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 August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Washington Soldiers Home during CMS and state inspections, most recent first.
Failure to ensure freedom from abuse occurred when two residents got into a physical altercation in the dining room after one resident moved another resident’s name plate. Staff intervened and separated the residents without injury, but one resident admitted to grabbing the other by the neck and placing them in a headlock, while the other resident reported being assaulted. Facility leadership stated they did not consider it abuse because no one was hurt and the resident did not feel abused.
Delayed Pressure Injury Prevention and Wound Development: A resident with hip fracture surgery, DM, HTN, and dementia was assessed as at risk for pressure injuries and had a wound nurse recommendation for an alternating pressure air mattress and bilateral heel lift boots. The interventions were not implemented timely, and the resident later developed a left buttock sore, a right heel ulcer, a left heel deep tissue pressure injury, and a sacral unstageable pressure injury; staff and the DON stated follow-up, documentation, education, and provider notification were expected when the resident refused care or preventive measures.
A resident with DM, quadriplegia, and kidney disease developed a painful foot blister/DFU after wearing shoes that were too tight. Staff knew the resident needed a podiatry shoe fitting, but the referral was not followed up on for 56 days, and the resident reported waiting over a month for new shoes and missing restorative and other activities because they had no shoes. PT later documented decreased strength and a slight functional decline.
Inaccurate psychotropic medication consents were completed for a resident with schizoaffective disorder, bipolar disorder, anxiety, depression, psychotic disorder, and PTSD. The resident received aripiprazole and quetiapine, but the consent for aripiprazole listed a different dose and route than the current order, and the quetiapine consent omitted the morning dose. The RN/RCM and DON stated the consents did not meet expectations.
A resident’s privacy was not protected when a Monitoring in Progress sign was posted on the room door and no consent for the recording device was documented in the EHR. The resident had HTN, DM, and dementia, and staff stated the roommate used a smart device capable of playing music or recording. The RN/RCM could not locate consent, and the DON stated consent was expected before use of the device.
A resident with stroke and R-sided hemiplegia who used a wheelchair had a damaged L armrest with torn vinyl and exposed padding observed repeatedly over several days. The resident said the damage had been present for about 10 months and staff were aware. The DON stated the armrest was peeling with exposed padding and was not a cleanable surface, and the Admin said the condition had not been addressed and did not meet expectations.
Missing Bed Hold Notice at Hospital Transfer: The facility failed to provide written bed hold notice when two residents were transferred to the hospital. One resident with chronic pain, anxiety, and DM had no documentation of receiving the bed hold notice or transfer form, and another resident with DM, depression, HF, and Charcot's joint stated they did not know about a bed hold after a hospital stay. Records showed spouse notification for the hospitalization, but no documentation of bed hold notice being given verbally or in writing.
MDS assessments were inaccurately coded for three residents. One resident with hemiplegia, heart failure, dysphagia, and dementia was observed with an uneaten meal and reported poor appetite and weight loss, yet the MDS showed a prescribed weight loss program despite nutrition supplements and a care plan focused on maintaining weight. A second resident reported weight loss and use of multiple shakes for weight gain, but the MDS also indicated a weight loss program without supporting care plan instructions. A third resident with depression and PTSD had a PASSAR level II referral and evaluation completed, but the admission MDS incorrectly coded the PASSAR item as No instead of Yes.
A resident admitted with anxiety disorder, DM, and CKD did not have PASARR screening completed prior to admission. Facility staff stated community admissions were treated as respite stays and that the level one PASARR would be completed later if the stay exceeded 30 days, while the Administrator stated the level one should have been completed before admission. The record showed a level one PASARR later identified the need for a level two assessment.
Failure to Follow Splint and Heel Boot Orders: A resident with hemiplegia/hemiparesis, HF, dysphagia, and dementia was observed in bed multiple times without the ordered right wrist extension splint or prevalon heel lift boots in place, despite care plan interventions and provider orders requiring both devices while in bed. The TAR was initialed as if the devices were on during the same period, and an RN stated the resident had refused the splint and the documentation should have reflected that; the DON stated licensed nurses were expected to follow orders and document accurately.
Failure to provide restorative nursing services: A resident with quadriplegia, DM, and kidney disease was ordered restorative programs for strength and mobility, but participation was not documented and the resident reported not taking part because they were waiting for wider shoes. The NA said the program was only offered about 3 times per week instead of 6, the resident reported losing strength, and a later PT eval showed a decline in transfer status; the DON stated a PT referral should have been made when the resident reported the weakness.
Fluid restriction documentation was inconsistent for a resident with kidney failure on dialysis, diabetes, and HF, with dietary and nursing records not matching and room signage still indicating a restriction despite the resident stating otherwise. In a separate issue, a resident with HTN, DM, and dementia had difficulty with a regular texture diet and a speech therapy referral was made, but staff later confirmed there was no follow-up on the referral.
