Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Washington Odd Fellows Home during CMS and state inspections, most recent first.
The facility failed to meet professional standards of practice for insulin administration and documentation for a resident with diabetes. A physician order required insulin at 1 unit per 10 g of carbohydrates consumed after meals, with a maximum daily dose, but review of MARs over several months showed no documentation of carbohydrate intake or insulin units given. An LPN reported visually estimating carbs from the meal tray and administering insulin accordingly without recording the carb count or dose, and the Nurse Manager confirmed there was no established process to document these elements. The Medical Director and DON both indicated that documentation should include total carbs, insulin dose, and rationale, but acknowledged that consistent documentation of carb counts and insulin administration was not occurring, placing residents at risk for unstable blood sugars, duplicate dosing, and adverse outcomes.
Food service staff failed to wear facial hair and beard restraints while serving meals in the kitchen tray line. The DS, a Cook, and two DAs all had exposed beards or moustaches while handling food, utensils, and resident trays, and one staff member moved around the steam table and food prep area with uncovered facial hair. The Dietary Manager stated beard restraints were available, but staff had not worn them.
PASARR Level II referrals were not completed or were delayed for multiple residents with SMI indicators. Residents had diagnoses including depression, PTSD, schizoaffective disorder, dementia, anxiety, and agitation, and several received antipsychotic and antidepressant medications. Facility staff said PASARRs were reviewed before admission and an audit was kept to track Level II needs, but the record showed missed or late referrals for residents whose PASARRs identified SMI or required further review.
Failure to Supervise Residents During Transfers and Follow Fall Care Plans: The facility did not consistently follow fall precautions or provide adequate supervision for three residents with repeated falls. A resident with supranuclear palsy and osteoporosis was left unattended at the bedside and fell with an eye injury; another resident with dementia and substantial ADL needs was left unattended after toileting and in the dining room, resulting in falls and a head hematoma; a third resident with cognitive impairment and a toileting program was observed transferring in the restroom without staff present, despite a history of multiple falls and injuries.
Visitation Rights Not Protected: A resident with schizophrenia and moderately impaired cognition was not informed when a friend was restricted from talking with them based on a POA request. The resident said they wanted to see and talk to the friend, while the POA said the restriction had been placed long ago due to concerns about money and cigarettes and may no longer have been needed. Staff stated the facility did not discuss the restriction with the resident and did not routinely review whether such restrictions still applied.
The facility failed to keep residents’ personal funds in an interest-bearing account and failed to make funds available when the business office was closed. Staff confirmed the pooled account had stopped earning interest, and weekend nursing staff stated residents could not access their money on weekends because office staff did not work. Two residents reported they did not think they could withdraw funds on the weekend, including one resident who was cognitively intact and another with impaired cognition.
Failure to identify, report, and investigate abuse/neglect grievances. Two residents reported rude, humiliating, or disrespectful treatment by NAs, including one resident with anxiety, depression, and moderate cognitive impairment and another resident who was dependent on staff for multiple ADLs. Staff acknowledged hearing or receiving the concerns, but one incident was not written up or investigated as possible abuse, and the other was forwarded without identifying the staff involved or completing an incident investigation.
Missed Scheduled Showers for Dependent Residents: Two residents who were dependent on staff for showering did not receive showers as scheduled. One resident with bladder dysfunction, muscle weakness, and cervical spondylotic myelopathy was observed with greasy hair and an unkempt appearance, and records showed multiple stretches of several days without documented showers. Another resident with heart disease, depression, anxiety, and disc degeneration reported receiving fewer showers than scheduled, with records showing repeated gaps in shower documentation. Staff said shower assignments were sometimes interrupted by floor duties, and the DON stated showers were expected to follow the schedule and be documented even if refused or not given.
A resident with PTSD, depression, anxiety, and impaired cognition had documented triggers including yelling and screaming, but the care plan contained no PTSD-focused goals or interventions. The resident reported childhood sexual and mental abuse and said yelling and screaming increased PTSD-related anxiety, while the SS Director stated TIC assessments were completed on admission and the PTSD dx was not recognized.
Controlled substance records were not completed accurately for medication cart counts and narcotic destruction documentation. The DON and RN stated two nurses were supposed to verify and sign each controlled substance count and disposition entry, but review found multiple shifts without the required dual signatures, one shift with no count documented, and a narcotic destruction entry for three residents with only one nurse signature and a blank second signature line.
The facility failed to fully implement its infection prevention program in two areas: Legionella water management and wound care. Its WMP identified only limited risk areas, did not include corrective actions when control measures were not met, and staff did not identify other potential water risks such as a decorative fountain, an infrequently used bathtub, or eye wash stations; ice machine filter changes were also overdue. In addition, an IP/TN performed wound care on a resident with heart disease, DM, a foot ulcer, and depression using the same contaminated gloves across multiple wound sites without hand hygiene or glove changes.
Uncleanable Kitchen Flooring: The kitchen had damaged flooring in the dry goods room entryway and under the tilt skillet/stove, including cracked and missing linoleum, broken and loose tile, and missing grout. Staff reported the flooring had been in disrepair for some time and was difficult to clean, and the DES later stated they were unaware of the needed repairs.
Outdated Nursing Staff Posting: The facility failed to keep the daily nursing staff posting current and accurate. Observations showed the posting was inaccurate on multiple days and, when checked, it was still dated several days earlier without reflecting actual staffing changes. Staff S said they were responsible for the posting, while the Staffing Coordinator said staffing was based on census and the posting duty belonged to Staff S. The Administrator and DON acknowledged the postings were outdated and incorrect.
Failure to review resident rights with residents and a resident representative was identified for multiple residents. A resident representative stated they had not had rights reviewed since admission and did not know where to access them, and several residents agreed. Meeting minutes showed no resident rights review during monthly council meetings, and staff and the DON stated rights were reviewed with staff but not with residents.
Missing Resident Advocacy Contact Information: The facility did not provide visible contact information for the ombudsman, SA, Aging and Long Term Care, or how to file a complaint with the SA for several residents and one resident representative. During a resident council meeting, a resident said they wanted to contact the ombudsman about concerns but did not know where to find the information, and others agreed they did not know how to file a complaint. Staff reported the information was either not known or only posted in a location not visible to residents in the LTC area.
The facility failed to implement proper infection control measures during a COVID-19 outbreak, with staff not using NIOSH-approved N95 masks and failing to clean face shields. Staff conducting COVID-19 tests did not wear appropriate PPE and allowed staff to return to work before test results were available. Interviews revealed a lack of understanding and training regarding PPE protocols.
The facility failed to provide timely and appropriate care for several residents, leading to significant harm and unmet care needs. A resident experienced a small bowel obstruction and urinary infection due to delayed assessments and lack of bowel protocol initiation. Two residents exceeded fluid restrictions due to inadequate monitoring and communication. Additionally, physician orders for lab work, medication changes, and wound care referrals were not completed, resulting in delayed treatment.
The facility failed to prevent and manage pressure ulcers for three residents, leading to harm and deterioration of their conditions. One resident developed a Stage 4 ulcer on their coccyx due to delayed treatment and inadequate pain management. Another resident's ulcers worsened due to tight shoes and insufficient pain relief, resulting in cellulitis and osteomyelitis. A third resident's pressure ulcers deteriorated due to ineffective interventions and non-compliance, with staff failing to advocate for increased measures.
