridge's temperature log was incomplete. Staff confirmed these practices were against policy, risking resident safety.
The facility failed to protect a resident from sexual abuse, resulting in psychological harm. A resident with severe decision-making impairments and a history of trauma was found in a compromising situation with another resident who had a documented history of sexual behaviors. The facility's inadequate supervision and documentation allowed the incident to occur, leading to the resident being transferred to a hospital for evaluation.
Failure to Complete Transfer Notices, Bed-Hold Offers, and LTCO Notifications
Penalty
Summary
The facility failed to complete required transfer and discharge notifications for multiple residents who were hospitalized. The report states that staff did not offer bed holds for Residents 1, 5, 11, 8, 23, and 4, did not provide written transfer notices for Residents 1, 5, 11, 8, 23, 4, and 105, and did not timely notify the State Long Term Care Ombudsman for Residents 1, 8, and 23. The cited policies required the facility to inform the resident or representative of a bed hold within 24 hours of transfer and to provide transfer/discharge notices that included appeal information and notification to the LTCO. Resident 1 was discharged to the hospital due to a change in condition, with diagnoses including bladder infection and lower back pain. The record review found no documentation that staff offered a bed hold or provided Resident 1 or the representative with a written notice explaining the reason for transfer. Staff stated nursing staff were responsible for offering bed holds and providing written discharge notices, and the DON confirmed these actions were not completed for Resident 1. Resident 5 was hospitalized for deficiency of red blood cells and change in mental status, and Resident 11 was hospitalized for multiple medical conditions including dialysis and leg fracture. For both residents, the record showed no documentation that the facility sent the e-INTERACT report to the hospital, offered a bed hold, or provided written transfer notices to the resident or representative. Resident 8 had multiple hospital transfers throughout the year, and the record showed no report to receiving facilities and no written transfer notifications for those transfers; several transfers also had no bed hold offered, and LTCO notifications were not done until November 2025 for earlier transfers. Resident 23, who had severe memory impairment, chronic respiratory disease, and a DPOA, was transferred for respiratory failure and fever, but the record showed no report to the receiving hospital, no bed hold offered, no written transfer notice to the DPOA, and LTCO notification occurred five months later. Resident 4, who had anxiety and depression and a DPOA, was transferred while unresponsive with low oxygen levels, and the record showed no written transfer notice to the DPOA, no bed hold offered, and no report to the receiving hospital. Resident 105 was transferred to the hospital, and the DON stated there was no documentation that the required written transfer notification was provided.
Incomplete Arbitration Agreement Process
Penalty
Summary
The facility failed to ensure residents and/or their representatives were informed of the nature and implications of entering into a binding Arbitration Agreement and of their right to refuse for 3 of 3 residents reviewed for arbitration. Resident 1 had intact memory and was able to make decisions per the 11/23/2025 Quarterly MDS, but the arbitration agreement was signed by the resident on 05/22/2025 without the column being checked to indicate acceptance or decline. In an interview on 12/12/2025, Resident 1 did not remember signing the agreement and stated they did not know what it was for. Resident 33 had no memory impairment and was able to make their own decisions per the 11/06/2025 Quarterly MDS, but their arbitration agreement was also signed by the resident on 05/20/2025 without the acceptance or decline column being checked. In interview, Resident 33 stated they did not know what the agreement was for, did not remember signing it, and said they would not sign it now that they knew what it was for. Resident 101 had severe memory impairment and was not capable of decision making per the 10/27/2025 Quarterly MDS, but the arbitration agreement was not signed by the resident or their representative and did not show acceptance or decline. The Administrator stated they were responsible for the arbitration agreement process and confirmed the agreements were not complete.
Failure to Obtain Proper Consent for Immunizations, Psychoactive Medication, and Elopement Devices
Penalty
Summary
The facility failed to provide care and services in a manner that maintained residents’ rights for Resident 23, Resident 25, and Resident 7 in relation to consent and refusal of services. The report states the facility did not follow resident wishes or obtain proper consent before administering immunizations and an antipsychotic medication to Resident 23, who had severe memory impairment and a diagnosis of dementia. Resident 23 had a signed vaccine consent form declining influenza and COVID-19 vaccines, yet the facility administered both vaccines. The record also showed a psychoactive drug consent form with verbal authorization for an antipsychotic medication given by someone other than Resident 23’s POA. Resident 25 was admitted with diagnoses including dementia, mood disturbance, and anxiety, and was documented as able to understand others. The resident had a history of wandering and attempts to leave the facility, and the care plan included use of a wander monitoring device. The device and enabler evaluation showed verbal consent with only one staff signature and no additional witness signature. Resident 25 stated staff would not let them leave and that they felt trapped, and also stated they would not wear the wander device. Staff interviews indicated the resident often removed the device, and staff placed it in the resident’s bag or on the resident because of repeated refusal. Resident 7 was admitted with gout and no cognitive impairment, later had confusion and attempts to leave the facility, and was placed on an elopement device order. The device was applied before the consent form reflected verbal consent, and the consent form had no staff signatures. Observations showed the device attached to the wheelchair handle rather than worn by the resident. Resident 7 stated staff placed the device on their wrist without permission, then attached it to the wheelchair after the resident refused to wear it, and the resident’s representative denied knowledge of the device placement and believed the resident could sign their own consents. Staff interviews confirmed the consent process was incomplete and that written informed consent and required staff signatures had not been obtained.
