Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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 Veteran Home-retsil during CMS and state inspections, most recent first.
Resident personal funds were not accessible after hours or on weekends for multiple residents. Several residents said they could only withdraw money during weekday business hours, while RN and LPN staff stated they had no access on night shift and would tell residents to wait until morning. An admin staff member said evening and night shift supervisors were aware of the process, but more training was needed, and the Administrator stated residents should have access after hours and on weekends.
Advance directive documentation and assistance were not ensured for 6 of 6 reviewed residents. Several residents said they had a DPOA for health care, but no copy was in the chart and there was no documentation staff tried to obtain it. Other residents wanted info or help with an advance directive, but the EHR had no documentation that staff provided it.
A facility failed to properly document and monitor psychotropic use for multiple residents. Records showed missing AIMS testing, no 14-day reassessment for PRN antianxiety meds, and no documented side effect monitoring for antipsychotic, antidepressant, or antianxiety medications. Staff also confirmed target behaviors were vague, overlapped across meds, or were not tied to specific psychotropics, and one resident’s quetiapine GDR was not supported by the charted behaviors.
Insufficient staffing during mealtimes delayed call light responses. Observations showed no CNA on the halls while CNAs assisted with feeding in the dining room, leaving the LPN as the only staff member available to answer call lights. Staff said residents needing 2-person assist had to wait until mealtime ended, and residents reported waits of an hour or more for brief changes and call lights, with one resident stating 911 arrived before staff responded.
Food service staff failed to maintain complete refrigerator/freezer and dish machine temp logs for multiple serveries, with numerous missing entries on the AC logs. In the AC servery, a Lead Food Services worker was observed plating lunch while repeatedly touching meat and other foods with gloved hands, wiping the gloves on a rag used on the steam table, and continuing to handle trays without changing gloves each time contamination occurred.
Two residents had electronic virtual assistant devices in their rooms without documented consent in the EHR. One resident had chronic pain, DM, and hypokalemia, and the other had Parkinson's disease, HTN, and aphasia with unclear speech. Staff said the device was present so family could look in on the resident, and the DON stated consent from the resident or representative and roommate, if applicable, was expected before use; the care plan for one resident only noted using the Alexa device to call family.
Failure to initiate a grievance for a resident’s missing personal property. A resident with moderate cognitive impairment reported a missing Bose stereo to a RN and CNA, and the CNA searched but did not find it. Staff later stated the complaint should have been reported to the SW/neighborhood coordinator and a grievance completed, but no progress note, email, or grievance was found in the record.
Failure to Identify and Report Allegations of Abuse or Neglect: The facility did not identify abuse or neglect allegations for two residents. One resident with hemiplegia and other chronic conditions reported being left in a soiled brief for long periods, painful sore areas, and rough handling, but the event was not logged as an incident. Another resident with HTN, HF, and COPD reported a verbal altercation with another resident who threatened them, and although staff intervened and social work documented the event, it was not entered in the incident log.
MDS assessments failed to accurately reflect a resident’s active diagnoses. A resident admitted with psychotic disturbance, mood disturbance, and anxiety had quetiapine ordered for psychosis, melatonin with sleep monitoring for insomnia, and earlier trazodone for insomnia, yet psychosis and insomnia were not coded on some MDSs. Depression was also coded as active even though the resident was not receiving antidepressant treatment or behavior monitoring, mood assessments showed a depression score of 0, and no documentation was provided showing depression affected the resident’s care or status.
A facility failed to ensure care plans accurately reflected residents’ needs for medication monitoring, behavioral symptoms, and ordered splint use. One resident with dementia, bipolar disorder, and anxiety had incomplete behavior and side effect monitoring for psychotropic meds; another resident’s wrist splint care plan conflicted with the provider order and did not match the resident’s actual use; and a third resident’s care plan did not address psychosis, hallucinations, antipsychotic use, target behaviors, or required AIMS monitoring. The DON acknowledged the missing and conflicting care plan details.
False Documentation of Wrist Splint Application: A resident with an order for bilateral wrist splints was repeatedly observed without the splints in place, and the resident stated they had not worn them for a long time and did not even remember what they looked like. Yet the TAR showed 17 of 17 nurses signed that the splints were applied every day over a 69-day period. An RN/Neighborhood Coordinator confirmed she had not seen the resident wearing the splints and said nurses were expected to sign only for tasks they completed or validated as complete.
A dependent resident who required staff help for toileting hygiene was often left in a soiled brief during mealtimes because staff were tied up with dining duties and two-person care was delayed until later. The resident reported painful sore areas and used personal wipes because washcloths were too painful, while records showed repeated red rashes to the peri-area, inner thighs, and buttocks, later progressing to raw, painful skin and an open area.
Failure to follow bowel protocol for residents with constipation. Three residents had extended periods without BM documentation, and ordered bowel meds were delayed or not documented as given or refused in a timely manner. Staff acknowledged the protocol should have been started after 72 hours without a BM, and one RN noted there should have been more documentation around medication refusals.
Failure to consistently provide restorative or ROM services for a resident with hemiplegia and declining mobility. The resident reported worsening weakness and difficulty standing and moving, and records showed PT/OT referral, restorative review, and later hoyer transfer. Staff said the restorative program had been stopped due to refusals, therapy was delayed because of an insurance/copay issue and poor communication between the business office, therapy, and restorative, and the resident was not offered a functional maintenance program while waiting.
A facility failed to ensure NPIs were attempted before PRN pain meds were given to two residents. One resident with severe cognitive impairment received PRN oxycodone without documented non-medication interventions, despite an order listing multiple options to try first. Another cognitively intact resident received PRN acetaminophen-codeine multiple times with no documented NPIs, even though a pain monitoring order listed interventions such as reassurance, repositioning, food or drink, rest, heat, cold, music, and massage.
A resident with severe cognitive impairment and independent mobility, previously identified as at risk for elopement and ordered a wander guard, had the device discontinued after the care team reviewed only progress notes and did not access available wander guard alarm event data showing multiple prior door alarms. Facility policies required identification and monitoring of residents at risk for wandering/elopement, but the wander guard procedure lacked a defined discontinuation process, and only select staff could access alarm reports. On a weekend, a nurse saw a man walking off the property and later confirmed he was a resident who could not be found in the building; the resident was subsequently located over a mile away and returned safely. Staff interviews revealed that reviewing wander guard event reports was not part of the elopement risk assessment process, and leadership was unaware the device had been discontinued until after the elopement.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, leading to increased risk for residents.