A facility failed to provide adequate supervision for a resident at risk of falls, resulting in injury. Additionally, the facility did not properly identify and supervise residents who were active smokers, leading to violations of the smoke-free policy. Residents were found smoking on facility property without proper supervision or storage of smoking materials, highlighting a lack of communication and enforcement of the facility's smoking policy.
The facility failed to provide dignified care, as seen in delayed toileting assistance for a resident with dementia, inconsistent meal service times causing frustration among residents, and mishandled admissions leading to confusion and neglect. Staff acknowledged these lapses, which did not meet the expected standards of care.
The facility failed to issue required Medicare notices, including NOMNCs and SNF ABNs, for several residents, impacting their ability to make informed financial and care decisions. A resident with kidney failure did not receive a timely NOMNC, and there was no documentation of a SNF ABN. Another resident with pneumonia did not receive a SNF ABN when Medicare benefits began, and a third resident with a stroke received a SNF ABN on admission but not before the last covered day. Staff were unfamiliar with the ABN process.
The facility failed to complete accurate PASARR assessments for four residents, leading to potential risks of not receiving appropriate mental health services. A resident with major depression and delusional disorder, another with dementia and agitation, and two others with various mental health diagnoses were not correctly identified in their PASARRs. The administrator cited the lack of a Social Services Director as a reason for these inaccuracies.
The facility failed to provide necessary social services, including Medicare notifications and accurate PASARR assessments, affecting several residents. A resident did not receive a NOMNC or ABN, while others lacked ABNs. PASARR assessments for residents with mental health diagnoses were inaccurate. Additionally, discharge planning was inadequate for two residents, with one having no support network and another desiring to return home without facility assistance.
The facility failed to maintain a clean kitchen environment, with non-functional ventilation, dirty air conditioners, and fans, and unclean utensils and ice machines, risking foodborne illness.
The facility failed to provide written notice of discharge to two residents and their representatives, as well as the LTC Ombudsman. One resident was transferred to the hospital for issues related to clostridium difficile, while another was transferred due to unresponsiveness. The LTC Ombudsman was not informed of these discharges, and the facility's administrator was unaware of who was responsible for the notifications.
The facility failed to provide written bed-hold notices to residents or their representatives during hospital transfers, affecting two residents. Despite notifying representatives by phone, the facility did not include required written details about the bed-hold policy, such as duration, payment, and return conditions. Staff interviews indicated a lack of awareness of the requirement for written notices.
The facility failed to effectively plan discharges for two residents, neglecting to address their goals and needs or involve them and their representatives. One resident's representative had to independently arrange for an assisted living facility, while another resident's preference to return home was not facilitated. The discharge process lacked coordination and communication among staff, with the absence of a social services staff member exacerbating the issue.
Two residents with dementia on timed toileting programs did not receive timely assistance, leading to incontinence. Staff were unaware of the specific toileting schedules, resulting in unmet care needs. The Director of Nurses expected adherence to Kardex directives, which was not followed.
A resident with impaired vision did not receive necessary optometry services due to a missed referral order. Despite a physician's order for an eye evaluation, the appointment was not scheduled, leaving the resident without eyeglasses and unable to see properly. Staff responsible for scheduling were unaware of the order, indicating a lapse in procedure.
A resident with a history of trauma and multiple diagnoses, including depression and dementia, did not receive adequate trauma-informed care at the facility. Despite recommendations for psychological evaluation and social worker assessment, these were not completed. The resident expressed ongoing distress, and staff interviews revealed a lack of trauma assessments and mental health services. The DON admitted to potentially conducting assessments incorrectly, leading to unmet care needs.
A facility failed to ensure an LPN had the necessary certification to administer IV medications, resulting in a missed dose for a resident with a PICC line. The LPN, who was not certified in Washington State, did not administer a scheduled antibiotic dose, and there was no record of completed competencies. Facility staff were unaware of the LPN's certification status, and expected communication protocols were not followed.
The facility failed to ensure medication storage rooms were free from expired medications, risking compromised or ineffective treatments for residents. Expired COVID-19 vaccinations and other medications were found in storage rooms, despite a policy requiring staff to check expiration dates. The night shift RN was responsible for this task, but expired items remained, indicating a lapse in procedure adherence.
A resident with dementia and severely impaired cognition was found with significant bruising on their left hand and forearm, indicating possible abuse/neglect. The facility failed to report the incident to the State Agency within the required 24-hour timeframe, despite the severity of the injury and a possible non-displaced fracture identified in an x-ray. This was a repeat citation for the facility.
A resident with dementia and impaired cognition was found with significant bruising on their left hand and forearm. The facility failed to conduct a thorough investigation into the cause of the bruising, as required by their policy. The medical director speculated trauma as a cause, but this was not confirmed. The resident's Power of Attorney reported the bruise, but no explanation was provided. The Assistant Director of Nursing admitted that not all necessary interviews were conducted to rule out abuse.
The facility failed to thoroughly investigate allegations of potential neglect and unwitnessed falls, resulting in substantial injuries to three residents. Investigations were incomplete, lacking necessary interviews, assessments, and reviews, and failed to address critical issues such as the use of gait belts and medication side effects.
The facility failed to honor the bathing frequency preferences of two residents, providing only one shower per week despite requests for more. Staff limitations were cited as the reason for not accommodating these requests.
The facility failed to report an allegation of neglect to the State Agency involving a resident with a stroke, aphasia, and osteoporosis, who sustained a fracture and dislocated shoulder during a transfer. Despite logging the incident, it was not reported as required, placing residents at risk for further neglect.
A resident with cellulitis and heart failure did not receive the increased dosage of furosemide as per hospital discharge orders upon returning to the facility. Staff believed the new orders would start the following day, leading to the resident missing the additional 40 mg dose on the day of return.
Failure to Document Carbohydrate Counts and Insulin Doses per Sliding Order
Penalty
Summary
The facility failed to follow professional standards of practice for insulin administration and documentation for one resident with diabetes. The resident was admitted with diagnoses including breast and colon cancer, malnutrition, and diabetes, and had intact cognition and was largely independent with activities of daily living. A physician’s order dated 09/29/2025 directed that insulin be injected subcutaneously at 1 unit for every 10 grams of carbohydrates consumed after meals, with a total daily dose not to exceed 40 units. Review of the Medication Administration Records from September 2025 through 02/11/2026 showed no documentation of the amount of carbohydrates the resident consumed or the amount of insulin administered. During interviews, an LPN stated they visually assessed the resident’s meal tray to estimate carbohydrate intake and then administered 1 unit of insulin per 10 grams of carbohydrates but did not document either the carbohydrate amount or the insulin units given, and indicated there was no place on the MAR to record the units. The Nurse Manager explained that dietary staff documented the total carbohydrate count for each meal on the tray card and saved the tray for nursing to observe intake, but confirmed there was no process in place to document the carbohydrate count or corresponding insulin dose. The Medical Director stated that documentation for insulin administration should include the total carbohydrate count, the amount of insulin given each time, and the rationale for the dose. The DON similarly described a process in which dietary documented total carbohydrates and nursing calculated and administered insulin, with the expectation that nursing would document in progress notes, but acknowledged there was no process to consistently document the carbohydrate count and insulin administered. This failure was cited as not meeting professional standards of quality and placed residents at risk for unstable blood sugars, duplicate insulin administration, and adverse outcomes.