Failure to Document Advance Directive Information
Penalty
Summary
The facility failed to ensure that residents and/or their representatives received written information about the right to accept or refuse treatment by formulating an Advance Directive for 2 residents. The facility policy stated residents were to be informed of their right to make health care decisions, including the right to refuse treatments and prepare an AD, and staff were to obtain written acknowledgements for the medical record. Resident 23 had severe memory impairment on the admission MDS and had AD paperwork from 03/15/2019 naming a POA, but the record did not contain contact information for the POA. The facility was communicating care and treatment with a family member who was not the appointed POA. Resident 105 was admitted with a brain infection, weakness, and no memory impairment, but stated they did not recall being offered information to review or establish an AD and would have assigned their brother as POA if unable to communicate preferences. The record listed the brother as the primary emergency contact, but there was no documentation that the facility helped Resident 105 understand or implement an AD, and staff stated they had not contacted the brother to offer the information.
Unsafe and Unhomelike Resident Room Conditions
Penalty
Summary
The facility failed to maintain resident rooms in a safe, clean, and homelike condition for multiple residents. Observations showed soiled privacy curtains in the rooms of two residents, with several small and large brown and red spots and splashes noted on repeated observations. A resident’s room also had a large gouge and hole in the wall behind the bed, and the Maintenance Director stated the hole and the soiled curtains were not identified in the maintenance log sheets. The DON stated staff should report environmental and homelike setting concerns when they find them. The facility also failed to maintain room heaters and to personalize one resident’s room. One resident’s baseboard heater had a bent metal end-bracket that was not attached at the bottom edge and protruded into the room; the resident stated they had repeatedly run into it with a wheelchair, got stuck on it, and had told a nurse about it more than a month earlier. Another resident’s baseboard heater was observed covered in dark brown spots, splashes, and debris, and the resident stated it was dirty and tried covering it up. A third resident’s room had no personal belongings, pictures, or decorations across multiple observations, and the DON stated the resident should have room decorations and personal items for a homelike environment.
Inaccurate PASRR Screenings for Residents With Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure PASRR screenings were accurate for four residents with documented mental health conditions. Resident 5 had diagnoses of schizophrenia, depression, and anxiety, was moderately cognitively impaired, and was receiving routine antipsychotic and antidepressant medications; however, the Level 1 PASRR in the record identified SMI and did not reflect the need for a Level 2 evaluation, and the Social Services Director stated the form was inaccurate. Resident 6 had diagnoses of schizophrenia, depression, and anxiety and was receiving routine antipsychotic and antidepressant medications, but the Level 1 PASRR in the record identified only depression and anxiety and was not updated to reflect the resident’s current mental condition or referral for Level 2 evaluation. Resident 11 had diagnoses of schizophrenia, depression, and anxiety and was receiving antipsychotic and antidepressant medications every day as ordered, yet the Level 1 PASRR in the record was not updated to reflect the resident’s current mental condition or referral for Level 2 evaluation. Resident 23 was admitted with dementia, was taking antipsychotic and antidepressant medications, and had records showing dementia with psychotic disturbances and hospital notes describing agitation, refusal of care, and medication use; however, the PASRR Level 1 in the record showed no serious mental illness and no Level 2 evaluation was indicated. In interview, the Social Services Director stated the PASRRs for these residents were not accurate and should have been updated to reflect their current mental conditions.
Care plans not updated to reflect current resident needs
Penalty
Summary
The facility failed to ensure care plans were updated and revised as needed for four residents whose current care needs were not reflected in their plans. The deficiency involved Resident 10, Resident 79, Resident 23, and Resident 5, and the report states that the lack of updated care plans left residents at risk for unmet care needs, delay in treatments, and a diminished quality of life. The facility administrator did not provide a care planning policy and stated it was standard of practice. Resident 10 was on end-of-life hospice care per the 11/23/2025 MDS and had pressure areas on the heel and back. The revised skin integrity care plan dated 11/24/2025 included hospice services for end-of-life care, but it did not include staff interventions for refusals of wound care treatments. Progress notes showed repeated refusals of wound care and/or skin assessments on multiple dates in December 2025. During interviews, Resident 10 stated they had skin problems and pain during wound care, staff reported the resident often refused wound care and skin assessments, and the DON stated nurses should notify the provider or care providers of refusals and update the care plan with staff interventions. Resident 79’s MDS showed dependence on staff for turning side to side in bed, and the care plans directed frequent repositioning and two-staff assistance to turn and reposition. During observation, Resident 79 was lying on their back and stated they needed staff to turn them on their sides and were concerned staff did not offer help with repositioning. Resident 23’s MDS showed substantial/maximal assistance was needed for turning side to side and that the resident was at risk for falls; care plans directed frequent repositioning, keeping the bed in the lowest position, and avoiding isolation. However, multiple observations showed Resident 23 lying on their back with the bed raised 36 inches and the door closed. Staff stated the resident should have been repositioned every two hours and the bed kept low with the door open, but this was not being followed. Resident 5’s MDS showed moderate cognitive impairment and dependence on staff for all ADLs, including repositioning in bed. The fall care plan directed the bed to remain in a low position, but observations showed the bed in a high position with a concave mattress. After a fall from bed with a forehead injury and hospital transfer, the record contained no physician order and no care plan for the concave mattress, and staff stated the care plan had not been updated after the fall.