Failure to document follow-up on pharmacist vaccination recommendations. A resident with diabetes, schizoaffective disorder, and depression had MRR recommendations to offer shingles and RSV vaccines, but the facility left the response section blank and did not document a clinical rationale for not following the pharmacist’s advice. A later note showed staff contacted the POA, who said the resident should decide, but no further EHR documentation showed the recommendations were addressed.
A resident with stroke, R-sided hemiplegia, and DM reported ongoing oral pain in a left upper molar and said they had asked staff weeks earlier to see a dentist for extraction, but no dental visit had been scheduled. Dental records showed tooth #15 was on a root canal watch and needed a buildup/crown and SDF, but the resident declined to pay out of pocket for the procedure and wanted the tooth pulled instead. Staff later confirmed the resident should have been assessed, the provider notified, and a dental appt scheduled for extraction, but the issue was not addressed timely.
A facility failed to post the actual hours worked in its nursing staffing postings for multiple observed days. Surveyors found the postings listed hours but did not show whether they were actual or scheduled hours for each discipline on each shift. An AA3 stated the night nurse prepared and posted the information daily, and the DON confirmed the postings reflected scheduled hours rather than actual hours worked.
A resident with a history of heart disease reported chest pain and difficulty breathing to staff on multiple occasions, but did not receive timely intervention and was sent to the hospital several hours later. The resident's subsequent allegation of neglect was not reported to the State Agency within the required timeframe, as facility procedures dictate, resulting in a delay of three days before the report was made.
The facility failed to serve food at appetizing temperatures, with residents reporting overcooked and flavorless meals. During a lunch service, a food service worker added gravy to dried-out meatloaf, which was not on the menu, and served tilapia at an inadequate temperature. The dietary manager confirmed these practices did not meet expectations.
The facility failed to provide physician-ordered therapeutic diets and portion sizes to 22 residents, risking medical complications and nutritional deficits. Observations revealed that residents on specific diets received incorrect items, such as garlic bread instead of wheat rolls, and incorrect portion sizes, such as insufficient protein servings. Staff acknowledged the discrepancies but could not explain the failure to adhere to dietary orders.
A facility failed to document and review a resident's healthcare advance directive (AD), leaving the resident without confirmed healthcare decision-making authority. The resident believed their sister was their DPOA for healthcare, but the EHR only showed a DPOA for financial matters. Staff interviews confirmed the absence of required documentation and review of the AD.
A resident reported concerns about personal items being stolen and was distressed over the lack of a lock on their closet. Despite filing a grievance, the facility did not report the alleged theft to law enforcement or the State Survey Agency. Interviews with staff confirmed that the required notifications were not made, placing the resident at risk for further abuse.
A resident reported concerns about stolen personal items and the lack of a lock on their closet, causing emotional distress. The facility addressed the lock issue but failed to investigate the theft allegations. Interviews with staff confirmed that an investigation should have been conducted, but it was not, leading to a deficiency finding.
A resident was admitted with diagnoses of depression and PTSD, but the PASRR assessment completed prior to admission failed to document these serious mental illness indicators. Facility staff acknowledged that the assessment was inaccurate and should have been updated upon admission.
A resident with a left leg amputation received a shrinker to prepare for a prosthetic leg, but the facility failed to document its arrival, obtain provider orders, or update the care plan. The resident applied the shrinker independently without formal guidance from nursing staff, leading to a deficiency in professional standards of care.
A resident with severe malnutrition, a sacral ulcer, and diabetes experienced a decline in ADLs due to the facility's failure to provide a wheelchair. The resident, dependent on staff for transfers, was confined to bed without mobility plans in their care plan or EHR. The DON stated that a loaner wheelchair should have been provided.
The facility failed to monitor and document bowel movements for a resident at risk of constipation, and did not implement the bowel program as needed. Additionally, two residents were not properly positioned or provided with necessary supportive devices, despite having care plans that required specific interventions. Staff interviews confirmed that expectations for monitoring, documentation, and use of devices were not met.
A facility failed to accurately assess a resident's smoking safety, leading to potential fire and injury risks. The resident, with multiple health issues and a history of stroke, was observed with a right-hand splint and an untrimmed beard, yet was allowed to smoke independently. Staff interviews confirmed the assessment was inaccurate, as the resident lacked the dexterity to hold a cigarette safely and had a large untrimmed beard.
A resident with chronic pain syndrome and a recent toe amputation reported inadequate pain management, with medication not administered on time and insufficient to control pain. Facility staff interviews confirmed a lack of documentation and monitoring of the resident's pain levels, contrary to the care plan and facility protocol.
A facility failed to limit PRN psychotropic medication to 14 days for a resident with chronic respiratory failure and anxiety. The resident had an order for lorazepam without a stop date, and the medication was administered multiple times over several months. The pharmacist and DON acknowledged the oversight, as the PRN lorazepam should have been discontinued or justified within 14 days.