Unrestrained Facial Hair During Food Service
Penalty
Summary
The facility failed to ensure food was prepared and served in accordance with professional standards of safety in the kitchen tray line. During observation of the noon meal service, the Dietary Supervisor, a Cook, and two Dietary Assistants were in the kitchen serving food while all had beards or long exposed facial hair over an inch long and none wore facial hair or beard restraints. The Dietary Supervisor walked around the steam table and preparation area where desserts, sandwiches, and other foods were located with an uncovered full beard and moustache. The Cook served food from the steam table to residents’ plates with an uncovered full beard and also worked over other food preparation surfaces without a beard restraint. One Dietary Assistant handled food utensils and placed them on resident trays with exposed facial hair, and the other handled resident trays with exposed facial hair. The Dietary Manager stated that facial hair/beard restraints were available, but staff had not worn them.
PASARR Level II referrals were not completed for residents with SMI indicators
Penalty
Summary
The facility failed to review and validate PASARR determinations for residents with positive Level I findings and failed to ensure required Level II referrals were completed for 4 of 7 residents reviewed. Resident 41 was admitted with anxiety and depression, had moderately impaired cognition, and the PASARR dated 10/02/2024 identified SMI indicators for depression, anxiety, and PTSD, but no Level II referral or evaluation was completed. The facility audit also showed the resident was admitted as a hospital-exempt stay, but the audit indicated a Level II evaluation and referral were needed and no referral had been submitted even though the stay had extended beyond 30 days. Resident 1 was admitted with depression, dementia, and anxiety, had moderately impaired cognition, and received treatment for depression and an antipsychotic medication, but the 10/24/2024 PASARR did not identify SMI and no Level II evaluation was obtained. Resident 5 was admitted with schizoaffective disorder, dementia with anxiety, and insomnia, had moderately impaired cognition, and received antipsychotic medications; the 08/21/2024 PASARR showed SMI indicators for schizoaffective disorder, but the form did not indicate a Level II evaluation, and the facility audit showed the Level II referral was not sent until nearly five months after admission and identification of SMI. Resident 30 was admitted with depression and dementia with agitation, had severely impaired cognition, and received antipsychotic and antidepressant medications; the 02/03/2025 PASARR showed SMI and required a Level II evaluation, but the facility audit showed the referral was not sent until two months after admission. Staff stated PASARRs were reviewed before admission and that an audit was kept to track Level II referrals, but also stated they were behind and that this may have caused the late submissions.
Failure to Supervise Residents During Transfers and Follow Fall Care Plans
Penalty
Summary
The facility failed to provide adequate supervision and to consistently follow care planned fall interventions for three residents with repeated falls. The report states that residents were assessed as fall risks and had interventions such as increased supervision, accessible call lights, scheduled toileting assistance, and instructions not to leave them unattended, but these measures were not consistently followed during the events reviewed. Resident 51 was admitted with diagnoses including a bladder infection treated at the hospital, falls, supranuclear palsy, osteoporosis, and hearing loss. The resident’s assessment showed memory issues, was alert, and required substantial assistance to transfer from a wheelchair. On 04/29/2025, the resident fell after being left alone seated at the side of the bed while a NA went down the hall to retrieve items, and the resident was found on the floor with a swollen right eye and bruise. The fall risk assessment identified the resident as high risk, and the baseline care plan did not include fall prevention interventions until 05/01/2025, when positioning bars and a fall mat were added. Resident 15 had dementia, repeated falls, a history of bladder infections, and spinal stenosis, and was cognitively impaired, spoke mainly in their native language, and required substantial assistance with all ADLs. The resident was left unattended after toileting and fell from the wheelchair with a large hematoma to the back of the head, and later was found on the floor in the dining room without supervision after breakfast. During survey observations, the resident was again left alone in the dining room in a wheelchair, leaning forward with eyes closed. Resident 28 had atrial fibrillation, a hereditary bleeding disorder, repeated falls, moderate cognitive impairment, and a toileting program. The resident was observed transferring in the restroom without staff supervision on two occasions, including standing and moving between the wheelchair, grab bar, door frame, and sink while staff were not present, and the facility incident log showed 12 falls from February through July 2025, with two injuries.
Visitation Rights Not Protected
Penalty
Summary
The facility failed to ensure visitation rights were protected for one resident when the resident’s friend was restricted from talking to the resident without the resident’s knowledge. Resident 5 had diagnoses including schizophrenia, and the 07/21/2025 comprehensive assessment showed moderately impaired cognition with staff supervision or touching assistance needed with most ADLs. During an interview, the resident stated they enjoyed writing letters to their friend but believed the friend had stopped contacting them and did not understand why they had not heard from or seen the friend. The resident’s Care Profile stated the friend was not to talk to the resident at that time per POA request. The POA document did not give authority to override the resident’s personal and health care decision making unless the resident was determined to be incapacitated, and the record contained no information that the resident had been deemed incapacitated. The POA stated the restriction had been placed long ago because of concern the friend would take advantage of the resident, but also stated the restriction could have been removed and that the resident had not been discussed with before the restriction was placed. The resident stated they had not been told by the facility or the POA about the restriction and would have wanted to see and talk to the friend. Staff stated the facility did not discuss the restriction with the resident and assumed the POA had done so, and also stated the facility had not normally followed up on restrictions periodically to see if they still applied to the resident’s current situation or condition.
Personal Funds Not Kept Interest-Bearing or Accessible on Weekends
Penalty
Summary
The facility failed to ensure residents’ personal fund accounts were deposited in an interest-bearing account for four of five residents reviewed. The facility policy stated resident funds over $100, or over $50 for Medicaid residents, were to be placed in an interest-bearing account. Review of the resident pooled funds account showed that no interest had been accrued in June 2025 or July 2025, and staff confirmed the account had been switched and was not interest-bearing since May 2025. Staff I, the Business Office Manager, and Staff H, the CFO, both stated no interest had been allocated in June or July, and Staff H said they had learned from the bank that the account was no longer interest-bearing. The facility also failed to make resident personal funds available on weekends for two residents reviewed. The facility’s guidelines stated residents must be allowed access to trust funds when the business office is closed, with the nurse supervisor responsible for maintaining petty cash for residents during those times. Resident 8, who was cognitively intact and able to make needs known, stated office staff were not working on weekends so money could not be withdrawn from the account. Resident 28, who had moderately impaired cognition but could make needs known, stated they had used personal funds for haircuts but did not think money could be withdrawn on weekends if needed. Weekend nursing staff stated residents with funds in the pooled account were unable to get money on weekends because office staff did not work, and other weekend staff were unaware of the process.