Physician Orders Not Followed for Oxygen, Pain, Bowel Program, and Monitoring Device Use
Penalty
Summary
Physician orders were not clarified and followed for multiple residents. Resident 11 had diagnoses including kidney failure, chronic pain, and impaired mobility. A physician order directed staff to provide oxygen at 2 liters per minute via nasal cannula continuously and keep oxygen saturation above 94%, but observations showed the resident receiving oxygen at 3 liters per minute on multiple occasions, and an RN confirmed the oxygen was running at 3 liters per minute. Resident 11 also had pain medication parameters ordered for non-narcotic medication at pain levels 1-3 and narcotic medication at pain levels 4-10, but the December MAR showed the non-narcotic medication was given for pain ratings of 5, 8, and 7, and the narcotic medication was given for pain rated 0. Resident 11 also had a physician order to follow the bowel movement program when no BM occurred for 3 days. The record showed periods of 5 days without a BM and another period of 4 days without a BM, and the December MAR showed staff did not follow the physician orders to administer medications as ordered when the resident had no BM for more than 3 days. Staff E reviewed the record and stated staff should have followed the physician orders for oxygen administration, pain medication parameters, and the bowel movement management program, but they did not. Resident 25 had a pain medication order for 325 mg, give three tablets every 8 hours as needed for pain or fever, but the order did not specify the parameter for how many tablets should be used for pain versus fever. The December MAR showed the medication was administered on three occasions without documentation showing whether it was used for pain or fever. Resident 25 also had an elopement risk care plan showing wandering and attempts to leave the facility, and staff provided a wander guard even though the record did not show a physician order or provider notification before the device was used. Resident 23 received scheduled pain medications, but the record contained no documentation of nonpharmacological pain interventions, and Staff B could not provide documentation of such interventions.
Failure to Provide and Reoffer ADL Assistance
Penalty
Summary
The facility failed to offer and provide assistance with ADLs for 2 of 7 residents reviewed who were dependent on staff for daily cares. Resident 23’s MDS showed frequent urinary incontinence and constant bowel incontinence, and the care plan indicated dependence on staff for bathing, dressing, oral hygiene, and a mechanical lift with two staff for transfers out of bed. The resident had a bathing schedule for Mondays and Fridays, but the POC record showed multiple refusals of bathing across September, October, November, and December 2025, including one scheduled bath that was not offered. The record also showed no bathing reoffered after refusals. During multiple observations, Resident 23 was found lying in bed on their back with hair not brushed, a sheet pulled to the waist, and no clothing. Resident 79’s MDS showed the resident required staff assistance with ADLs and was always incontinent of urine and bowels. The care plan showed dependence on staff for bathing, dressing, oral hygiene, and use of a mechanical lift with two staff for transfers out of bed. During observations and interview, Resident 79 was seen lying in bed wearing a gown with messy hair and stated staff did not offer assistance with hygiene, dressing, or getting out of bed. Staff interviews indicated morning care should include washing, grooming, dressing, brief changes if needed, helping the resident out of bed, and reapproaching residents who refused care, but staff stated these actions were not consistently done.
Unsecured chemicals and sharps in utility and linen rooms
Penalty
Summary
The facility failed to ensure the resident environment was free of accident hazards by not keeping hazardous chemicals and sharps secured in several utility and linen rooms. In the 2 [NAME] Soiled Utility Room, the door was not closed or locked, and the room contained a bottle of shower cleaning chemical, a can of stainless-steel cleaner, and a container for Sani wipes filled with a blue liquid chemical cleaner. Staff K stated the door should be pulled closed and locked because chemicals were stored there, and Staff L also stated the door should be locked for resident safety. In the 2 [NAME] Clean Linen Room, which was behind the nurse's station and had no lock on the door, two bottles of drug disposal chemical digestion gel containing medications were observed. Staff L stated those bottles should be stored behind a locked door in the medication room. In the 2 East Clean Utility Room, the keypad lock was present but the door was not locking when closed, and the room contained 50 razors, 10 fingernail clippers, and 5 toenail clippers. Staff M stated the sharps should be stored there but the door was not locked because the keypad was not working. The DON stated all chemicals and sharps were expected to be stored behind locked doors for resident safety.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to appropriately use PPE in accordance with Enhanced Barrier Precautions for two residents who had EBP signage posted outside their rooms. For Resident 28, staff entered the room without performing hand hygiene, then transferred the resident from bed to wheelchair, moved the urinary catheter bag, and assisted with dressing and hygiene without wearing gowns. The room sign indicated staff must clean their hands before entering and wear gloves and gowns for high-contact resident care activities, including dressing, transferring, and providing hygiene and care of a urinary catheter. For Resident 10, a RN medication nurse applied medicated skin cream to the resident’s left lower leg without wearing a gown, despite the EBP sign outside the room indicating gloves and gowns were required for high-contact resident care activities. During interview, the RN stated they should have worn a gown for infection control reasons but did not. The Infection Preventionist stated staff should follow the EBP directions on the sign and wear gloves and a gown when administering skin treatments.