Failure to Ensure Freedom From Abuse During Resident Altercation
Penalty
Summary
Freedom from abuse was not ensured when two residents became involved in a physical altercation in the dining room after one resident moved another resident’s name plate as a joke. When the second resident entered the dining room and sat at the newly assigned seat, staff attempted to advocate for the resident and directed the first resident to move the name plates back to their assigned places. The first resident responded by telling the other resident they could “just be a man,” and the second resident then physically attacked the first resident by grabbing the neck from behind and placing the resident in a headlock. Staff intervened and separated the residents without injury. The resident who was grabbed and placed in a headlock had diagnoses including dementia/cognitive decline and stroke with left-sided weakness, and was able to make needs known with minimal to moderate assistance for activities of daily living. During interview, that resident stated the other resident assaulted them physically and put them in a headlock, but reported no injury or pain and said there was not enough force to cause damage. The other resident stated they felt offended after the name tag was moved and admitted to attacking the resident, demonstrating a headlock motion and stating, “I tried to break [the resident’s] neck.” Facility staff stated they did not feel abuse had occurred because the resident did not feel abused and no one was hurt, and the Administrator and DON stated they would not have concluded there was failed facility practice because nothing could have been done differently and the altercation could not have been foreseen.
Delayed Pressure Injury Prevention and Wound Development
Penalty
Summary
The facility failed to address identified risk factors for pressure ulcer development and did not implement recommended preventive interventions in a timely manner for Resident 3. Resident 3 was readmitted after a hip fracture and surgery, with diagnoses including hypertension, diabetes, and dementia, and was assessed as at risk for pressure ulcer/injury without any unhealed pressure injuries at readmission. A wound nurse recommended a low air loss or alternating pressure air mattress and bilateral heel lift boots for skin integrity and prevention, but the record showed delays in implementation while staff documented that the resident was resistive and combative about moving for the specialty mattress installation. During routine care on 08/13/2025, staff observed an open sore on the left buttock and a right heel diabetic foot ulcer. The next day, the resident was enrolled with an outside wound provider for a left heel deep tissue pressure injury and a sacral unstageable pressure injury. The treatment record showed the alternating air mattress started on 08/15/2025 and heel lift boots started on 08/14/2025, after the wounds had already been identified. Interviews with the RN/RCM and DON indicated staff should have followed up on the mattress and boots, reapproached the resident about implementation, documented the outcome, educated the resident, and contacted the provider when the resident refused care or preventive measures.
Delayed Podiatry Follow-Up and Ill-Fitting Shoes
Penalty
Summary
The facility failed to ensure timely podiatry care and services for a resident with diabetes, quadriplegia, and kidney disease. Resident 39 reported that their shoes were not wide enough and caused a painful blister on their foot, and they stated they had been waiting more than a month for new shoes. A progress note documented a tender diabetic foot ulcer on the bottom of the right foot, and the resident was enrolled with an outside wound provider the following day. Staff interviews and record review showed the resident had requested a podiatry appointment in June 2025 because the shoes were too tight, but the referral was not followed up on until 56 days later. The resident stated they had not been able to participate in restorative or other activities because they did not have any shoes. The restorative record showed the resident was marked not available for participation for multiple days in August, and the PT evaluation later showed a decrease in strength and a slight functional decline compared with prior functioning.
Inaccurate Psychotropic Medication Consents
Penalty
Summary
The facility failed to have psychotropic medication informed consents accurately completed before administering medications for one sampled resident. Resident 8 was readmitted to the facility and was able to make needs known. The quarterly MDS dated 08/06/2025 listed diagnoses including schizoaffective disorder, bipolar disorder, anxiety disorder, depression, psychotic disorder, and PTSD. The MAR for August 2025 showed the resident received aripiprazole 20 mg once daily for schizoaffective disorder with hallucination and quetiapine fumarate 50 mg in the morning and 100 mg at bedtime for schizoaffective disorder. Review of the resident's consent for aripiprazole dated 03/18/2025 showed a dose of 15 mg by mouth once daily for schizoaffective disorder, bipolar type, which did not match the current provider order for 20 mg via G-tube once daily. Review of the consent for quetiapine fumarate dated 03/18/2025 showed 100 mg via G-tube at bedtime, but it did not include the current morning dose of 50 mg via G-tube once daily. Staff C, RN/RCM, and Staff B, DON, both stated the consents did not meet expectations because the aripiprazole consent was inaccurate for dose and route and the quetiapine consent was missing the morning dosage.
Failure to Protect Resident Privacy with Recording Device in Room
Penalty
Summary
The facility failed to ensure personal privacy was protected for 1 of 3 sampled residents, Resident 50, when a Monitoring in Progress sign was observed on the exterior of the resident’s room door and no documentation of consent to the recording device in the room was found in the electronic health record. Resident 50 was admitted with diagnoses including high blood pressure, diabetes, and dementia, and was able to make needs known. Staff reported that the roommate used an [NAME], described as a smart device capable of playing music or recording, and the RN/RCM was unable to locate consent for Resident 50. The DON stated the expectation was for consent to be signed by the resident or resident representative before use of the recording device.