The facility did not follow manufacturer instructions for mechanical lift sling use, resulting in a resident falling and sustaining injuries. Staff were trained incorrectly, and care plans lacked specific guidance. Additionally, fall investigations for several residents were incomplete, with missing assessments and interventions, and required monthly inspections of lift slings were not documented.
The facility did not accurately complete MDS assessments for five residents, including failing to conduct required BIMS interviews for residents who could participate and not properly documenting diagnoses such as dementia. Staff interviews and record reviews confirmed that assessments were either bypassed or incorrectly coded, and that written or alternative communication methods were not utilized when appropriate.
The facility did not ensure that PASRR Level I screenings were complete and accurate for several residents with mental health diagnoses, resulting in missing or incorrect documentation of conditions such as major depressive disorder, anxiety disorder, psychosis, PTSD, and schizoaffective disorder. Staff acknowledged errors in the PASRR forms and confirmed that necessary updates or referrals were not made when required.
The facility did not follow physician orders for medication administration and failed to ensure timely Covid vaccination with proper informed consent for several residents. Antihypertensive medications were given despite vital signs below ordered parameters, and multiple residents experienced delays or lacked documentation of risk/benefit discussions and VIS provision for Covid vaccination.
The facility did not consistently screen residents for influenza and pneumococcal vaccinations, failed to document the review of risks and benefits, and did not always provide the required Vaccine Information Sheet or obtain informed consent. In several cases, vaccines were not offered or administered as required, and staff confirmed these lapses in documentation and process.
Multiple deficiencies were identified, including a resident's urinary catheter bag being left uncovered and visible, mail privacy not being honored for a resident despite repeated requests, two residents missing medical appointments due to lack of available escorts, and a resident left waiting for an extended period in the dining area without being served a meal.
The facility did not transfer trust fund balances to the representatives or estates of two residents within the required 30-day period after discharge or death. Instead, the funds were sent more than two months later, as confirmed by review of account records and staff interviews.
A resident who used essential oils for insomnia was told by staff they could no longer use their diffuser due to complaints about the scent. Although the resident expressed discontent, social services did not offer to file a grievance and no grievance was documented, despite facility expectations that staff initiate grievances for resident concerns.
Two residents did not have accurate or complete care plans: one did not have the correct schedule for passive ROM restorative nursing, and another had a documented dementia diagnosis without a corresponding care plan. Staff confirmed discrepancies in both cases, including errors in the MDS and care plan documentation.
A resident who was dependent on staff for most ADLs, including oral care, did not consistently receive assistance with oral hygiene as required by their care plan. Staff reported that oral care was missed over several days due to time constraints and short staffing, despite facility expectations for care to be provided on both day and evening shifts.
Two residents did not receive care according to their orders and facility protocols: one experienced a six-day delay in bowel management interventions despite clear protocols, and another did not receive properly sized compression stockings for lymphedema, with staff unable to verify use or size despite documentation indicating otherwise.
Three residents received PRN opioid pain medications without documentation or provision of non-pharmacological interventions (NPIs) beforehand, despite facility policy and provider orders requiring this. Staff interviews confirmed that NPIs were not consistently offered or documented prior to administering pain medications, and pain medication records did not meet expectations.
A resident with moderate cognitive impairment was prescribed psychotropic medications, but the facility failed to complete and document required Gradual Dose Reductions (GDRs) as per regulatory standards. Only one GDR attempt was made for each medication over extended periods, and there was no supporting documentation for GDRs or contraindications. Staff were unclear on GDR requirements, and facility policy lacked specific time frames for GDR attempts.
Staff failed to lock medication carts when stepping away, leaving medications accessible while attending to residents or walking to the nurse's station. Multiple staff, including LPNs and nursing leadership, confirmed that carts should have been locked when unattended, but observations showed this was not consistently done.
The facility did not consistently record or verify dishwasher temperatures, failed to discard expired and moldy food items, and allowed staff to handle ready-to-eat food with gloved hands without changing gloves or using utensils. These actions resulted in multiple breaches of food service safety and sanitation standards.
Staff did not consistently follow infection control protocols, including failing to change N95 masks after exiting rooms of COVID-positive residents, improper use of hand sanitizer on gloved hands, and not adhering to Enhanced Barrier Precautions during urinary catheter care for two residents. These actions resulted in lapses in PPE use, hand hygiene, and catheter care standards.
Multiple incidents of resident-to-resident altercations and an allegation of theft by a staff member were not reported or logged to the state agency within the required timeframe. These events involved residents with varying cognitive impairments and resulted in injuries such as skin tears and bruising. Staff interviews revealed inconsistent reporting practices and a lack of awareness regarding proper procedures.
The facility did not investigate multiple incidents where two residents with severe cognitive impairment were involved in altercations with other residents, including physical and verbal threats. Despite facility policy requiring investigation of such events, no documentation or evidence of investigations was found.
A resident with severe cognitive impairment and multiple diagnoses experienced several falls due to the facility's failure to consistently implement and monitor fall prevention interventions. Despite a care plan requiring hourly toileting, staff documentation showed non-compliance, with only four out of 60 shifts meeting the requirement. The resident attempted to use the bathroom independently, leading to falls and injuries, while the facility failed to determine effective interventions for the resident's behavior.
A resident with severe cognitive impairment and urologic issues frequently disconnected their catheter, leading to falls and a urinary tract infection. The facility failed to provide adequate monitoring, follow-up with urology, or specific care plan interventions, resulting in the resident's hospitalization for septic shock.
A resident with severe cognitive impairment did not receive consistent oral care as required by their care plan. Despite being dependent on staff for all ADLs, the resident's oral care was not documented on multiple occasions, leading to poor oral hygiene. Staff interviews revealed time constraints and lack of awareness of refusals as contributing factors.
The facility failed to ensure sufficient qualified nursing staff were available to provide care and services, leading to long wait times for assistance, missed ADLs, and delays in meal tray delivery. The Restorative Nursing Program was also impacted due to staff being pulled to cover absences.
The facility failed to thoroughly investigate allegations of abuse, neglect, and misappropriation for two residents, leading to deficiencies in ensuring resident safety and proper documentation. Incidents involving threats and aggressive behavior were not properly documented or investigated, and care plans were incorrectly updated. Additionally, behavior monitoring was not implemented for a resident involved in an altercation.