Failure to Monitor Antibiotic Use
Penalty
Summary
The facility failed to implement an Antibiotic (ABO) Stewardship program to promote appropriate ABO use and reduce the risk of unnecessary ABO use for 2 of 3 residents reviewed for unnecessary antibiotics, Resident 8 and Resident 4. The facility policy titled, ABO Stewardship Program, dated March 2018, stated the facility would ensure residents met McGeers criteria for ABO usage, use standard evaluations and communication tools for residents with suspected infections, utilize Antibiogram reports, and implement ABO time outs. Resident 8 received an ABO from 01/23/2025 until 02/02/2025 for a urinary tract infection and another ABO from 04/01/2025 until 04/04/2025 for an upper respiratory infection. Resident 4 received an ABO from 07/01/2025 until 07/02/2025 for a fever only. During an interview and record review on 12/12/2025, the Infection Preventionist stated both residents' ABOs were not on the facility ABO Stewardship line listing and did not have an ABO timeout or McGeers assessment completed for the 01/2025, 04/2025, and 07/2025 ABOs, although they should have been.
Failure to Provide Required Two-Person Assistance During Mechanical Lift Transfer Resulting in Resident Injury
Penalty
Summary
A resident who required total assistance with all activities of daily living, including transfers using a mechanical lift with two-person assistance, experienced a fall resulting in significant injuries. The resident's care plan, as documented in the Kardex and Minimum Data Set (MDS), specified the need for two staff members to assist with all transfers due to the resident's high risk for falls and significant cognitive impairment. Despite these documented requirements, a Certified Nursing Assistant (CNA) provided care and attempted a transfer using the mechanical lift without a second staff member present. This action was contrary to the resident's assessed needs and the facility's established protocols. As a result of the CNA's failure to follow the care plan, the resident fell from the mechanical lift, landed on the floor, and sustained a traumatic brain injury, multiple areas of bleeding in the brain, an upper neck fracture, and facial fractures. Facility records and staff interviews confirmed that the CNA did not review or adhere to the Kardex instructions, which were designed to ensure resident safety and prevent such incidents. The incident placed not only the affected resident but also other residents requiring similar assistance at risk for harm.
Failure to Follow Care Plan Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident, who was assessed as requiring two staff members for repositioning and turning in bed due to paraplegia, seizure disorder, respiratory failure, and other comorbidities, was repositioned by a single CNA. The resident rolled off the bed during this process, resulting in three fractures to the hip, knee, and back, and required increased pain management, including narcotic medications. The resident's care plan and Kardex both specified the need for two-person assistance, but this was not followed. Facility records and interviews revealed that the CNA involved provided care independently, contrary to the resident's care plan. The facility's investigation confirmed that the fall and resulting injuries could have been prevented if the care plan had been followed. Additionally, review of staff training records showed that several CNAs had not completed required Kardex Protocol training prior to returning to work, with only 75% of CNA staff having completed the training. Staff interviews indicated issues with training reminders and access, contributing to inadequate education on following care plans.
Inadequate Infection Control Practices and PPE Availability
Penalty
Summary
The facility failed to establish and maintain effective infection control practices, as evidenced by the lack of Personal Protective Equipment (PPE) availability for staff caring for 12 out of 19 residents requiring Enhanced Barrier Precautions (EBP) due to specific diagnoses such as wounds and indwelling medical devices. Observations revealed that isolation carts outside resident rooms were not stocked with the necessary PPE, and staff interviews indicated inconsistency in PPE supply and accessibility. Staff members reported not knowing where to obtain PPE supplies and disregarded isolation signs when providing care, highlighting a lack of guidance and resources following the departure of the Infection Preventionist Nurse. Additionally, the facility failed to ensure that alcohol-based hand sanitizer dispensers were functioning properly in 25 out of 46 rooms, both inside and along the hallway outside occupied resident rooms. Interviews with residents confirmed that staff did not consistently wear gowns and gloves during care, and malfunctioning hand sanitizer dispensers were reported but not addressed. The Director of Nursing acknowledged the expectation for accurate isolation signs and PPE restocking, while the Regional Administrator emphasized the importance of functioning hand sanitizer dispensers and staff knowledge of supply locations.