Failure to identify, report, and investigate abuse/neglect grievances
Penalty
Summary
The facility failed to implement 4 of 8 components of its abuse/neglect policy and procedure, including identifying, protecting, reporting, and investigating allegations after grievances were reported for two residents. One resident had diagnoses of anxiety and depression and was described as moderately cognitively impaired but able to understand and make needs understood. That resident stated a nursing assistant had been very rude, had an attitude, and talked down to them, and the resident said they reported the concern to another NA who knew who the staff member was. Staff interviews showed the concern was discussed among staff, but it was not treated as a potential abuse allegation. One NA said the resident was upset and that they believed the concern had been reported to the medication nurse. Another NA stated they overheard the conversation in the dining room, did not receive a report from the resident or the NA, and did not complete an incident report because the resident said they were okay. The DON stated the incident was not reported, written up, or investigated as potential abuse. For the second resident, who had respiratory and heart failure and was dependent on staff for toileting, hygiene, transfers, bathing, and dressing, the resident and representative reported that several NAs were rude and rushed the resident during toileting and transfer care, causing humiliation and distress. The grievance log showed the concern was reported and education was noted, but the staff involved were not identified in the grievance. Email review showed the representative reported three named NAs and described the resident as feeling humiliated and very upset, yet the concern was forwarded without an incident being logged or investigated as a possible abuse allegation. Staff interviews confirmed the staff who received the concern did not interview the resident or staff, and the DON stated they would have investigated if they had seen the resident was still upset, but the concern was not investigated deeper.
Missed Scheduled Showers for Dependent Residents
Penalty
Summary
The facility failed to provide the necessary care and services to ensure residents who were dependent on staff received consistent showers for 2 of 5 residents reviewed for ADL care. Resident 6 was admitted with diagnoses including dysfunction of the bladder, muscle weakness, and cervical spondylotic myelopathy. The comprehensive assessment showed intact cognition and a need for two staff members for toileting hygiene, showering, and lower body dressing. The care plan indicated a preference for two showers per week, and the facility shower schedule listed Sunday and Wednesday as shower days. However, observations showed the resident with greasy hair and unkempt appearance, and the resident stated they were unsure when their last shower was and that they had not received the shower due the prior day. Record review showed multiple periods with no documented shower, including 6 days in June, 6 days in late June, 12 days in July, and 7 days in late July. Resident 41 was admitted with diagnoses including heart disease, depression, anxiety, and intervertebral disc degeneration. The comprehensive assessment showed intact cognition and dependence on staff for toileting hygiene, showering, and transfers. The resident stated they were scheduled for showers two days a week, but reported receiving only one shower the prior week and none the week before, and believed their last shower was about a week earlier. The care plan showed a preference for two showers per week, and the facility shower schedule listed Tuesday and Friday as shower days. Record review showed no documented shower for 10 days in June, 8 days in early July, and 9 days from late July into early August. A nursing assistant stated they were assigned to showers but were sometimes pulled to work on the floor, and the DON stated staff were expected to follow the shower schedule and document showers even if refused or not given.
Failure to Address PTSD Triggers in Care Planning
Penalty
Summary
The facility failed to ensure trauma-informed care by not adequately assessing trauma history and identifying trigger-specific interventions for a resident with a known history of PTSD. The facility’s trauma-informed care policy stated that it would identify a resident’s history of trauma and cultural preferences, identify triggers that may re-traumatize residents, and add trigger-specific interventions to the care plan. However, Resident 41’s care plan, dated 04/01/2024, contained no focused areas, goals, or interventions related to PTSD. Resident 41 was admitted with diagnoses including heart disease, depression, anxiety, and intervertebral disc degeneration, and the comprehensive assessment dated 07/07/2025 showed moderately impaired cognition and extensive assistance needed from two staff members for transfers. A provider progress note dated 12/16/2024 documented a history of PTSD with symptoms including flashbacks, nightmares, and increased anxiety when triggered, and noted that yelling and screaming could trigger the resident. During interview, the resident stated they had experienced childhood sexual and mental abuse and that yelling and screaming increased PTSD-related anxiety. A Trauma Informed Care assessment also showed PTSD triggers when the resident heard yelling and screaming. The Social Services Director stated the TIC assessments were done on admission and that Resident 41’s PTSD diagnosis was not recognized.
Controlled Substance Count and Destruction Records Were Incomplete
Penalty
Summary
The facility failed to implement and ensure its system for controlled substance records, disposition, and accurate reconciliation was completed in sufficient detail to allow accurate accounting of controlled medications. During interview, the RN and DON stated the facility’s process for controlled substance disposition was to place unused medications in the Drug Buster and document the specific resident and medication information in the narcotics destruction logbook, with two RNs signing together to verify accurate reconciliation. However, review of the January 2025 through August 2025 controlled substance shift count verification logbooks showed 24 nursing shifts on 20 different days without the required two nursing staff signatures, and one day with no count completed by any staff. Review of the narcotics destruction logbook showed that on one occasion, five controlled substances from three residents were destroyed with only one staff nursing signature and a blank space where the second signature should have been. During interview, an RN stated that two nurses completed a narcotics count of all controlled substances in the medication cart every shift and both nurses were supposed to sign the shift count verification logbook, but signatures were missing throughout the logbook. The DON and Administrator stated the controlled substance shift count verification logbook was not filled out correctly and that the process requiring two nurses to verify the controlled medication count was not being followed; they also stated the accurate accounting for the three residents’ narcotic disposition was not followed.
Infection Control Failures in Legionella Management and Wound Care
Penalty
Summary
The facility failed to develop and implement components of its infection prevention and control precautions related to Legionella management. The facility’s Legionella Management Program, dated 06/03/2025, identified two areas at risk for Legionella growth: the ice machines and hot water storage. The policy stated the ice machines were to be cleaned and sanitized weekly, with a full deep clean and filter change every three months, but it did not include documentation of corrective actions to take when control measures were not maintained or within acceptable ranges. The facility’s water management team, which included the Director of Environmental Services and the Infection Preventionist, did not identify several other potential areas of risk, including the decorative water fountain, the residents’ infrequently used bathtub, and infrequently used eye washing stations. During observation, one ice machine showed a filter change date of 03/05/2025 and the other showed 02/12/2025, both past the quarterly control measure schedule. Staff stated the eye washing stations were not routinely flushed and that this was not part of their process. Staff also stated they were unsure of the facility’s process when control measures were not met. The facility also failed to maintain infection control during wound care for a resident with heart disease, diabetes, a foot ulcer, and depression who was cognitively intact and dependent on staff transfers. During observed wound care, the IP/TN removed dressings from both feet, sanitized hands, and applied clean gloves, but then continued care on the resident’s left foot, left big toe, left heel, right heel, and right foot using the same contaminated gloves without removing them or performing hand hygiene between tasks. The IP/TN later acknowledged the infection control breach and stated they realized it when moving from the left foot to the right foot.
Uncleanable Kitchen Flooring
Penalty
Summary
The facility failed to provide a clean sanitary environment in the kitchen area because 1 of 1 kitchen floor areas observed had an uncleanable surface. During observation and interview, the Dietary Supervisor noted cracked, damaged, and missing linoleum in the threshold entryway to the dry goods food storage room and stated the floor had been that way for some time and was difficult to clean. In the kitchen, the tile floor beneath the tilt skillet/stove was observed to have a four-foot by three-foot area of broken and loose tile with missing and loose grout between several tiles, and the tiles were wet from steam produced by the heated tilt skillet during use. Staff stated the tiles had been coming up and that there were places of missing grout between the tiles that needed to be replaced and repaired. The Director of Environmental Services later stated they were unaware the tile under the tilt stove and the linoleum in the dry goods room entryway were in disrepair.