The facility failed to offer and honor bathing choices for three residents, leading to a deficiency in promoting resident self-determination. Residents expressed preferences for more frequent showers, but their electronic health records lacked documentation of these preferences, and they were not provided showers as scheduled. The Director of Nursing confirmed the failure to adhere to care plans.
The facility failed to provide necessary restorative services to three residents, leading to a risk of avoidable decline in their ability to perform activities of daily living. Staffing issues were identified as the primary barrier, with restorative aides frequently reassigned from their duties.
The facility failed to follow bowel management protocols for five residents and did not adhere to a fluid restriction order for another resident. This led to extended periods without bowel movements and excessive fluid intake, placing residents at risk for various health complications. Staff interviews confirmed these deficiencies.
The facility failed to ensure resident safety from falls, particularly for a resident with dementia who experienced multiple falls. Despite care plan interventions, bedrails were not installed, and a recliner identified as a fall risk was not promptly removed or replaced. Staff acknowledged communication lapses and failure to conduct regular safety assessments.
The facility failed to ensure medications were properly dated when opened, discarded expired drugs, and secured medications in locked storage. Undated and expired medications were found in two medication carts and two medication rooms, and two residents had unsecured medications at their bedside.
The facility failed to serve food at appetizing temperatures, with observations showing that food temperatures were not taken before service and delays in delivering room trays led to cold meals for residents. Two residents reported consistently receiving cold breakfast, particularly eggs.
The facility failed to maintain a current hospice Plan of Care (POC) for four residents receiving hospice services. Staff were unable to locate the necessary documentation in both electronic health records and hospice binders, leading to a lack of proper documentation of hospice services provided.
The facility failed to provide dignified and respectful care for a resident with multiple diagnoses, leaving him in an unkempt state and neglecting essential care tasks such as oral care and feeding due to staffing constraints. Observations and staff interviews confirmed these deficiencies, which were contrary to the facility's stated standards.
The facility failed to accurately assess a resident for a significant change in condition. The resident, admitted with Parkinson's disease, Lewy Body Dementia, and a UTI, was not marked as receiving hospice care in the Significant Change in Status Assessment MDS, despite being admitted to hospice. Staff confirmed that the hospice care should have been marked in the MDS.
The facility failed to ensure care plans were reviewed, revised, and accurately reflected the care needs of four residents. Issues included missing care instructions for a PICC line, lack of a required PASRR Level II referral, outdated mobility and continence plans, and missing hospice care instructions. The Director of Nursing and MDS Coordinator acknowledged these deficiencies.
Resident Personal Funds Not Accessible After Hours or on Weekends
Penalty
Summary
The facility failed to ensure that residents with personal funds accounts had access to their accounts after business hours and on weekends for 7 of 10 sampled residents. During interviews, Resident 121 said money could be obtained whenever wanted except on Saturday and Sunday because the doors were locked on weekends. Resident 135 said they had been told they could withdraw up to $100 at the front desk on weekends, but no one was there on weekends and during the week money could only be withdrawn before 3 PM. Resident 15 said money could only be withdrawn during normal business hours because no one was in the administrative area at night, and Resident 3 said access was limited to Monday through Friday from 8 AM to 4 PM because the office door was closed on weekends. Resident 232 said they could plan ahead if money was needed on the weekend, and Resident 4 said they could not access money on Saturday or Sunday because the cashier did not work weekends and money could not be obtained after 3:00 PM on Friday night. Resident 14 also said money could only be withdrawn during business hours and had to be planned ahead for weekends. Staff N and Staff O stated they did not have access to resident trust money on night shift and would tell residents to wait until morning or speak with social work. Staff P said evening and night shift supervisors were aware of the process for accessing resident personal funds after hours and that more training was needed, while the Administrator stated residents should have access after hours and on weekends.
Advance Directive Documentation and Assistance Not Ensured
Penalty
Summary
The facility failed to develop and implement a system to ensure copies of advance directives were requested from residents who stated they had one and to provide information and assistance to residents who wanted help formulating an advance directive. Review of admission agreements and electronic health records for 6 of 6 residents identified for advance directive review showed that several residents indicated they had a durable power of attorney for health care but no copy was present in the record, and there was no documentation that staff attempted to obtain one. For other residents, the admission agreements showed they did not have an advance directive but wanted further information and/or assistance with formulating one, yet the electronic health record contained no documentation that staff provided that information or assistance. On 05/07/2026, the Administrator and DON were asked for documentation of staff attempts to obtain the missing advance directives and documentation of information or assistance provided to residents who requested help, and the Administrator confirmed that the requested documentation was not present in the residents' records.
Psychotropic Medications Not Properly Monitored or Documented
Penalty
Summary
The facility failed to ensure psychotropic medications were properly documented and monitored for several residents. For Resident 19, who had diagnoses including unspecified dementia without behavioral disturbance, bipolar disorder, and generalized anxiety, the record showed quetiapine for bipolar with psychosis, sertraline for depression, and lorazepam PRN for terminal anxiety. The chart did not show an AIMS test completed on or after the ordered timeframe, no 14-day reassessment was documented for the PRN antianxiety medication, and there was no documentation of side effect monitoring for the antipsychotic, antidepressant, or PRN antianxiety medication. The resident’s care plan and MAR listed only limited target behaviors, and staff confirmed the behaviors were not specific enough to clearly match each psychotropic medication. For Resident 2, who had diagnoses including major depressive disorder, unspecified dementia with agitation, anxiety disorder, and unspecified psychosis, the record showed lorazepam PRN for terminal anxiety for 90 days. Staff confirmed there was no side effect monitoring, no target behaviors documented for the antianxiety medication, and no original 14-day order or reassessment for continued use. For Resident 121, who had diagnoses of major depressive disorder and anxiety disorder and was cognitively intact, the record showed buspirone for anxiety and fluoxetine for MDD. Review of the MAR, TAR, care plan, and CNA behavior documentation showed adverse side effects were not monitored for buspirone, and the target behaviors documented in the care plan and task records did not differentiate which behaviors were tied to which medication. For Resident 13, who had severe cognitive impairment and diagnoses including dementia with behavioral disturbance, anxiety disorder, and depression, the record showed quetiapine for psychosis with hallucinations, buspirone for anxiety, and lorazepam for advanced dementia with severe agitation. The chart showed an AIMS assessment completed, but there was no baseline AIMS when quetiapine was started. The care plan and MAR did not identify or monitor specific target behaviors or adverse side effects for the psychotropics, and staff acknowledged the behaviors were not linked to each medication. The record also showed a gradual dose reduction of quetiapine, followed by an increase back to a higher dose after a provider note described agitation and combativeness, but the chart did not contain documentation supporting increased behaviors after the dose reduction, and staff stated the documentation did not support a failed GDR.