Failure to Obtain Informed Consent for Medications
Penalty
Summary
The facility failed to ensure that residents were provided informed consent for treatments, specifically regarding the explanation of risks and benefits of medications. This deficiency was identified for three residents whose medication regimens were reviewed. Resident 113, diagnosed with depression and anxiety, was prescribed an antidepressant for insomnia without evidence of informed consent. Staff C, the Regional Director of Clinical Operations, confirmed the absence of informed consent documentation for this resident. Similarly, Resident 17, who had a diagnosis of depression with suicidal ideation, received antidepressant and antipsychotic medications without documented informed consent. Staff C acknowledged the lack of consent for this resident as well. Additionally, Resident 21, with diagnoses including depression, anxiety, and a psychotic disorder, had outdated and incomplete consent forms for antipsychotic and antidepressant medications. Staff C noted that the reasons and diagnoses for these medications were not explained to the resident or their representative prior to administration.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a homelike environment in two of its units and the entryway, as observed by surveyors. On the 100 Unit, the first-floor shower room door had multiple tan smears visible from the hallway, and a shared bathroom had dried brown debris on the walls and floor, which remained uncleaned for several days. The supply closet doors were misaligned and could not be closed, and ceiling tiles in a resident's room were hanging down precariously. A box fan in another room was covered in dust debris, which was being blown around the room. Staff X, the Maintenance Director, confirmed these issues and stated that they should have been addressed promptly. On the 200 East Unit, a room had a wheelchair with a dirty commode bucket parked in the bathroom, and deep scratches were observed on the wall behind a resident's bed. The closet had missing wood chunks and exposed metal hardware. Another room had a broken floor tile, and closets in two rooms were worn with missing wood, with one supported by adhesive tape. A privacy curtain in a room was stained, and Staff X acknowledged the unclean conditions and broken fixtures, noting that the facility was awaiting an order for backing behind the beds. Additionally, the facility entrance had broken and missing cement tiles, posing a risk of injury, as confirmed by Staff X.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide required written notices to residents and their representatives at the time of transfer or discharge to an acute care hospital. This deficiency was identified for five residents who were reviewed for hospitalizations. The lack of written notification was confirmed through interviews and record reviews, which showed no documentation of such notices being provided. Specifically, Residents 127, 34, 113, 55, and 96 were transferred to hospitals without receiving the necessary written communication regarding their discharge. Staff E, the Social Services Director, acknowledged during an interview that they did not complete written notices of transfer when residents were sent to the hospital. Staff E stated that they were unaware of the requirement to provide written notifications for hospital transfers and only completed notices when residents were discharged from the facility. This oversight placed residents at risk of being discharged without alignment with their care goals and preferences, as there was no documentation of the reasons for their discharge in a language and manner they understood.
Failure to Complete PASRR Level II Evaluations
Penalty
Summary
The facility failed to ensure that Pre-admission Screening and Resident Review (PASRR) Level II comprehensive evaluations were obtained for three residents who were identified as needing them. Resident 134, who had diagnoses of anxiety disorder and a chronic mental illness, was not referred for a Level II PASRR evaluation despite indicators of a serious mental illness (SMI) being present. Staff E, the Social Services Director, confirmed that a referral should have been made but was not. Similarly, Resident 85, who had diagnoses including anxiety, depression, and bipolar disorder, was identified as needing a Level II PASRR evaluation due to SMI indicators. However, no Level II evaluation was completed, as confirmed by Staff E. Resident 113, with complex medical conditions and taking antipsychotic and antidepressant medications, also required a Level II PASRR evaluation, which was not in place. Staff E acknowledged that Level II services should have been followed up on but were not.
Inaccurate PASRR Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate Pre-Admission Screening and Resident Review (PASRR) assessments for three residents, which is crucial for determining their mental health needs and appropriate care. Resident 34, who had diagnoses of depression and PTSD, was not identified with Serious Mental Illness (SMI) indicators in their Level I PASRR, despite requiring antidepressant and antianxiety medications. Staff E, the Social Services Director, acknowledged the inaccuracy of Resident 34's PASRR Level I, which needed updating to reflect the resident's mental health conditions accurately. Resident 113's Level I PASRR did not reflect their psychosis diagnosis or auditory hallucinations, despite the resident taking antipsychotic and antidepressant medications for these conditions. Staff E confirmed that the PASRR should have included this information. Additionally, Resident 17, who had schizophrenia and depression, was inaccurately documented in their Level I PASRR as not requiring a Level II evaluation, and there was no documentation of an invalidation report. Staff E noted the inaccuracies in Resident 17's PASRR, including the language used and the need for a Level II evaluation.