Outdated Nursing Staff Posting
Penalty
Summary
The facility failed to ensure the nursing staff posting was posted daily and/or reflected the actual nursing staff hours worked during 4 of 5 days of the survey period. Observations on 08/04/2025 at 11:40 AM, 08/05/2025 at 8:44 AM and 3:31 PM, and 08/06/2025 at 8:50 AM showed inaccurate postings for actual nursing staff hours worked. On 08/07/2025 at 10:02 AM, the nursing staff posting across from the nurses' station was dated 08/03/2025 and did not show any actual adjustments or changes to the nursing staff hours posted. During interviews, Staff S, NA, stated they were responsible for the daily staff posting, that they were off on 08/04/2025 and 08/06/2025, and that the second lead NA was responsible for the posting on weekends. Staff S stated that if changes were needed, they were entered into the computer and re-posted. Staff T, Staffing Coordinator, stated staffing levels were based on the facility census and Staff S was responsible for the daily nursing staff postings. Staff A, Administrator, and Staff B, DON, acknowledged the daily nurse staff postings were outdated and incorrect.
Failure to Review Resident Rights With Residents and Representative
Penalty
Summary
The facility failed to periodically inform residents of their rights after admission for 7 of 10 residents reviewed, including Residents 2, 5, 8, 10, 16, 28, and 31, and for 1 of 1 resident representative reviewed, Resident 19's RR. During a Resident Council meeting, Resident 19's RR stated they were told they would be asked to leave the room while staff cared for Resident 19, but they had never asked Resident 19 if that was what they wanted or if it was okay. The RR also stated they had not had Resident Rights reviewed with them since admission and did not know where they could access or find them. Residents 2, 5, 8, 10, 16, 28, and 31 were present at the meeting and agreed with the RR. Review of Resident Council meeting minutes from January 2025 through August 2025 showed no review of Resident Rights, written or verbal, during the meetings. Staff stated they did not review Resident Rights with residents during monthly Resident Council meetings or periodically after admission, and the DON stated rights were reviewed with staff during hall meetings but not with residents.
Missing Resident Advocacy Contact Information
Penalty
Summary
The facility failed to provide required contact information for resident advocacy resources, including the ombudsman, State Agency, and Aging and Long Term Care, as well as information on how to file a complaint with the State Agency, for 7 of 11 residents reviewed for required notices and contact information and for 1 of 1 resident representative. Residents 2, 5, 8, 10, 16, 28, and 31, along with Resident 19's representative, did not have access to this information in a format they could understand or readily locate. During a resident council meeting, Resident 8 stated they had wanted to contact the ombudsman about concerns but did not know where to find the information, and the other residents and the resident representative agreed. They also stated they did not know how to file a complaint with the State Agency and were not aware that this was an option. Staff W, the Activities Director, stated they did not know where the resident advocacy resource information was posted. Staff A, the Administrator, stated Staff W had access to ombudsman information in their cubicle, but it was not visible to all residents, resident representatives, or visitors. An observation at the main entrance showed a sign with resident advocacy resource contact information, but it was not visible to residents in the long-term care area. Staff B, the DON, stated the only signage they were aware of was Mandatory Reporter contact information, which did not include resident advocacy resource contact information.
Inadequate PPE Use and COVID-19 Testing Protocols
Penalty
Summary
The facility failed to consistently implement infection control interventions during a COVID-19 outbreak, as observed in the use of personal protective equipment (PPE) by staff. Specifically, staff members did not wear the required NIOSH-approved N95 masks, face shields, gowns, and gloves when entering rooms of COVID-19 positive residents. Instead, some staff used KN95 masks, which are not NIOSH-approved, and were not properly fit-tested for N95 masks. Additionally, face shields were not cleaned and disinfected after use, contrary to CDC guidelines. The report highlights that staff members conducting COVID-19 testing did not adhere to proper PPE protocols. Staff G, who was responsible for performing nasal swab tests, wore only a surgical mask and gloves, rather than the required N95 mask, gown, and eye protection. Furthermore, staff members returned to work before receiving their COVID-19 test results, which is against the facility's policy and CDC guidance. Interviews with staff revealed a lack of understanding and training regarding the differences between KN95 and N95 masks, as well as the proper procedures for fit testing and PPE usage. Staff members, including those with facial hair, were improperly fit-tested, and there was confusion about the reuse and cleaning of face shields. The facility's administrator acknowledged these deficiencies and the need for retraining and proper fit testing.
Failure to Provide Timely and Appropriate Care
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards and the comprehensive, person-centered care plan for several residents. Resident 54 experienced significant harm due to the facility's failure to conduct timely assessments and initiate bowel protocols. Despite receiving narcotic pain medication, the resident did not have a bowel movement for four days, leading to a small bowel obstruction and urinary bladder infection, which required hospitalization. Observations and interviews revealed that the resident was in pain, nauseated, and unable to eat, yet no thorough assessments or interventions were documented. Resident 11 and Resident 38 were both affected by the facility's failure to adhere to fluid restriction orders. Resident 11 had a water pitcher at their bedside, which was not accounted for in their fluid restriction, potentially leading to excessive fluid intake. Staff were unaware of the resident's fluid restriction status, and no monitoring was in place. Similarly, Resident 38 exceeded their fluid intake limits on multiple occasions, with no documentation of risk/benefit discussions or physician notifications, despite the resident's non-compliance with fluid restrictions. The facility also failed to implement physician orders for Residents 13 and 36. Resident 13's lab work and medication changes were not completed, with staff citing the resident's refusal as a reason, yet no further attempts or documentation were made. Resident 36 experienced a significant delay in receiving a referral to an outside wound care clinic for a pressure ulcer, with the first appointment occurring 50 days after the physician's order. Staff interviews indicated a lack of follow-up and communication regarding the scheduling delay, contributing to the deficiency.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent and manage pressure ulcers for three residents, leading to harm and deterioration of their conditions. Resident 48, who was admitted with Alzheimer's disease, CIDP, and diabetes, developed an avoidable Stage 4 pressure ulcer on their coccyx. The facility did not follow physician orders for a wound vac and surgical consult, resulting in delayed treatment. Additionally, Resident 48 experienced severe pain during wound care, which was not adequately managed with pain medication, as staff failed to administer appropriate analgesics before or after dressing changes. Resident 108, with a history of dementia, heart disease, and diabetes, developed pressure ulcers on their left heel and great toe due to tight shoes. The facility did not remove the shoes promptly, leading to the worsening of the ulcers. Despite the resident's complaints of significant pain, the facility did not pre-medicate before dressing changes, and the resident's condition deteriorated to the point of requiring a narcotic pain reliever. The resident's left foot developed cellulitis and osteomyelitis, and a physician recommended amputation due to the decline. Resident 13, with Alzheimer's disease and severe cognitive impairment, developed deep pressure ulcers on their right foot. The facility's interventions, such as floating feet on pillows and using padded boots, were ineffective as the resident was non-compliant. Despite requests for a specialized air mattress, the facility did not provide one, and the resident's wounds continued to deteriorate. Staff failed to report the non-compliance and advocate for increased interventions, leading to the worsening of the resident's condition.