Insufficient Staffing During Mealtimes Delayed Call Light Responses
Penalty
Summary
The facility failed to provide sufficient staff to ensure residents received timely call light responses during mealtimes. During observation on 05/11/2026, no CNA was present on the A hall at 11:01 AM and no CNA was present on the B hall at 12:45 PM. Staff stated that during mealtimes CNAs were assisting with feeding residents in the dining room, leaving the licensed nurse on the hall to answer call lights. Staff G, an LPN, stated that during mealtimes they were responsible for responding to call lights for about an hour, and residents who required two staff for care during that time were told they would need to wait until mealtime was over. Staff interviews confirmed that CNAs left the halls to assist with dining and feeding, leaving only one staff member on the hall to pass trays and answer call lights. Staff S, a CNA, stated they left the hall at 11:35 AM to assist in the dining room, leaving one CNA on the hall until that CNA also went to feed residents. Staff R, an LPN, stated the CNAs left the hall at 11:45 AM and usually returned around 12:40 PM, and that they answered all call lights during that time. Resident interviews described long waits for call lights and care, including waits of over an hour and a half for brief changes, a call light still on after being activated at 12:30 PM, and one resident reporting that 911 arrived before staff responded to a call light. The DON stated that during mealtimes the licensed nurse was the only staff member on the halls and was responsible for answering call lights, while CNAs assisted with feeding in the dining rooms.
Food Service Temperature Logs Missing and Cross-Contamination Observed During Meal Prep
Penalty
Summary
The facility failed to maintain proper refrigerator, freezer, and dishwasher temperature logs for the AC, ABCD, EG, and EFGH serveries, and failed to prevent contamination during meal preparation services in the AC servery. On 05/06/2026, Staff J, Lead Food Services worker, was observed plating lunch meals while wearing gloves and handling multiple items in sequence, including reviewing meal card tickets in plastic sleeves, touching and cutting pork, touching pureed vegetables and mashed potatoes, and handling a vegetarian patty and vegetarian hotdog. During this process, Staff J repeatedly wiped a gloved hand on a rag sitting on the steam tray table, used the same rag after touching meat/protein, and continued dishing meal trays without changing gloves each time contamination occurred. Record review showed missing documentation on the March 2026 AC Refrigerator/Freezer Temperature Log and the March 2026 AC Dish Machine Temperature Log. The refrigerator/freezer log was missing entries on multiple dates, including several days with no temperature recorded and only an X marked, and the dish machine log was missing entries for numerous breakfast, lunch, and dinner periods throughout the month. When asked about missing log entries, the Food Services Manager and Administrative Assistant acknowledged the omissions and stated the entries should have been filled in. When the observations of Staff J were discussed, the Food Services Manager and other staff stated Staff J should not have touched the food, the cleaning rag, or other environmental surfaces, and should have changed gloves and washed hands before touching anything else.
Failure to Protect Resident Privacy With Recording Devices
Penalty
Summary
Keep residents' personal and medical records private and confidential was not maintained for two sampled residents. Resident 25 was admitted with chronic pain, diabetes, and hypokalemia, and was able to make needs known. On 05/04/2026 at 11:01 AM, Resident 25 was observed with an electronic virtual assistant device on the bedside table. The EHR contained no documentation of consent for the recording device in the room, and the care plan had no documentation related to the device. Resident 75 was admitted with Parkinson's disease, high blood pressure, and aphasia, and had unclear speech and sometimes understood others. On 05/04/2026 at 12:56 PM, Resident 75 was observed with an electronic virtual assistant device with a screen on the bedside table. The EHR contained no documentation of consent for the recording device in the room, and the care plan included an intervention to encourage the resident to call a family member on the Alexa device. Staff stated the device was in the room because family liked to look in on the resident, and staff were unaware of any special process to ensure privacy during care. The DON stated consent from the resident or representative and roommate, if applicable, was expected before use of the recording device, and the device should have been care planned so staff knew to turn the screen when providing care.
Failure to Initiate Grievance for Missing Personal Property
Penalty
Summary
The facility failed to initiate a grievance for one resident who reported missing personal property, specifically a Bose stereo, after the item could not be located. The facility policy titled Missing Items, effective 04/03/2025, required staff to check areas where the item may have been misplaced and, if not found, complete a grievance the same day when a resident or resident representative reported missing money or personal possessions. Resident 215 was admitted to the facility and had a quarterly MDS dated 02/03/2026 documenting moderate cognitive impairment. On 05/04/2026, Resident 215 told a RN that the stereo equipment was missing and also told a CNA that the stereo was gone. The CNA asked what was missing, and the resident stated it was a Bose stereo. The CNA looked in the cupboard at 11:18 AM but did not locate the item. Staff later stated that when a resident reports a missing personal item, staff should talk with the social worker and the social worker would talk with the resident and fill out a grievance if needed, and that staff were expected to alert the neighborhood coordinator and social worker. The social worker stated she had not been notified of the missing stereo, found no progress note, email, or grievance in the record, and said the staff who heard the complaint should have initiated the grievance.
Failure to Identify and Report Allegations of Abuse or Neglect
Penalty
Summary
The facility failed to identify allegations of abuse or neglect for 2 of 4 sampled residents reviewed for abuse. The deficiency was based on the facility not recognizing reported events as abuse or neglect and not logging them as incidents. The facility policy stated that all incidents of alleged or suspected abuse, neglect, personal and/or financial exploitation, abandonment, or mistreatment, including injuries of unknown source and misappropriation of resident property, are to be reported and investigated in accordance with federal and state rules. One resident, admitted with diagnoses including overactive bladder, depression, chronic right heart failure, and hemiplegia/hemiparesis affecting the right side, was able to make needs known. The resident reported being left in a soiled brief for long periods during mealtimes after becoming a hoyer transfer requiring two staff, and stated sore areas had developed that were painful. The resident also stated they purchased their own wipes for staff to use because washcloths had become too painful. Staff were made aware of the resident’s concerns, and social work documented discussion about sitting in feces and long wait times for toileting, but the facility did not log an incident related to the allegations. Staff later stated the resident was not concerned about abuse or neglect, and the facility did not believe the incidents were allegations of abuse or neglect. Another resident, admitted with diagnoses including hypertension, heart failure, and COPD, reported being involved in a verbal altercation with another resident who threatened to whip them. The resident stated staff intervened and there were no further issues. Social work documented that another resident yelled at the resident on the hall and that two CNAs were present and did their best to break up the disagreement. The facility investigation identified the verbal altercation, but the incident was not logged in the Accident and Incident Log. Staff later stated that when a resident-to-resident altercation is witnessed, the expectation is to keep residents safe, complete an incident report, complete an investigation, and report to the hotline when there is abuse or neglect.