Wheelchair Armrest Left in Damaged, Uncleanable Condition
Penalty
Summary
The facility failed to maintain a sanitary and homelike environment for 1 of 4 halls reviewed when Resident 19’s wheelchair left armrest was found with the black vinyl covering missing and torn off toward the back of the armrest, exposing cream-colored padding. The resident was admitted with diagnoses including stroke and right-sided hemiplegia and used a wheelchair for mobility. Resident 19 was able to make needs known, and multiple observations showed the armrest remained in the same condition over several days, with the exposed material described as not a cleanable surface or a homelike environment. During interview, Resident 19 stated the damage to the left armrest had started small, had gotten bigger, and had been present for about 10 months, with staff aware of it. Staff B, the DON, stated the armrest was peeling and missing black covering with exposed padding underneath and acknowledged it was not a cleanable surface and did not meet expectations. Staff B located documentation showing an armrest replacement on 02/13/2025, but no other documentation was found after that date. Staff A, the Administrator, also stated the wheelchair left armrest condition with exposed substructure cloth had not been addressed prior to now and did not meet expectations.
Missing Bed Hold Notice at Hospital Transfer
Penalty
Summary
The facility failed to provide written bed hold notice at the time of transfer to the hospital for 2 of 4 sampled residents, Residents 93 and 5. Resident 93 was admitted with diagnoses including chronic pain, anxiety, and diabetes, and was able to make needs known. Review of the electronic health record showed hospitalization on 06/01/2025, but there was no documentation that the resident or resident representative was provided written copies of the bed hold notice or transfer form. Resident 5 was admitted with diagnoses including diabetes, depression, heart failure, and Charcot's joint, and was also able to make needs known. During an interview, Resident 5 stated they had been in the hospital for six days and did not know about a bed hold. The electronic health record showed a signed bed hold form for leave on pass with family in August 2025, but no signed form for bed hold during the June 2025 hospitalization. Progress notes showed the spouse was notified about the hospitalization, but there was no documentation of a bed hold being discussed or provided verbally or in writing.
MDS Assessments Were Inaccurately Coded for Three Residents
Penalty
Summary
The facility failed to ensure the minimum data set (MDS) accurately reflected resident status for 3 of 19 sampled residents. Resident 1 was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, heart failure, dysphagia, and dementia. During an observation and interview, Resident 1 was sitting on the bed with an uneaten lunch tray and stated they did not have an appetite, had lost weight, and were shrinking away. The significant change MDS showed Resident 1 was on a prescribed weight loss program, while provider orders showed Prostat for decreased muscle mass and a high-calorie shake three times daily for weight loss. The care plan identified a potential for weight loss and included interventions to maintain weight, but there were no instructions about a planned weight loss. Resident 5 was admitted with diagnoses including diabetes mellitus, depression, heart failure, and Charcot's joint. During interview, Resident 5 stated they had lost a lot of weight because they could not eat the facility food and were drinking four shakes a day to help with weight gain. The quarterly MDS showed Resident 5 was on a prescribed weight loss program, while provider orders showed Glucerna three times daily. The care plan identified a nutritional problem, but there were no instructions about a planned weight loss. Resident 6 was readmitted with depression and post-traumatic stress disorder. The level I PASSAR showed a level II evaluation referral for serious mental illness, and the level II PASSAR evaluation was completed. However, the admission MDS coded section A1500 as No for being considered for the level II PASSAR process when it should have been coded Yes. Staff B and the RN/MDS Coordinator stated the MDSs for Residents 1, 5, and 6 were coded in error and did not meet expectations.
Failure to Complete PASARR Screening on Admission
Penalty
Summary
The facility failed to screen for mental health services on admission for one sampled resident who was reviewed for PASARR. Resident 30 was admitted with diagnoses including anxiety disorder, diabetes, and chronic kidney disease, and was able to make needs known. The electronic health record showed a PASARR level one dated 05/09/2025 that indicated the resident required a level two PASARR assessment. The care plan, initiated 04/18/2025, also documented that Resident 30 had a level one PASARR and that a level two PASARR was requested on 05/09/2025. During interviews, the Social Worker stated that residents admitted from the community would be considered respite stays and that the PASARR would be completed within the first month of admission. Admissions staff stated that residents admitted from the community would not have a level one PASARR completed before admission and that social workers would complete the level one if it was determined the resident would stay greater than 30 days. The Admissions staff also stated the provider did not determine whether the level one PASARR should be completed because of a hospital exempted stay. The Administrator stated the PASARR level one should be completed prior to admission.