Deficiencies in Care Plan Updates and Accuracy
Penalty
Summary
The facility failed to ensure that care plans (CPs) were accurate, regularly reviewed, and revised to reflect the current status and needs of seven residents. For Resident 48, there were conflicting CPs regarding bladder continence, with one indicating continence and another indicating incontinence. Staff acknowledged that CPs should be updated to reflect the resident's current condition. Resident 113's CP still included interventions for antipsychotic medication use, despite the medication being discontinued, indicating a lack of timely updates to the CP. Resident 10's CP did not specify the level of assistance required for eating, despite observations showing the resident struggled with eating independently. Resident 150's CP and Kardex lacked specific instructions for tube feeding precautions, such as keeping the head of the bed elevated to prevent aspiration. Staff confirmed that these instructions were necessary but not included in the CP. Resident 55 experienced significant weight loss, yet their CP did not document this or provide any interventions for staff to follow. Resident 99's CP did not include instructions related to the use of an antibiotic for a bladder infection, and Resident 85's CP lacked instructions for applying compression hose for edema, despite a physician's order. Staff interviews confirmed that these omissions were contrary to the facility's requirements for maintaining accurate and up-to-date CPs. These deficiencies left residents at risk for unmet care needs and a diminished quality of life.
Inadequate Assistance with ADLs in LTC Facility
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADLs) for several residents, leading to issues with personal hygiene and grooming. Residents 21, 55, 99, 134, 10, 150, and 71 were observed with long, broken fingernails, greasy hair, and in some cases, strong odors due to infrequent showers and inadequate personal care. These residents were dependent on staff for assistance with tasks such as bathing, dressing, and oral hygiene, yet the facility did not meet these needs consistently. For instance, Resident 21 was noted to have received only three showers in the past 30 days, despite requiring assistance due to physical weakness. Staff interviews revealed systemic issues in the facility's approach to providing care. Staff I, a registered nurse, confirmed the lack of adequate personal hygiene care for Resident 21, citing a urine odor in the resident's room due to nighttime incontinence. Similarly, Staff L, a CNA, indicated that the facility did not have an assigned shower aide, and CNAs were responsible for providing showers, which were often limited to residents who could walk to the shower rooms. This practice left residents like 55 and 99, who required maximal assistance, without proper bathing and grooming care. The facility's failure to adhere to its own policies and care plans was evident in the lack of documentation and follow-up on residents' ADL needs. Staff S, a unit manager, acknowledged that staff should provide all necessary ADL care, including oral care, dressing, and showers, and document any refusals. However, the observations and interviews indicated that these practices were not consistently followed, resulting in diminished quality of life for the affected residents.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services to a resident with pressure ulcers, consistent with professional standards of practice. The resident, who was admitted with weakness on the left side of their body, developed pressure ulcers in the facility and was at risk for more due to decreased bed mobility. The facility did not complete weekly skin assessments as required, with only one skin check documented in July and none in August. Observations showed the resident lying on their back without heel/elbow protectors, and the air mattress settings were not adjusted according to the resident's weight, which was significantly lower than the settings indicated. Interviews revealed that the resident refused certain interventions like heel floaters and pillows under their heels due to discomfort, and staff were unaware of how to adjust the air mattress settings. The resident expressed that they stayed in bed due to wounds on their back and buttocks, and lying on their side was painful. A contracted wound care provider noted that all of the resident's wounds had deteriorated. The facility's failure to follow physician orders, care plans, and facility policies contributed to the resident's condition worsening.
Failure to Secure Smoking Materials and Hazardous Items
Penalty
Summary
The facility failed to maintain an environment free from accident hazards, particularly concerning the supervision and storage of smoking materials for several residents. Residents 135, 117, 54, 43, and 22 were observed with smoking materials in their possession, contrary to the facility's smoking policy, which mandates that all smoking materials be stored with the activities or nursing departments. Resident 135, who had balance problems, was seen with cigarettes and a lighter in their room and during a smoke break, refused to wear a smoking apron, and was not supervised adequately as per the policy. Similarly, Resident 117, who also had balance issues, was found with cigarettes in their lap, and Resident 54, who had limited range of motion, was observed with cigarettes in their room. Resident 43 and Resident 22 were also found with smoking materials on their person, violating the facility's policy. The facility also failed to secure chemicals and sharps in designated areas, posing additional safety risks. Observations revealed that the janitor room on the first floor and the Second Floor-West clean utility room were left unlocked, with various hazardous chemicals accessible. These included disinfectants, glass cleaners, and a bottle of Super Blue Mild Acid Bowl Cleaner, all labeled with cautionary warnings. Additionally, the clean utility room on the first floor contained unsecured shaving razors, which were accessible due to a malfunctioning door lock that had not been addressed for nearly two months. Interviews with staff confirmed these lapses in safety protocols. Staff A, the Administrator, acknowledged that smoking supplies should be kept with the smoking aid, while Staff S, the Unit Manager, and Staff C, the Regional Director of Clinical Operations, confirmed that chemicals and razors should not be left unsecured. These failures in supervision and securing hazardous materials placed residents at risk for smoking-related injuries and other accident hazards, compromising their safety.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain proper infection control practices, as evidenced by multiple observations and interviews. Staff members did not perform hand hygiene (HH) during resident care and dining services, despite the facility's policy requiring HH before and after resident contact and room entry or exit. For instance, a Certified Nursing Assistant (CNA) was observed delivering meal trays to multiple residents without washing or sanitizing their hands, citing being too busy as the reason for non-compliance. This lack of adherence to HH protocols was confirmed by the Infection Control staff, who stated that HH was expected before and after resident interactions. Additionally, the facility did not ensure the use of Personal Protective Equipment (PPE) for residents under Transmission Based Precautions (TBP). Staff members were observed entering rooms with posted contact enteric precautions without wearing the required gowns and gloves. In one case, a CNA entered a resident's room, who was on contact enteric precautions for a contagious bacterial infection, without donning PPE and only used hand sanitizer upon exiting, contrary to the posted instructions to wash hands with soap and water. The facility also failed to identify and initiate Enhanced Barrier Precautions (EBP) for residents who required them. Observations revealed that residents with urinary catheters, pressure ulcers, and feeding tubes did not have EBP signs posted on their doors, which are necessary to instruct staff on the required precautions. Furthermore, staff were seen wearing contaminated gloves in the hallways after providing care, which is against the facility's expectations. These lapses in infection control practices were acknowledged by the Infection Control staff, who admitted that EBP signs should have been placed and gloves should not be worn in hallways.