MDS assessments inaccurately coded active diagnoses
Penalty
Summary
The facility failed to ensure minimum data set (MDS) assessments accurately reflected the health status and care needs of one resident. Resident 13 was admitted with provisional diagnoses of psychotic disturbance, mood disturbance, and anxiety, and the record showed quetiapine was ordered for psychosis with hallucination, melatonin was ordered for insomnia with nurse monitoring of sleep hours, and trazodone had been ordered earlier for insomnia. The resident’s MDSs completed in October 2025 and January 2026 coded anxiety and depression, but did not code psychosis or insomnia as active diagnoses, even though staff later acknowledged psychosis and insomnia should have been coded based on the resident’s treatment and monitoring. The record also showed no antidepressant medication after early March 2025 and no behavior monitoring for target behaviors for depression since admission, while all mood assessments completed with the resident’s MDSs showed a depression score of 0. Despite this, the October 2025, January 2026, and April 2026 MDSs coded depression as an active diagnosis. When questioned, the MDS Coordinator stated depression had been listed in provider notes within 60 days of each MDS, but acknowledged the resident was not being treated for depression with medication, counseling, or behavior monitoring. No documentation was provided to show how depression affected the resident’s care or functional, cognitive, mood, or behavior status during the assessment periods.
Care plans failed to reflect residents’ medication needs, behaviors, and ordered splint use
Penalty
Summary
The facility failed to develop, implement, and/or ensure comprehensive care plans accurately reflected the care needs of 3 residents reviewed for care planning. The deficiencies involved Resident 19, Resident 4, and Resident 13, and were identified through observation, interview, and record review. The report states these failures placed residents at risk for unidentified and/or unmet care needs, medical complications, and a diminished quality of life. Resident 19 was admitted with diagnoses including unspecified dementia without behavioral disturbance, bipolar disorder, and generalized anxiety. The resident had orders for quetiapine at bedtime for bipolar with psychosis, sertraline in the morning for depression, and lorazepam PRN for terminal anxiety. The Mood State care plan listed only one target behavior for quetiapine, paranoid statements, and one for sertraline, tearfulness, but there was no Comfort Care care plan and no side effect monitoring or target behaviors listed for the antianxiety medication. The DON confirmed there should have been side effect monitoring and that all associated target behaviors should have been listed under each medication type on the MAR and care plan, and acknowledged the care plan was not person centered. Resident 4 had a provider order directing staff to assist with bilateral wrist splints every morning and remove them at bedtime, but two care plans stated the resident would wear the splints at night, which conflicted with the order. The resident was observed without wrist splints on multiple occasions, stated he did not wear wrist splints and had only worn them briefly years earlier, and no wrist splints were found in the room. Staff also stated they did not recall ever seeing the resident wear wrist splints and acknowledged the care plans needed to be updated. Resident 13 received quetiapine for psychosis with hallucinations, but the comprehensive care plan did not address the antipsychotic use, the psychosis diagnosis, the history or content of hallucinations, the target behaviors for quetiapine, or the required AIMS monitoring at least every six months. The DON acknowledged these items should have been care planned. The report also states Resident 4's comprehensive care plan failed to address paranoia and associated behavioral manifestations, and the DON agreed such a plan should have been care planned.
False Documentation of Wrist Splint Application
Penalty
Summary
The facility failed to ensure services provided met professional standards of practice for one resident reviewed for limited range of motion. A provider order dated 09/17/2024 directed staff to assist with applying the resident’s bilateral wrist splints every morning and removing them at bedtime. However, the resident was observed without wrist splints in place on 05/04/2026, 05/06/2026, and 05/07/2026. When asked about the splints, the resident stated they did not wear wrist splints and had not worn them for a long time, and allowed review of the dresser drawers, where no wrist splints were found in the room. Review of the March, April, and May 2026 TARs showed that from 03/01/2026 through 05/08/2026, the resident’s bilateral wrist splints were signed off as applied on all 69 days by 17 of 17 nurses who worked. A RN/Neighborhood Coordinator stated she did not recall ever seeing the resident wearing wrist splints since starting work at the facility and confirmed the TAR documentation showed staff had signed that they assisted with application daily as ordered. She stated it was concerning and that the expectation was nurses only sign for tasks they completed or validated as complete.
Delayed Incontinent Care for Dependent Resident
Penalty
Summary
The facility failed to provide timely incontinent care for a dependent resident who was unable to toilet independently and required staff assistance for toileting hygiene. The resident was admitted with diagnoses including overactive bladder, depression, chronic right heart failure, and hemiplegia and hemiparesis affecting the right side, and was dependent on staff for toileting hygiene. During an interview, the resident stated they were often left in a soiled brief for long periods during mealtimes when they became a Hoyer transfer requiring two staff, and stated they had developed sore areas that were painful. The resident also stated they purchased their own wipes for staff to use because washcloths had become too painful. Observation and staff interviews showed that during mealtimes there were no CNAs on the hall, with staff assisting in the dining room and the nurse on the hall responsible for answering call lights. Staff stated that residents needing two-person care during that time were told they would have to wait until mealtime was over or until additional staff returned to the hall. Record review showed the resident had been downgraded from a sit-to-stand to a Hoyer lift for transfers, had been prescribed Ozempic, and had repeated weekly skin assessments documenting multiple red rashes on the buttocks, inner thighs, and peri-area. A later progress note documented the entire peri area, inner thighs, and abdominal folds as red, raw, painful, and sensitive to touch, with a right inner thigh open area, and the resident later went to the emergency room for increased pain, burning, itching, and rash to the vaginal area.