Inadequate Supervision and Smoking Policy Violations
Penalty
Summary
The facility failed to provide the necessary supervision to prevent avoidable accidents for Resident 54, who was at a moderate risk for falls. Despite having a care plan that required assistance with transfers, hourly safety checks, and a scheduled toileting program, Resident 54 fell while attempting to use their walker unsupervised to go to the bathroom. This fall resulted in a laceration above the right eyebrow and fractured right ribs. The resident's cognitive impairment and physical unsteadiness, combined with inadequate supervision, contributed to the incident. Additionally, the facility did not adequately identify and supervise residents who were active smokers, as evidenced by the cases of Residents 214, 216, and 212. Resident 214 was observed smoking on facility property without proper supervision or storage of smoking materials, contrary to the facility's smoke-free policy. Staff were unaware of the resident's possession of cigarettes and a lighter, and the resident was not informed of the facility's smoking restrictions upon admission. Similarly, Resident 216 was observed attempting to smoke on facility property without supervision, and the facility failed to secure their smoking materials. Resident 212 also experienced issues related to smoking supervision. The resident's cigarettes and lighter were taken by staff, but the resident was not given access to them as promised. The facility's failure to properly assess and manage the smoking habits of these residents, along with inadequate communication of the smoke-free policy, resulted in unsafe conditions and non-compliance with the facility's smoking policy.
Deficiencies in Resident Care and Admission Process
Penalty
Summary
The facility failed to provide dignified care and services to its residents, as evidenced by several incidents. One such incident involved a resident with dementia who required assistance with toileting. Despite the resident's repeated requests for help, staff delayed providing assistance, resulting in the resident experiencing an incontinent episode. This delay in care was observed over a period of 35 minutes, during which the resident expressed distress and embarrassment. In another instance, the facility did not serve meals simultaneously to all residents at a dining table, causing some residents to wait while others ate. This was observed on multiple occasions, with delays ranging from 17 to 21 minutes. Residents expressed frustration and hunger, yet staff did not address their concerns promptly. The facility's administrator acknowledged the expectation that all residents at a table should receive their meals at the same time, which was not met. Additionally, the admission process for two residents was mishandled, leading to feelings of neglect and confusion. One resident arrived at the facility without their representative, contrary to prearranged plans, and was left unattended in a room. Another resident's admission was marked by a lack of staff presence and guidance, resulting in confusion about room assignments and care preferences. The facility's staff admitted that the standard admission process was not followed for these residents.
Failure to Issue Required Medicare Notices
Penalty
Summary
The facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) and a Skilled Nursing Facility (SNF) Advance Beneficiary Notice (ABN) as required for several residents, which placed them at risk for not being able to make informed financial and care decisions. Resident 215, who was admitted with diagnoses including kidney failure and weakness, did not receive a timely NOMNC, as it was issued on the first date of non-coverage instead of at least two days prior. Additionally, there was no documentation of a SNF ABN being provided. Staff C, the Assistant Director of Nursing Services, acknowledged the delay and unfamiliarity with the ABN process. Resident 50, admitted with conditions such as pneumonia and dysphagia, did not receive a SNF ABN when their Medicare A benefits began or when a NOMNC was issued. Similarly, Resident 52, who required maximum assistance due to a stroke and heart failure, received a SNF ABN on the day of admission but not prior to the last covered day of Medicare Part A benefits. Staff A, the Administrator, was unaware of the regulation for ABN issuance and considered the late NOMNC for Resident 215 an isolated incident.
Inaccurate PASARR Assessments for Residents
Penalty
Summary
The facility failed to ensure the Pre-Admission Screening and Resident Review (PASARR) was completed correctly for four residents, which placed them at risk for not receiving appropriate mental health services. Resident 6 was admitted with mental health diagnoses including major depression and delusional disorder, but their PASARR did not identify these conditions. Similarly, Resident 11, who had dementia with agitation and behavioral disturbances, was not accurately reflected in their PASARR. Resident 210's PASARR also failed to include their diagnoses of anxiety and depression. Resident 23 was admitted with multiple diagnoses, including stroke, depression, psychoactive substance abuse, and severe dementia with mood disturbance. However, their PASARR, completed at the hospital, did not reflect these mental health conditions. The facility's administrator attributed these inaccuracies to the absence of a Social Services Director, who would typically be responsible for ensuring the accuracy of PASARR assessments upon residents' admission.
Deficiencies in Medicare Notifications, PASARR Assessments, and Discharge Planning
Penalty
Summary
The facility failed to provide necessary medically related social services to residents, specifically in the areas of Medicare notifications and assessments. For Resident 215, the facility did not issue a Notice of Medicare Non-Coverage (NOMNC) within the required timeframe, nor did they provide an Advanced Beneficiary Notice (ABN) to inform the resident of potential out-of-pocket costs. Similarly, Residents 50 and 52 did not receive ABNs, leaving them uninformed about the financial implications of their continued care. The facility also neglected to ensure accurate Pre-Admission Screening and Resident Review (PASARR) assessments for several residents. Resident 6, who was admitted with major depression and delusional disorder, had a PASARR assessment that failed to accurately reflect these mental health diagnoses. Similarly, Residents 11, 210, and 43 had PASARR assessments that did not accurately identify their respective mental health conditions, such as dementia, depression, and anxiety. This lack of accurate assessment placed these residents at risk of not receiving appropriate mental health services. Additionally, the facility did not adequately plan for the discharge of residents. Resident 208, who had no family or support network, did not receive assistance from the facility in planning their discharge, leaving the responsibility to their representative. Resident 38 expressed a desire to return home, but the facility had not discussed discharge options with them or their representative. The facility's lack of social services staff contributed to these deficiencies in discharge planning, as acknowledged by the Director of Nursing Services.
Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, which is essential for ensuring food safety. During an observation, it was noted that the janitor's closet in the kitchen contained a mop and bucket filled with chemicals, and the ventilation fan in the closet was not operational, leading to a chemical odor. Additionally, two mounted portable air conditioners in the food preparation areas were found to be dirty, with dust and grime accumulation. The fans blowing air over food preparation areas were also covered in dust and grime. The floor in the dry goods room was dirty, with a black substance and dirt along the baseboards. Kitchen utensils were stored in trays and containers with food crumbs, and there was an open container of bene-protein powder with dirt and food crumbs on the serving tray. Furthermore, an ice machine in the East dining service area was observed to have a yellowish slime on the metal plate inside. Interviews revealed that maintenance and dietary staff shared the responsibility of cleaning the fans and air conditioners, but there was no specific task for cleaning them on the Daily Kitchen Form. The ice machines were on a cleaning schedule of every three months, but the last cleaning was completed over a month prior, and the ice machine was not clean. These deficiencies in maintaining cleanliness and sanitation in the kitchen and dining areas placed residents at risk for potential foodborne illness.