Failure to Provide Bed-Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of its bed-hold policy to residents or their representatives at the time of transfer to a hospital or within 24 hours, as required. This deficiency was identified for four residents who were transferred to acute care hospitals with the anticipation of return. For Resident 127, there was no documentation indicating that the facility provided the required written information regarding the bed-hold policy when the resident was transferred to the hospital for stomach issues and blood loss. Similarly, Resident 34's records lacked documentation of the bed-hold policy being communicated, despite the resident being transferred to a hospital. Interviews with facility staff revealed inconsistencies in the process of documenting and communicating bed-hold information. Staff E, the Social Services Director, and Staff W, the Admissions Coordinator, provided conflicting accounts of which department was responsible for completing bed-hold documentation. Additionally, Staff C, the Regional Director of Clinical Operations, noted that the eINTERACT Transfer Form, which should include bed-hold information, was not completed for Residents 127 and 34. The records for Residents 55 and 96 also showed no documentation of bed-hold notifications, indicating a systemic issue in the facility's process for informing residents and their representatives of their rights regarding bed-hold policies during hospital transfers.
Deficiencies in Following Physician's Orders and Documentation
Penalty
Summary
The facility failed to ensure that Physician's Orders (POs) were followed for several residents, leading to unmet care needs and potential negative health outcomes. For Resident 1, the facility did not consistently flush the feeding tube with the prescribed amount of water, as documented in the Medication Administration Record (MAR). Despite observations showing the tube feeding pump was set correctly, the actual amounts recorded varied significantly from the ordered 640 CC daily. This inconsistency in following POs was acknowledged by the Regional Director of Clinical Operations. Additionally, the facility did not ensure that nurses signed only for tasks completed, as evidenced by the cases of Residents 10 and 85. Resident 10 had a pain medication patch that was not removed as scheduled, despite documentation indicating otherwise. Similarly, Resident 85 was supposed to have compression stockings applied daily, but observations showed they were not wearing them, and the resident confirmed they were never provided. Staff interviews revealed awareness of the orders but a failure to execute them properly. The facility also failed to clarify POs for Residents 10 and 107, leading to confusion and potential medication errors. Resident 10's pain patch order lacked specific instructions on placement and frequency, while Resident 107's dialysis schedule conflicted with their medication times, with no orders to hold or adjust medications. Furthermore, Resident 34 received a narcotic pain medication outside the prescribed parameters, and Resident 150's tube feeding supplies were not labeled as required. These deficiencies highlight significant lapses in following and clarifying POs, as well as in medication administration and documentation practices.
Failure to Provide Individualized Activities for Residents
Penalty
Summary
The facility failed to provide individualized activity programs for two residents, leading to a risk of boredom and diminished quality of life. Resident 95, who was assessed with a slightly impaired mood and diagnosed with anxiety and depression, had a care plan that included goals for engaging in independent activities and attending group activities weekly. However, from the time of admission until mid-August 2024, there was minimal documentation of activities offered or participated in by Resident 95. The resident expressed that staff did not provide them with things to do, and observations confirmed the lack of available activity materials and control over their television. Resident 150, with complex medical diagnoses including stroke and paralysis, was also not provided with meaningful activities as per their care plan. Despite the resident's preferences for outdoor activities, religious services, and crafts, observations showed the resident lying in bed without engaging in any activities. The activity documentation for the previous 30 days showed no recorded activities, and the staff admitted to difficulties in understanding the resident's communication, relying on family input for activity preferences. The facility's activity program policy aimed to support residents' well-being through independent and group activities, but the implementation for Residents 95 and 150 was inadequate. The Activity Director acknowledged the importance of activities for residents' mental well-being but failed to ensure that the residents' preferences and needs were met, as evidenced by the lack of documented activities and the residents' reports of insufficient engagement.