Failure to Follow Bowel Protocol for Residents With Constipation
Penalty
Summary
The facility failed to provide bowel care in accordance with its bowel protocol and provider orders for 3 of 8 residents reviewed for bowel management. Resident 3, who was cognitively intact, reported struggling with constipation. The April 2026 bowel record showed a 7-day period without a bowel movement from 04/15/2026 through 04/21/2026, and the April 2026 MAR showed that as-needed bowel medication was not provided until 04/20/2026, the sixth day without a bowel movement. Resident 3 had multiple as-needed bowel care orders, including Miralax, Milk of Magnesia, bisacodyl tablets, bisacodyl suppository, and mineral oil enema. Resident 8, who was cognitively intact, had standing and as-needed bowel medications ordered, including lactulose, senna, docusate sodium, Milk of Magnesia, bisacodyl tablets, MiraLax, and a bisacodyl suppository if no bowel movement after Miralax. The bowel record showed no bowel movement from 04/12/2026 through 04/16/2026, and the April 2026 MAR documented refusals of Miralax, senna, and docusate sodium, with no other as-needed bowel medications documented as given or refused during that period. Resident 29, who had diagnoses including hypertension, depression, and constipation and was able to make needs known, had no bowel movement documented from 04/22/2026 through 04/28/2026, and bowel medications including Milk of Magnesia, Dulcolax suppository, and MiraLAX were not documented until 04/29/2026. Staff stated the bowel protocol should have been initiated after 72 hours without a bowel movement and documented when a resident had no bowel movement for 3 days.
Failure to Consistently Provide Restorative or ROM Services
Penalty
Summary
The facility failed to ensure one resident was consistently offered or received services to maintain or prevent declines in mobility when reviewed for ROM. The resident was admitted with diagnoses including overactive bladder, depression, chronic right heart failure, and hemiplegia and hemiparesis affecting the right side, and was able to make needs known. During an interview, the resident stated they had recently requested restorative or PT services because of declining mobility, and said that in the past medical issues had interfered with therapy participation but staff did not reapproach them and restorative was not offered consistently. Record review showed the resident reported increasing weakness in both lower extremities and difficulty standing and moving, with a referral sent to PT/OT for bilateral lower extremity weakness affecting transfers. A later note documented the resident felt they were losing strength and were agreeable to a more aggressive exercise program while awaiting guidance from restorative nursing. Another note showed the resident was transferred via hoyer. Staff interviews revealed the restorative program had been discontinued due to refusals, the resident later requested to restart it and was evaluated by therapy, but therapy was not provided because of an insurance copay issue and the business office had not communicated approval status to therapy. Staff stated the resident should have been referred back to restorative while waiting, but was not, and the DON stated the resident should have been offered some type of functional maintenance or restorative program during the approval process.
PRN Pain Medications Given Without Documented Non-Pharmacological Interventions
Penalty
Summary
The facility failed to ensure non-pharmacological interventions were attempted before administering PRN pain medications for two residents reviewed for unnecessary drugs. Resident 2, who was severely cognitively impaired and able to make needs known, had a physician order requiring multiple pain-related non-medication interventions to be attempted before PRN oxycodone was given. Review of the April and May 2026 MAR showed oxycodone was administered on several occasions for reported pain levels, and no non-pharmacological interventions were documented before those doses. Staff H and the DNS reviewed the record and confirmed that the listed interventions had not been attempted and should have been. Resident 121, who was cognitively intact, had PRN orders for acetaminophen-codeine for pain and a separate pain monitoring order listing non-prescription interventions to document. Review of the April and early May 2026 MAR showed the PRN acetaminophen-codeine was administered multiple times, including 26 times in April and 6 times in early May, with no non-pharmacological interventions attempted. The DNS reviewed the MAR and progress notes and confirmed that NPIs had not been attempted prior to the PRN pain medication administrations and that this did not meet her expectations.
Failure to Use Wander Guard Alarm Data in Elopement Risk Assessment Leading to Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly assess and monitor a resident’s elopement risk and to provide adequate supervision to prevent elopement. Facility policies on Missing Resident, Wandering/Unsafe Resident, and the Wander Guard Wander Management System required identification of residents at risk for wandering/elopement and monitoring of those residents, including use of wander guards for safety. However, the wander guard procedure did not include a process for evaluating potential discontinuation of the device. Resident 1, who had severe cognitive impairment, was independent in mobility and had a care plan identifying elopement risk due to a history of attempts to walk outside, inability to find the way back, and impaired safety awareness. A physician’s order had been in place for a wander guard for this resident’s safety. A wander risk assessment completed in August 2025 identified the resident as at moderate risk for wandering. Despite this, a progress note dated 08/19/2025 documented that the wander guard alarm was discontinued. The wander guard event report for the resident’s bracelet showed 76 alarm entries at three different doors between April and early August 2025, with the most recent alarm on 08/01/2025, indicating repeated door alarm activations prior to discontinuation. Staff involved in the assessment and care planning process reported that, when deciding to discontinue the wander guard, they reviewed progress notes and believed the resident had not demonstrated exit-seeking behaviors for several months, but they did not review the wander guard event report because they either did not know how to access it or did not have access. Staff stated that, had they been aware of the alarm history, they would not have recommended discontinuing the device. On the day of the elopement, a nurse observed a man at the bottom of the facility’s driveway around midday, who stated he was just going for a walk. Only later did staff inquire whether he was a resident, at which point they realized he might be missing and were unable to locate him in the building. The resident was ultimately found off-site, approximately 1.7 miles away, and returned to the facility. The facility’s investigation documented that the resident had a previous elopement in April 2025. Multiple staff, including the MDS RN, RN/Resident Care Manager, Investigative Nurse, and Administrator, acknowledged that reviewing the wander guard event report was not part of the current risk assessment process, that only certain staff had access to those reports, and that leadership was not aware the wander guard had been discontinued until after the elopement event.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Follow Mechanical Lift Guidelines and Incomplete Fall Prevention Measures
Penalty
Summary
The facility failed to follow manufacturer guidelines during the use of a mechanical lift and sling for two residents who required assistance with transfers. In one incident, a resident who was dependent on staff for activities of daily living and had no recent history of falls was transferred using a red toileting sling. Staff did not crisscross the sling straps between the resident's legs as required by the manufacturer's instructions, resulting in the resident sliding through the sling and falling to the floor, sustaining a hip fracture and a head laceration. Staff interviews revealed that multiple nursing assistants were trained to use the sling in a manner inconsistent with manufacturer instructions, and neither the investigation nurse nor the director of nursing could state the correct method for using the sling. The care plan also lacked specific instructions on proper sling use. The facility also failed to conduct thorough fall investigations and implement individualized fall prevention interventions for several residents with a history of falls. For one resident with multiple falls, investigations were incomplete, often missing assessments of environmental factors, last toileting assistance, or staff interviews. Root causes were not consistently identified, and interventions were either not documented or not followed up. Another resident with a neurological condition and multiple falls did not have timely or adequate interventions, such as anti-roll back wheelchairs, and care plans were not updated to reflect new interventions or equipment provided. Additionally, the facility did not adhere to manufacturer requirements for routine inspection and documentation of mechanical lift slings. The operating manual specified that slings must be inspected monthly for damage and a permanent record kept, but the director of nursing confirmed that no such records were maintained. These failures in following equipment guidelines, conducting comprehensive fall investigations, and maintaining required documentation contributed to the deficiencies identified during the survey.