Failure to Follow Splint and Heel Boot Orders
Penalty
Summary
The facility failed to ensure licensed nurses followed orders for a right wrist extension splint and prevalon heel lift boots for one resident who was admitted with hemiplegia and hemiparesis following cerebral infarction, heart failure, dysphagia, and dementia. The resident was able to communicate needs. The care plan included interventions for a right wrist extension splint and prevalon boots, and the provider’s orders directed staff to apply the right wrist extension splint to the right wrist and prevalon heel lift boots to both feet/lower legs while the resident was in bed. Observations on 08/21/2025, 08/22/2025, 08/25/2025, and 08/26/2025 showed the resident in bed without the splint or boots on, although the splint was seen on the nightstand during one observation. During interview, the resident stated staff had placed the right-hand splint on them a couple of days earlier. The August 2025 treatment administration record showed licensed nurses initialed that the splint and boots were on during the same time period as the observations. An RN stated the resident refused the splint in the morning and the documentation should reflect that, and the DON stated the expectation was for licensed nurses to follow orders and document accurately.
Failure to Provide Restorative Nursing Services
Penalty
Summary
The facility failed to ensure a resident with quadriplegia, diabetes, and kidney disease received restorative treatment and services to maintain or improve range of motion and mobility. The resident was admitted able to make needs known, and the PT discharge summary recommended a restorative nursing program for maintenance and strength building. The care plan included multiple restorative programs, including lower extremity exercises, upper extremity exercises, a sci-fit bike, and trunk reaching exercises, each to be encouraged six times per week and charted when participated in. The resident stated they had not participated in restorative because they had been waiting for wider shoes to be ordered and reported increased weakness in their legs, but could not recall the last time they participated. The restorative participation record showed "Not available" for daily entries from 08/07/2025 through 08/28/2025, with no documentation found for 08/01/2025 through 08/06/2025. A NA stated they did not know why the resident had not been participating, and also stated the resident was only offered the program about three times per week instead of six. A later PT evaluation documented a decline in transfer status from Total A to Dependent, and the DON stated a referral to PT should have been made when the resident reported losing strength.
Fluid Restriction Documentation and Speech Therapy Referral Follow-Up Failures
Penalty
Summary
The facility failed to monitor and accurately document fluid restrictions for Resident 2, who was readmitted with kidney failure requiring dialysis, diabetes, and heart failure. The current provider diet order dated 03/31/2025 showed a regular diet with thin liquids and a 1000 ml/24-hour fluid restriction, with specific amounts assigned to dietary and nursing. A later provider order dated 07/29/2025 also showed a 1000 ml fluid restriction, but its breakdown for dietary and nursing did not match the earlier dietary order. Resident 2’s Kardex dated 08/27/2025 reflected the 07/29/2025 fluid restriction breakdown and directions to document all fluids consumed during each shift in ml. Review of Resident 2’s EHR tasks for nutrition from 07/29/2025 through 08/26/2025 showed the resident was provided over 760 ml on multiple dates, and staff interviews confirmed the documentation process was inconsistent. Staff stated the dietary order should have been updated when the new fluid restriction order was obtained, and that nursing assistants documented fluids in tasks while licensed nurses documented in the MAR. Staff also stated the amounts documented in tasks did not appear to be included in the July and August 2025 MARs, and this did not meet expectations. During observation and interview, Resident 2 stated they used to be on a fluid restriction but was no longer on one, while a sign in the room still indicated no water pitcher due to fluid restriction. The facility also failed to follow up on a speech therapy referral for Resident 3, who was readmitted after hip surgery with diagnoses including hypertension, diabetes, and dementia. A progress note dated 08/06/2025 stated Resident 3 was starting to have a problem with a regular texture diet and could not eat, was given a supplement to drink, and staff referred the resident to speech therapy for an evaluation. Staff later stated there had been no follow-up on the speech referral, and the DON stated referrals were expected to be followed up on and completed timely.
Failure to Document Follow-Up on Pharmacist Vaccination Recommendations
Penalty
Summary
The facility failed to act on the consultant pharmacist’s medication regimen review recommendations and did not clearly document a clinical rationale for not following the recommendations for Resident 8. Resident 8 was readmitted with diagnoses including diabetes, schizoaffective disorder, and depression, and was able to make needs known. The pharmacist’s 06/09/2025 Pharmacist Report of Irregularity recommended that Resident 8 be offered the shingles vaccination and the RSV vaccination, but the Facility Response section on the form was left blank and did not include a justification for not following either recommendation. A progress note dated 07/08/2025 showed the facility contacted Resident 8’s POA to obtain consent for the shingles and RSV vaccinations, and the POA stated it was up to Resident 8 to decide and staff should ask Resident 8 for consent. No other documentation was found in the EHR related to the pharmacist’s recommendations. During interview, the RN/Resident Care Manager stated the facility tried to follow up on pharmacist recommendations within a week depending on the recommendation, but there was no other progress note showing follow-up on the vaccination recommendations. The DON stated the 06/09/2025 pharmacist recommendations for shingles and RSV vaccinations should have been followed up on prior to now and did not meet expectations.