Failure to Notify Residents and Ombudsman of Discharges
Penalty
Summary
The facility failed to provide a written notice to two residents and their representatives regarding the facility's intention and justification for their discharge. This deficiency was identified during a review of the medical records for two residents who were transferred to the hospital. Resident 39, who had diagnoses including clostridium difficile, kidney failure, and gastrointestinal hemorrhage, was transferred to the hospital for nausea, vomiting, diarrhea, dehydration, and possible C-diff. Similarly, Resident 55, with diagnoses including a urinary tract infection, atrial fibrillation, and diabetes, was transferred due to unresponsiveness. In both cases, there was no documentation indicating that a notice of transfer or discharge had been provided to the residents, their representatives, or the LTC Ombudsman. Interviews conducted during the investigation revealed that the LTC Ombudsman had not received any notifications of transfers or discharges from the facility. The facility's administrator acknowledged awareness of the regulation requiring notification to the Office of the State LTC Ombudsman but admitted to not knowing who was responsible for ensuring the notifications were completed. This lack of communication and documentation resulted in the residents and their representatives not being informed of their rights and the rationale for the discharges, as well as the LTC Ombudsman not being aware of the facility's practices related to transfers or discharges.
Failure to Provide Written Bed-Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to issue a written notice of bed-hold to residents or their representatives at the time of hospital transfer, as required by policy. This deficiency was identified for two residents who were transferred to the hospital. Resident 39, who had severe cognitive impairment and was dependent on staff for activities of daily living, was transferred to the hospital for nausea, vomiting, and diarrhea. Although the facility notified the resident's representative of the transfer via phone call, they did not provide the required written information about the bed-hold policy, including the duration of the bed-hold, payment details, and conditions for return. Similarly, Resident 55, who required maximum assistance for activities of daily living and had multiple diagnoses including a urinary tract infection and diabetes, was also transferred to the hospital. The facility issued a notice of bed-hold to the resident's representative, but it lacked the necessary written details. Interviews with facility staff revealed a lack of awareness and understanding of the requirement to provide written bed-hold notices before and upon transfers, contributing to the deficiency.
Inadequate Discharge Planning for Two Residents
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process for two residents, which did not address their goals and needs, nor involved them or their representatives adequately. Resident 208, who was admitted with diagnoses including metabolic encephalopathy, high blood pressure, and depression, had no comprehensive discharge plan initiated. The resident's representative had to independently arrange for an assisted living facility and coordinate care, as the facility staff did not assist with the discharge planning. Interviews revealed that the facility's discharge process was not functioning effectively, with social services being spotty and no stand-up meetings occurring due to state surveyors' presence. Resident 38, admitted with congestive heart failure, high blood pressure, and anxiety, also experienced inadequate discharge planning. The resident expressed a desire to return home, but no discussions or plans were made to facilitate this option. The care plan indicated a potential long-term stay, but the resident was not involved in the care conference meeting. Interviews with staff revealed that the discharge process was supposed to start upon admission, but due to the absence of a social services person, the process was not properly executed. The therapy department had recommended discharge to an assisted living facility, but the resident's preference to return home was not adequately explored or facilitated. Overall, the facility's discharge planning process was inconsistent and lacked coordination among the interdisciplinary team. Staff interviews highlighted a lack of communication and involvement of the residents and their representatives in the discharge planning process. The absence of a social services staff member further complicated the situation, leading to a deficiency in meeting the residents' discharge goals and needs.
Failure to Provide Timely Toileting Assistance
Penalty
Summary
The facility failed to provide timely assistance with toileting for two residents, both of whom were on timed toileting programs due to cognitive impairments. Resident 11, diagnosed with dementia and type 2 diabetes, was observed on multiple occasions not receiving assistance according to their scheduled toileting program. Despite being scheduled for assistance at specific times throughout the day, Resident 11 was left in their wheelchair for extended periods without being taken to the bathroom. Staff members were unaware of the resident's specific toileting program, leading to the resident experiencing incontinence and requiring a change of a saturated brief. Similarly, Resident 10, also diagnosed with dementia, was on a timed toileting program requiring assistance every two hours during the day and evening. However, the resident was observed waiting 35 minutes for assistance after requesting help, resulting in incontinence of stool. Staff interviews revealed a lack of adherence to the Kardex directives for toileting assistance, as expected by the Director of Nurses. These failures in providing timely toileting assistance placed both residents at risk for unmet care needs related to incontinence.
Failure to Provide Vision Services and Assistive Devices
Penalty
Summary
The facility failed to provide necessary vision services and assistive devices to Resident 23, who was admitted with diagnoses including stroke and depression. The comprehensive assessment indicated that the resident had moderately impaired vision and cognition and was dependent on two staff members for activities of daily living. Despite a physician's order dated 07/08/2024 for an optometry referral to evaluate the resident's vision, the appointment was not scheduled. This oversight left the resident without the necessary eyeglasses, impacting their ability to see the television remote and read. Interviews revealed a breakdown in the process for scheduling outside facility appointments. Staff K, responsible for obtaining optometry appointments, was unaware of the referral order for Resident 23, indicating a lapse in communication and procedure. The Director of Nursing Services outlined the process, which involved the charge nurse obtaining and submitting the signed order to Staff K. However, the order for Resident 23 was missed, resulting in the resident not receiving the required vision care.
Failure to Provide Trauma-Informed Care for a Resident
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for Resident 23, who was identified as a trauma survivor. Resident 23 was admitted with diagnoses including stroke, depression, substance abuse, and severe dementia with mood disturbance. Despite the resident's history of trauma, including an abusive household and lifelong alcoholism, the facility did not complete a psychological evaluation or a social worker assessment as recommended. The Trauma Informed Care assessment noted trauma from a stroke, but the resident expressed ongoing distress related to their life experiences, which was not adequately addressed by the facility. Observations and interviews revealed that Resident 23 often stayed in a dark room, expressing feelings of hopelessness and a lack of motivation to engage with their environment. Staff interviews indicated a lack of trauma assessments and mental health services for residents, even those with known histories of depression or trauma. The Director of Nursing Services admitted to potentially conducting the Trauma Informed Care assessments incorrectly, as they did not thoroughly review or inquire about the resident's history. This oversight placed residents at risk for unidentified triggers, re-traumatization, and unmet care needs.
LPN Lacked Certification for IV Medication Administration
Penalty
Summary
The facility failed to ensure that a Licensed Practical Nurse (LPN), identified as Staff AA, possessed the necessary competencies and skill sets to safely administer intravenous (IV) medication to residents. Specifically, Staff AA was not certified to administer IV medications in Washington State, which was required for the care of Resident 208, who had a Peripherally Inserted Central Catheter (PICC) line for the administration of antibiotics. This deficiency was identified when the 6:00 AM dose of cefazolin sodium, an antibiotic prescribed for Resident 208, was not administered as scheduled. Staff AA documented that they were not certified to give IV medications, and there was no record of completed nursing competencies in their personnel file. Interviews with facility staff revealed a lack of awareness and communication regarding Staff AA's certification status. The Director of Nursing Services (DNS) was unaware of Staff AA's inability to administer IV medications, and the Staff Development/Staff Coordinator confirmed that LPNs without IV certification should not care for residents with IVs. The facility's Administrator expected LPN staff to inform the Registered Nurse (RN) on duty if they were unable to administer IV medication and to notify the Assistant Director of Nursing Services and the DNS if a medication was not administered. However, these protocols were not followed, leading to the deficiency.