Failure to Accurately Complete MDS Assessments and Cognitive Status Interviews
Penalty
Summary
The facility failed to ensure accurate and complete Minimum Data Set (MDS) assessments for five residents, resulting in deficiencies related to cognitive status, diagnoses, and communication abilities. For several residents, the Brief Interview for Mental Status (BIMS) was not conducted as required, despite documentation and staff interviews indicating that the residents were able to understand, be understood, and participate in interviews. Instead, staff completed the Staff Assessment for Mental Status (SAMS) or incorrectly coded the MDS, bypassing the resident interview process without appropriate justification. In one case, a resident who was non-verbal but able to communicate via written means or technology was not given a written BIMS assessment, contrary to protocol. Additionally, there were discrepancies in the documentation of diagnoses. For one resident, the MDS did not reflect a diagnosis of dementia or Alzheimer's disease, despite multiple physician notes in the medical record indicating a diagnosis of dementia. Staff interviews confirmed that the provider's documentation should have been recognized and incorporated into the MDS, but this was not done, resulting in an inaccurate assessment. Another resident's MDS was not assessed for BIMS despite the resident being present and able to participate, as confirmed by staff. The Resident Assessment Instrument (RAI) Manual requires that staff attempt a BIMS on all residents unless specific criteria are met, such as the resident being rarely or never understood or unable to respond by any method. The facility's failure to follow these guidelines led to incomplete and inaccurate assessments regarding residents' cognitive status, communication, and diagnoses, as evidenced by the review of records and staff interviews.
Incomplete and Inaccurate PASRR Documentation for Multiple Residents
Penalty
Summary
The facility failed to ensure that Level I Preadmission Screening and Resident Reviews (PASRR) were complete and accurate for four out of seven sampled residents. For one resident with diagnoses including major depressive disorder, anxiety disorder, and unspecified psychosis, the PASRR Level I forms did not consistently reflect all current diagnoses, and a Level II evaluation was not completed despite changes in the resident's condition. Staff acknowledged that a new referral was not sent and that errors in the PASRR documentation were not corrected in a timely manner. Another resident with diagnoses of PTSD, major depressive disorder, anxiety disorder, and schizoaffective disorder had a PASRR Level I that failed to indicate any serious mental illness, which staff later confirmed was incorrect. Additional residents with diagnoses such as major depressive disorder, unspecified dementia, and anxiety disorder also had PASRR Level I forms that omitted relevant diagnoses. Staff interviews confirmed that these omissions were recognized but not addressed at the time, resulting in incomplete and inaccurate PASRR documentation for multiple residents.
Failure to Follow Physician Orders and Vaccination Protocols
Penalty
Summary
The facility failed to ensure that medications were administered according to physician orders and that vaccinations were provided in a timely manner with proper informed consent. For one resident, antihypertensive medications (amlodipine and metoprolol) were administered despite a diastolic blood pressure below the threshold specified in the physician's order, which required the medications to be held. Staff confirmed that the medications should have been withheld as per the order. Additionally, multiple residents experienced deficiencies related to the administration of Covid vaccinations. In several cases, there was a lack of timely administration following consent, missing documentation of risk/benefit discussions, and failure to provide or document the Vaccine Information Statement (VIS). Some residents did not receive the vaccine for months after consent, and in one case, a resident's refusal was not accompanied by documentation that risks and benefits were reviewed. Staff interviews confirmed that these actions did not meet facility expectations for timely vaccination and informed consent procedures.
Failure to Screen, Document, and Obtain Informed Consent for Vaccinations
Penalty
Summary
The facility failed to ensure that residents were properly screened and provided with informed consent for influenza and pneumococcal vaccinations. For five residents reviewed, there were multiple instances where either the risk and benefits of the vaccines were not documented, the required Vaccine Information Sheet (VIS) was not provided, or the vaccines were not offered or administered according to protocol. In several cases, consent for vaccination was obtained, but there was no documentation that the risks and benefits were reviewed with the resident or their representative. In one instance, a resident's refusal of the influenza vaccine was documented, but there was no evidence that the risks and benefits of refusal were discussed. Another resident had not been offered either the influenza or pneumococcal vaccine since admission, and their vaccination status had not been reviewed as part of the admission process. Staff interviews confirmed these deficiencies, with the Infection Preventionist and Director of Nursing Services acknowledging that the review of risks, benefits, and provision of VIS were not consistently documented or completed for every vaccine administration. The Director of Nursing Services also confirmed that it did not meet expectations for residents' vaccination status to go unreviewed or for vaccines not to be offered as required.
Failure to Honor Resident Dignity, Privacy, and Rights to Services
Penalty
Summary
The facility failed to maintain resident dignity and privacy in several instances. One resident with a neurogenic bladder and an indwelling urinary catheter was observed multiple times with their urinary drainage bag visible from the hallway and door side of the bed, without a dignity cover in place. Staff acknowledged that a dignity cover should have been used, but the issue persisted over several days. Another resident, dependent on staff for most activities of daily living and with a diagnosis of obstructive and reflux uropathy, reported ongoing issues with their roommate tampering with their mail. Despite repeated requests and documentation in the electronic health record for mail to be delivered directly to them or inside their room, mail continued to be left outside the room. Staff interviews revealed a lack of awareness of the resident's request and a breakdown in communication, resulting in the resident's mail privacy not being honored. The facility also failed to ensure residents' rights to attend medical appointments. Two residents missed important medical appointments because the facility was unable to provide an escort due to staff call outs. In one case, a resident's surgery consultation was canceled and not yet rescheduled, and in another, a resident who did not require an escort still had their appointment canceled. Additionally, a resident was left waiting for 24 minutes in the dining area without being served a meal, ultimately leaving the dining room without eating. Staff confirmed that meals should be served promptly upon seating, and the delay was not acceptable.