Delayed Dental Follow-Up and Tooth Extraction
Penalty
Summary
The facility failed to schedule a follow-up dental appointment and provide prompt dental services for a resident who was able to make needs known and had diagnoses including stroke, right-sided hemiplegia, and diabetes. The resident had missing upper and lower teeth and a focused care plan for oral/dental health problems related to natural teeth, cracked/broken teeth/fillings, heavy build-up, and the need for encouragement with daily brushing, with an intervention to coordinate dental care and transportation as needed. The resident reported oral pain at times in the left upper back molar and stated they told staff three or four weeks earlier that they wanted to see a dentist to have the tooth pulled, but they still had not seen a dentist. A dental appointment in April showed tooth #15 was on a root canal watch and needed a buildup/crown and SDF, and a progress note stated the resident would need a buildup crown but would not pay out of pocket. The resident later stated they told staff they did not want to pay for a root canal and only wanted the tooth pulled to prevent further occasional oral pain. A later progress note placed the resident on alert for reports of pain of the left upper molar at times, and staff interviews confirmed the resident should have been assessed, the provider notified, and a dental appointment scheduled to have the tooth extracted, but that this had not been addressed timely.
Nursing Staffing Postings Did Not Show Actual Hours Worked
Penalty
Summary
The facility failed to post the actual hours worked in the nursing staffing postings for 5 of 5 observed days during the survey period. Observations on 08/21/2025, 08/22/2025, 08/25/2025, 08/26/2025, and 08/27/2025 showed the staffing postings listed the number of hours, but did not indicate whether those hours were actual or scheduled hours for each discipline on each shift. During interview, the Administrative Assistant 3 stated the night nurse made up and posted the nursing staffing information daily and that the postings showed scheduled hours worked rather than actual hours worked. The DON also stated that the scheduled hours were what was being posted, but the postings should have reflected the actual hours worked for each discipline.
Failure to Timely Report Allegation of Neglect
Penalty
Summary
The facility failed to identify and timely report an allegation of neglect for one resident. The resident, who had a history of atherosclerotic heart disease and prior heart attacks, reported experiencing chest pain and difficulty breathing during the early morning hours. Despite informing staff of these symptoms multiple times, the staff did not take immediate action, and the resident was not sent to the hospital until several hours later. The resident later reported this incident to facility staff, expressing that their concerns were not addressed promptly and that they felt their life was at risk while waiting for assistance. A grievance form documented the resident's complaint, and the staff member who received the complaint reported it to their supervisor. However, the facility did not report the allegation of neglect to the State Agency until three days after the resident voiced the allegation. The facility's operating procedure required immediate reporting of suspected abuse or neglect to a licensed nurse and the State Agency hotline, but this protocol was not followed. The Director of Nursing Services confirmed that the delay in reporting was not acceptable and did not meet facility expectations.
Failure to Provide Appetizing and Safe Food Temperatures
Penalty
Summary
The facility failed to provide food at an appetizing temperature, as observed during a review of Kitchen Services. Residents expressed dissatisfaction with the quality of the food, noting that the meat was overcooked and lacked flavor. Specifically, one resident mentioned that the meat was overcooked, while another stated that the food did not taste good. A third resident commented on the lack of flavor and dryness of the chicken and other meats. These observations were made during interviews conducted on July 15, 2024. On July 17, 2024, during the lunch tray service, it was observed that a food service worker was adding gravy to meatloaf slices that appeared dried out, even though gravy was not listed on the menu for regular diets. The temperatures of the food items on a test tray were taken, revealing that the orzo and asparagus were at 135 degrees Fahrenheit, the meatloaf at 136 degrees Fahrenheit, and the tilapia at 125 degrees Fahrenheit. The food service worker acknowledged that the tilapia was not at an appropriate temperature. The dietary manager confirmed that only altered texture diets should have received gravy and that dried-out menu items should not have been served. The tilapia's temperature did not meet the facility's expectations, indicating a failure to maintain proper food quality and safety standards.
Failure to Provide Physician-Ordered Therapeutic Diets and Portion Sizes
Penalty
Summary
The facility failed to ensure that 22 out of 90 sampled residents received physician-ordered therapeutic diets or portion sizes, which placed them at risk for medical complications, nutritional deficits, and a decreased quality of life. During an observation of the lunch tray preparation service, it was noted that residents on Easy to Chew, Soft and Bite Sized, and Puree diets were served garlic bread instead of the wheat roll specified in the lunch extension menu. Staff L, a Food Service Worker Lead, confirmed that only garlic bread and garlic bread sticks were prepared, and there were no wheat rolls available. Staff L was unsure why the wheat rolls were not prepared, indicating a failure to follow the prescribed dietary requirements. Additionally, there were discrepancies in portion sizes provided to residents. For instance, Resident 60's tray card indicated a Large Portion, but they received only one and a half portions of meatloaf, with regular diet portion sizes for other items. Similarly, Resident 48's tray card indicated Double Protein, but they were initially served only one slice of meatloaf, consistent with the regular diet. Staff N, the Food Service Supervisor, had to intervene to correct the portion size for Resident 48. Staff M, the Dietary Manager, acknowledged that tray cards indicating Large Portion should have received one and a half portions of protein and starch, and that the expectation was for extension menus and tray cards to be followed. However, Staff M could not explain why the wheat rolls were not prepared, highlighting a lapse in adherence to dietary orders.