Deficiencies in Pain Management, Diarrhea Monitoring, and Edema Care
Penalty
Summary
The facility failed to provide adequate pain management and care for Resident 60, who was suffering from multiple chronic conditions including a venous skin ulcer. Despite a recommendation from an outside wound team to administer pain medication 30 minutes prior to wound treatment, the facility's records showed no pain medication was given to Resident 60 from the beginning to the middle of August 2024. Interviews with Resident 60 revealed complaints of pain, and observations confirmed the resident experienced pain during wound care, contradicting staff claims that pain medication had been administered. Additionally, the facility did not properly monitor or document Resident 60's episodes of diarrhea, which were frequent and severe enough to cause incontinence issues. The care plan did not address the risk of diarrhea, and staff failed to notify the provider of these episodes, indicating a breakdown in the facility's diarrhea management system. Interviews with staff revealed an expectation for care staff to inform nurses of such issues, which did not occur, potentially missing serious health concerns. For Resident 85, the facility neglected to follow physician orders for the application of compression stockings to manage edema. Despite documentation indicating that compression stockings were applied daily, observations showed Resident 85 was not wearing them, and staff interviews confirmed the absence of compression stockings. The care plan lacked instructions for this essential treatment, and staff were unable to locate the necessary compression stockings, highlighting a failure in executing prescribed care for edema management.
Deficiency in Bowel and Bladder Care for Two Residents
Penalty
Summary
The facility failed to provide adequate care for two residents, leading to deficiencies in managing bowel and bladder incontinence. Resident 21, who had impaired memory and required assistance with personal hygiene, was observed in a room with a strong urine odor and was found with wet clothes due to urine. Despite being able to use the bathroom independently during the day, Resident 21 was incontinent at night and used briefs. The facility did not complete a bowel and bladder assessment for Resident 21, and there was no documentation of staff offering assistance at night or assessing the resident's bladder needs, which could have made Resident 21 a candidate for bladder training. Resident 71, who required moderate assistance for mobility and was dependent on staff for toileting, reported frustration due to staff not providing a bedpan when requested, leading them to use briefs instead. The facility's care plan directed staff to assist Resident 71 with toileting, but no bladder assessment was completed to evaluate the resident's incontinence needs. Interviews with staff revealed a lack of completed assessments for Resident 71, despite expectations for such assessments to be conducted on admission, quarterly, and as needed. This oversight in assessing and addressing the residents' incontinence needs contributed to the deficiency.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage, labeling, and disposal of medications and medical supplies across multiple medication carts and rooms. Observations revealed expired medications and supplies, such as nicotine gum, needles, and ointments, were not removed from the medication carts. Additionally, some medications were not labeled with resident names, and opened medications were not dated, which is against the facility's policy. For instance, a loose green pill was found in a drawer, and several expired needles and medications were present in the carts. In the medication rooms, an opened vial of a Tuberculosis skin testing agent was found to be over 30 days old, and the temperature log for a medication fridge was not maintained for seven consecutive days. Interviews with staff, including the Assistant Director of Nursing, confirmed that expired medications and supplies should be removed, and refrigerator temperatures should be monitored nightly. These lapses in medication management placed residents at risk for ineffective treatment and exposure to expired or contaminated medications.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse, resulting in psychological harm to Resident 1. Resident 1, who had severe impairments to their decision-making ability and a history of trauma, was found in a compromising situation with Resident 2. Staff observed Resident 2 with their pants down on top of Resident 1, who was exposed from the waist down. Despite Resident 1's initial statements to the police and hospital staff that the interaction was consensual, the facility's failure to prevent the incident led to Resident 1 being transferred to a hospital for evaluation. Resident 2 had a documented history of sexual behaviors and fluctuating levels of confusion due to dementia and other mental health conditions. Despite this, the facility did not maintain adequate supervision or documentation of Resident 2's behaviors. Staff were unaware of Resident 2's sexual inappropriateness, and previous incidents involving Resident 2 were not properly documented or followed up with consistent monitoring. This lack of oversight allowed Resident 2 to engage in inappropriate behavior with Resident 1. Interviews with staff revealed that there was no consistent monitoring of Resident 2's sexually inappropriate behaviors, and the one-on-one caregiver assigned to Resident 2 was discontinued without clear documentation or rationale. The facility's failure to adhere to its own policies and protocols regarding abuse and neglect, as well as inadequate supervision and documentation, placed all residents at risk for potential sexual abuse and psychological harm.
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Illustrative
What surveyors actually found near you
We read the 1,419 citations issued within 25 miles in the last 12 months — including the 3 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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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Seattle
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kin On Health Care Center | 1.6 mi | ★★★★★ | 1 | 0 |
| Transitional Care Of Seattle | 1.6 mi | ★★★★★ | 49 | 0 |
| Seattle Medical Post Acute Care | 2.4 mi | ★★★★★ | 71 | 0 |
| The Terraces At Skyline | 2.7 mi | ★★★★★ | 1 | 0 |
| Caroline Kline Galland Home | 2.9 mi | ★★★★★ | 27 | 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.