Expired Medications Found in Storage Rooms
Penalty
Summary
The facility failed to ensure that medication storage rooms were free from expired medications, which placed residents at risk for receiving compromised or ineffective medications. During an observation and interview, it was found that the [NAME] Hall medication storage room refrigerator contained four expired COVID-19 vaccinations. A registered nurse acknowledged that nursing staff should be checking expiration dates on medications. Additionally, the East Hall medication storage room was found to contain several expired items, including povidone iodine swab sticks, saline enemas, a glucagon emergency kit, fecal collector bags, and medication cards of omeprazole and Methenamine Hippurate. The facility's policy on medication administration required staff to identify medication expiration dates and notify the nurse manager. However, during an interview, the facility administrator stated that the night shift RN was responsible for checking for expired medications and supplies, and expressed an expectation that nurses should remove expired medications. Despite this policy, expired medications were still present in the storage rooms, indicating a lapse in adherence to the facility's procedures.
Failure to Timely Report Abuse/Neglect Incident
Penalty
Summary
The facility failed to report an allegation of abuse/neglect to the State Agency within the required 24-hour timeframe for a resident who was found with significant bruising on their left hand and forearm. The resident, who had dementia, heart disease, and depression, was dependent on staff for activities of daily living and had severely impaired cognition. On observation, the resident's left hand and forearm were bruised and swollen, and the resident was unable to recall how the injury occurred. The facility's investigative report noted the bruising was identified on 07/14/2024, but the State Agency was not notified. The facility's investigation included an x-ray of the resident's left hand and wrist, which showed a possible non-displaced fracture. Despite the severity of the injury, the facility did not report the incident to the State Agency, as confirmed by the Assistant Director of Nursing Services during an interview. This failure to report in a timely manner was a repeat citation, indicating a pattern of non-compliance with the reporting requirements outlined in the Nursing Home Guidelines.
Failure to Investigate Alleged Abuse Resulting in Unexplained Bruising
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse concerning a significant bruise of unknown origin on a resident, identified as Resident 28. The resident, who has dementia and other medical conditions, was observed with severe bruising and swelling on their left hand and forearm. Despite the visible injuries, the facility did not conduct a comprehensive investigation as required by their policy. The policy mandates immediate investigation upon suspicion of abuse, including interviewing all involved parties and documenting the investigation thoroughly. However, the Assistant Director of Nursing admitted that not all staff or resident interviews were completed to rule out abuse. The resident's medical records indicated dependency on staff for daily activities and impaired cognition, which could have contributed to the difficulty in identifying the cause of the bruising. The medical director speculated that the bruising might have been caused by the resident hitting their hand against a surface, but this was not confirmed. An x-ray revealed mild tissue swelling and a possible non-displaced fracture. The resident's Power of Attorney reported the bruise to the nursing staff but received no explanation. The incident follow-up report suggested possible causes like tight clothing or bumping against a table, but these were not substantiated by a thorough investigation.
Failure to Investigate Allegations of Neglect and Falls
Penalty
Summary
The facility failed to thoroughly investigate an allegation of potential neglect and unwitnessed falls, resulting in substantial injuries to three residents. Resident 2, who had a stroke with right-sided weakness and osteoporosis, sustained a fracture and dislocation of the right arm and shoulder during a transfer without the use of a gait belt. The investigation did not include interviews with all relevant staff, the resident, or their representative, and failed to address the lack of gait belt usage during the transfer. Additionally, education on gait belt usage was delayed and incomplete. Resident 3, who had dementia and was at high risk for falls, was found on the bathroom floor with a large bump and bruise on the right side of their head after an unwitnessed fall. The investigation into this incident was not thorough, lacking interviews, a review of the resident's last toileting, type of footwear, medication review, and environmental observations. The investigation did not provide a conclusive statement regarding the fall, and corrective actions were insufficient. Resident 4, who had moderately impaired cognition and a history of falls, was found on the floor with a fractured left hip and a mildly displaced middle finger. The investigation into this incident was also inadequate, as it did not include interviews, an assessment of the environment, a medication review, or an evaluation of the resident's last observation by staff. The resident had recently been started on Namenda, which has side effects of sleepiness and dizziness, but this was not considered in the investigation.
Failure to Honor Resident Choice in Bathing Frequency
Penalty
Summary
The facility failed to ensure residents had the ability to exercise self-determination related to the frequency of bathing. Resident 5, who was admitted with diagnoses including stroke, depression, and anxiety, expressed a desire to have more than one shower per week but was only receiving one shower on Thursdays. Despite multiple requests, Resident 5 did not receive additional showers. Similarly, Resident 6, who was readmitted with heart failure and kidney disease, also requested two showers per week but was only receiving one shower on Wednesdays. Resident 6 had been receiving two showers per week until a few months ago but this was no longer accommodated. Interviews with staff revealed that the facility had only one bath aide on duty, making it challenging to provide more than one shower per week per resident. Staff F, the Nursing Assistant Bath Aide, confirmed the limitation, while Staff E, the Staffing Coordinator, stated that the facility should be able to provide showers once or twice a week based on resident preferences. Review of the shower records for both residents showed they only received one shower per week with no refusals documented.
Failure to Report Allegation of Neglect
Penalty
Summary
The facility failed to report an allegation of neglect to the State Agency as required, involving a resident who had a stroke with right-sided weakness, aphasia, and osteoporosis. The resident, who required extensive assistance with transfers, was found with a bruise on their right arm, which was reported by a Nursing Assistant and assessed by a Licensed Nurse. The resident complained of pain and was sent for x-rays, which later revealed a fracture and dislocated shoulder. Despite logging the incident, the facility did not report it to the State Agency as mandated by regulations. The deficiency was identified during a review of the resident's medical records and progress notes, which documented the injury and subsequent diagnosis. The facility's Reporting Log confirmed that the incident was not reported to the State Agency, as required for allegations of neglect. This failure to report placed residents at risk for further neglect and was a repeat deficiency from a previous Statement of Deficiencies.
Failure to Administer Prescribed Medication Dosage
Penalty
Summary
The facility failed to follow and/or clarify physician orders for a resident who was admitted with diagnoses including cellulitis and heart failure. Upon the resident's return from the hospital, the discharge orders indicated an increase in the dosage of furosemide to 80 mg every morning and an additional 40 mg at 1:00 PM for seven days. However, the staff did not administer the additional 40 mg dose on the day of the resident's return, as they believed the new orders would become effective the following day. This failure was confirmed through interviews with the resident and staff, as well as a review of the Medication Administration Record, which showed the increased dose was not given on the specified date. During interviews, the resident stated that staff refused to administer the additional dose of furosemide, and staff members confirmed they did not give the medication as per the new orders. Staff C entered the orders to begin the following day, and Staff D followed this instruction, resulting in the resident not receiving the prescribed medication on the day of their return from the hospital. This oversight placed the resident at risk for negative health outcomes and unmet care needs.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 59 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Walla Walla
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Park Manor Rehabilitation Ctr | 1.9 mi | ★★★★★ | 12 | 0 |
| Washington State Walla Walla Veterans Home | 2.4 mi | ★★★★★ | 28 | 0 |
| Regency At The Park | 2.7 mi | ★★★★★ | 13 | 0 |
| Milton Freewater Health And Rehabilitation | 9.6 mi | ★★★★★ | 6 | 0 |
| Willowbrook Post Acute | 37.1 mi | ★★★★★ | 18 | 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.