Failure to Document and Review Healthcare Advance Directive
Penalty
Summary
The facility failed to obtain or offer assistance in formulating or periodically checking if a resident had a healthcare advance directive (AD). This deficiency was identified for one of the sampled residents, who was able to make their needs known upon admission. The resident believed their sister was their durable power of attorney (DPOA) for healthcare, but there was no documentation to confirm this in their electronic healthcare record (EHR). The resident's care plan only indicated a DPOA for financial matters, not healthcare. Interviews with facility staff revealed that the necessary documentation and review of the resident's AD for healthcare were not conducted as required. The psychiatric social worker confirmed the absence of documentation offering AD information or reviewing it in the EHR. The facility administrator acknowledged that AD information should be offered, obtained, and reviewed upon admission and quarterly, and that the lack of documentation did not meet the facility's expectations.
Failure to Report Alleged Theft of Resident's Property
Penalty
Summary
The facility failed to report an incident of potential abuse involving the misappropriation of personal property for one resident. Resident 37, who was able to communicate their needs, expressed concerns about personal items being stolen and was distressed over the lack of a lock on their closet. Despite the resident's grievance filed on June 10, 2024, which highlighted their emotional distress and the need for a lock, the facility did not address the allegation of stolen items or report the incident to law enforcement and the State Survey Agency as required. The facility's incident reporting log from February 2024 through July 12, 2024, showed no record of the alleged theft. Interviews with the Director of Nursing Services and the Administrator revealed that the police and State Agency should have been notified, but this did not occur. The failure to report the allegation of misappropriation of personal property placed the resident at risk for further abuse and diminished their quality of life.
Failure to Investigate Alleged Misappropriation of Resident's Property
Penalty
Summary
The facility failed to identify and investigate possible misappropriation of personal property for a resident who was able to communicate their needs. The resident, who had previously experienced theft of personal items, expressed concerns about stolen belongings and the lack of a lock on their closet, which caused them emotional distress. Despite the resident's grievance form indicating these concerns, the facility only addressed the installation of locks on the closet and did not investigate the allegations of stolen items. The facility's incident report log showed no recorded investigation into the resident's allegations of theft. Interviews with the Director of Nursing Services and the Administrator revealed that an incident report investigation should have been initiated but was not, which did not meet the facility's expectations. The failure to investigate the resident's allegations of misappropriation of personal property was identified as a deficiency.
Inaccurate PASRR Assessment for Resident
Penalty
Summary
The facility failed to ensure that the Pre-Admission Screening and Resident Review (PASRR) assessment was accurately completed for a resident upon or prior to admission. This deficiency was identified for one of seven residents reviewed for PASRRs and/or unnecessary medications. The resident in question was admitted with diagnoses including depression, adult failure to thrive, and post-traumatic stress disorder (PTSD). However, the PASRR assessment completed by the hospital prior to admission did not document any serious mental illness indicators, and it incorrectly indicated that no Level II evaluation was needed. Interviews with facility staff revealed that the PASRR assessment was not accurate and should have been reviewed and updated upon the resident's admission to include the diagnoses of depression and PTSD. Both the Psychiatric Social Worker and the Director of Nursing Services acknowledged that the PASRR did not meet expectations and should have been corrected to reflect the resident's mental health conditions.
Failure to Document and Plan for Shrinker Use in Resident with Amputation
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice for a resident with an amputation of the left lower leg. The resident, who was admitted with a diagnosis of an amputation, was waiting for a shrinker to arrive in the mail to help prepare for a prosthetic leg. Upon receiving the shrinker, the resident was responsible for applying it themselves without any documented assessment, provider orders, or care plan in place. The resident was advised by a Certified Nursing Assistant/Restorative Aide to wear the shrinker for about an hour daily and to monitor for skin reactions, but there was no formal guidance or documentation from the nursing staff or physician. Interviews with staff revealed a lack of awareness and documentation regarding the resident's use of the shrinker. The Licensed Practical Nurse confirmed the absence of a provider order or care plan for the shrinker, and the Director of Nursing Services was unaware of the shrinker's arrival and use. The facility did not document the arrival of the shrinker, notify the provider, obtain necessary orders, or update the care plan, which led to a deficiency in meeting professional standards of care for the resident.
Failure to Provide Wheelchair Leads to ADL Decline
Penalty
Summary
The facility failed to provide necessary care and services for a resident, identified as Resident 57, leading to a decline in their ability to perform activities of daily living (ADLs). Resident 57 was admitted with severe malnutrition, a large sacral skin ulcer, and diabetes, and was dependent on staff for transfers in and out of bed. Despite being able to communicate their needs, Resident 57 was observed lying in bed continuously over several days without a wheelchair, which was necessary for their mobility. The resident expressed frustration about being confined to bed since March, unable to go outside or attend medical appointments. The electronic health record and care plan for Resident 57 lacked any mention of a wheelchair or mobility plan. The Director of Nursing Services acknowledged that the facility's expectation was to provide a loaner wheelchair until the resident's personal wheelchair was available.
Deficiencies in Bowel Monitoring and Positioning
Penalty
Summary
The facility failed to consistently monitor and document bowel movements and implement the bowel program for Resident 28, who was at risk for constipation due to impaired mobility, medications, and diet. Despite having a care plan that required monitoring and documentation of bowel movements, there was no record of bowel movements for several days, nor was there documentation of administering constipation medications or any refusals. Interviews with staff revealed that the expectation was to administer medications if the resident did not have a bowel movement for more than 72 hours and to document any refusals, which was not done. Additionally, the facility did not properly position Resident 12, who was dependent on staff for bed mobility due to Parkinson's disease. Observations showed that the resident was not repositioned every two hours as required, and palm protectors were not used consistently, despite the resident having sores on their fingertips and being unable to use the call light. Staff interviews confirmed that the resident should have been repositioned every two hours and should have had palm protectors on at all times. For Resident 52, the facility failed to use prescribed positioning devices, such as an air cast and palm splint, for a resident with a stroke and a leg fracture. Observations showed that the resident's left hand was not supported with a splint, and the left leg was not properly positioned in an air cast. Documentation did not reflect the use of these devices, contrary to the care plan and treatment administration record. Staff interviews indicated that the expectation was for clear documentation and the use of devices as ordered, which was not met.
Inaccurate Smoking Safety Assessment for Resident
Penalty
Summary
The facility failed to provide necessary supervision and safety monitoring for a resident, identified as Resident 28, who was reviewed for accidents. The deficiency was related to an inaccurate smoking safety assessment, which placed the resident and the facility at risk for possible fire and serious injury. The facility's policy on smoking and tobacco use required smoking assessments for residents who smoked upon admission, quarterly, and when warranted by circumstances. However, the assessment for Resident 28, conducted on 06/11/2024, inaccurately indicated that the resident had the hand dexterity to safely hold a cigarette and that their facial hair was trimmed to avoid lit cigarette or ashes falling on it, despite observations to the contrary. Resident 28 was admitted with multiple diagnoses, including heart, lung, and kidney disease, and had a history of stroke with hemiplegia. During an observation, the resident was seen with a right-hand splint and a large, untrimmed beard, and stated they smoked independently after obtaining cigarettes and a lighter from the nurse's station. Interviews with facility staff revealed that the smoking safety assessment was not accurate, as the resident lacked the dexterity to hold a cigarette safely and had a large untrimmed beard, which posed a safety risk. The Director of Nursing Services confirmed that the assessment should have been accurate and that the resident's beard should be trimmed for safe smoking.
Failure to Monitor and Manage Resident's Pain
Penalty
Summary
The facility failed to adequately monitor and manage pain for a resident, identified as Resident 67, who was admitted with a diagnosis of left toe amputation, chronic pain syndrome, and post-traumatic stress disorder. The resident had a provider order for narcotic pain medication to be administered three times a day. However, during an interview, the resident reported that the medication was not administered on time and was insufficient to control their pain, which was described as out of control. A review of the electronic health record revealed a lack of documentation regarding the resident's pain levels, which is necessary to assess the effectiveness of the pain medication. Interviews with facility staff, including the Resident Care Manager and the Director of Nursing Services, confirmed that the facility's protocol required pain levels to be documented every shift and the physician to be notified if the medication was ineffective. Despite this, the resident's care plan, which instructed staff to monitor and document pain management, was not followed. The resident reported experiencing pain at a level of 9 out of 10, and was observed shaking due to the intensity of the pain, indicating a significant lapse in the facility's pain management practices.
Failure to Limit PRN Psychotropic Medication to 14 Days
Penalty
Summary
The facility failed to ensure that as-needed (PRN) psychotropic medications were limited to 14 days for one resident, identified as Resident 59, when reviewed for unnecessary medications. Resident 59, who was admitted with multiple diagnoses including chronic respiratory failure and anxiety, had an order for lorazepam, an antianxiety medication, to be administered every four hours as needed, starting on February 21, 2024, without a stop date. The monthly pharmacy recommendations did not include a suggestion to discontinue the lorazepam PRN after 14 days. The medication administration record indicated that Resident 59 received lorazepam three times in July 2024, seven times in June 2024, and nine times in May 2024. During interviews, both the pharmacist and the Director of Nursing Services acknowledged that the PRN lorazepam should have been discontinued or justified within 14 days, which was not done, leading to the deficiency.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 684 citations issued within 25 miles in the last 12 months — including the 4 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.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Orting
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Center Of South Hill | 7 mi | ★★★★★ | 18 | 1 |
| Puyallup Post Acute | 7.1 mi | ★★★★★ | 38 | 0 |
| Rainier Rehabilitation | 7.6 mi | ★★★★★ | 0 | 0 |
| Linden Grove Health Care Center | 7.9 mi | ★★★★★ | 49 | 0 |
| Life Care Center Of Puyallup | 7.9 mi | ★★★★★ | 23 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.