Delayed Transfer of Resident Trust Funds After Discharge or Death
Penalty
Summary
The facility failed to transfer resident trust fund balances to the appropriate resident representatives or estates within the required 30-day period following discharge or death. For one resident who was discharged on 11/25/2024, the trust account balance of $83 was not conveyed until 70 days later, as confirmed by the facility's fiscal analyst. Similarly, another resident discharged on 11/29/2024 had a trust account balance of $50, which was not sent to the representative or estate until 66 days after discharge. These delays were verified through review of trust account ledgers and staff interviews, demonstrating noncompliance with regulatory requirements for timely transfer of resident funds.
Failure to Initiate and Resolve Resident Grievance Regarding Aromatherapy Use
Penalty
Summary
The facility failed to initiate, investigate, and resolve a grievance for one resident who was admitted with a diagnosis including insomnia and was able to communicate their needs. The resident expressed being upset after being told by staff that they could no longer use their essential oils due to complaints about the strong smell. Documentation showed that the resident was informed by social services that the use of their diffuser was not allowed, and they were provided with a fragrance-free facility policy. Despite the resident expressing discontent, no grievance was filed or documented in the grievance log for the relevant period. Social services staff did not offer to file a grievance, stating the resident could initiate one independently, which was contrary to the administrator's stated expectation that staff should initiate grievances for resident concerns.
Deficient Care Planning for Restorative and Dementia Care
Penalty
Summary
The facility failed to accurately complete and update care plans for two residents, resulting in deficiencies related to care planning. For one resident, the care plan for the restorative nursing program (RNP) was not consistent with the intended schedule. The resident was supposed to receive passive range of motion (ROM) exercises to both upper and lower extremities on alternating days, but the care plan listed both as occurring on the same days. The resident reported not receiving the RNP daily as expected, and the restorative nurse confirmed the care plan needed revision to reflect the correct alternating schedule. Another resident was admitted with a diagnosis of traumatic brain injury and was cognitively intact according to the Minimum Data Set (MDS), with no documented diagnosis of dementia or Alzheimer's disease. However, physician notes indicated a diagnosis of dementia, and staff confirmed this diagnosis was present in the electronic health record. Despite this, there was no dementia care plan in place for the resident, and staff acknowledged that the MDS was incorrect and a dementia care plan should have been developed based on the diagnosis.
Failure to Provide Consistent Oral Care Assistance
Penalty
Summary
Staff failed to provide consistent assistance with activities of daily living (ADLs), specifically oral care, for one resident who was dependent on staff for most ADLs. The resident, who had diagnoses including diabetes, obstructive and reflux uropathy, and depression, reported that staff were inconsistent in providing oral care. The resident's care plan required oral care in the morning, after meals, and at bedtime with substantial dependent assistance. A certified nursing assistant confirmed that oral care was not provided to the resident over the past few days due to lack of time and short staffing. The Director of Nursing Services stated that the expectation was for oral care to be provided on both day and evening shifts.
Failure to Follow Bowel and Edema Management Protocols
Penalty
Summary
The facility failed to provide appropriate treatment and care for two residents, resulting in deficiencies related to bowel management and edema management. For one resident with moderate cognitive impairment, the facility did not follow its bowel care protocol or the resident's medication orders when the resident experienced six consecutive days without a bowel movement. Although the facility's protocol required specific interventions and provider notification after three days without a bowel movement, documentation showed that bowel medications were not administered until the sixth day, and there was no record of the resident refusing medications or being monitored for refusal. In a separate incident, another resident with acute heart failure and lymphedema did not receive timely or appropriate compression stockings as ordered. Despite nurses documenting that the resident wore compression stockings on certain days, multiple observations confirmed that the resident was not wearing them, and the correct size could not be verified. The compression stockings were found in the resident's room, unlabelled and unused, and staff were unable to confirm the appropriate size. The DON acknowledged that documentation and adherence to provider orders for compression stockings did not meet expectations.
Failure to Document and Provide Non-Pharmacological Interventions Prior to PRN Pain Medication Administration
Penalty
Summary
The facility failed to ensure that non-pharmacological interventions (NPIs) were offered, provided, and documented prior to administering as-needed pain medications for three residents. For one resident with bipolar disorder, depression, and anxiety who required substantial assistance with daily living, hydrocodone-acetaminophen was administered eight times in April without any documentation that NPIs were offered or provided, contrary to facility expectations. The Director of Nursing Services confirmed that NPIs should have been documented in the Medication Administration Record (MAR) or progress notes before giving as-needed pain medication. Another resident with severe cognitive impairment had an order for oxycodone that specifically required documentation of NPIs prior to administration, but the MAR and TAR showed multiple instances where the opioid was given without such documentation. Additionally, a resident with chronic pain, depression, diabetes, and other conditions received oxycodone 20 times in April without NPIs being provided beforehand. Staff interviews confirmed that NPIs were not documented or available for these residents as required, and that pain medication records did not meet facility expectations.
Failure to Complete and Document Required Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a Gradual Dose Reduction (GDR) was completed for one resident reviewed for unnecessary medications. The resident, who was moderately cognitively impaired, was prescribed Sertraline for depression and Zyprexa for dementia with psychotic disturbance. Documentation showed only one GDR attempt for Sertraline in over two years and only one GDR attempt for Zyprexa in the previous thirteen months. There was no supporting documentation in the electronic health record (EHR) for a GDR on the date indicated in the Minimum Data Set (MDS), nor was there documentation from the pharmacy or provider requesting a GDR or supporting contraindications for GDR. Staff interviews revealed confusion regarding the requirements for GDRs, with staff referencing facility policy and pharmacy guidelines but unable to provide documentation supporting their practices. The facility's policy did not specify time frame requirements for GDR attempts, and no further documentation was provided to support that appropriate GDRs or contraindications had been addressed for the resident's psychotropic medications.
Medication Carts Left Unlocked When Unattended
Penalty
Summary
Staff failed to ensure that medication carts were locked when unattended, as required by professional standards and facility policy. On multiple occasions, staff members left medication carts unlocked while stepping away or attending to residents, including on the dementia unit where an LPN left the cart unattended with residents nearby. The LPN acknowledged that the cart should have been locked, and other staff, including the Medicare Coordinator, Interim Assistant Director of Nursing Services, and Director of Nursing Services, confirmed that the expectation was for carts and computer screens to be locked when unattended. Additional observations revealed that another medication cart was left unlocked while an LPN was working with a resident and then walked away to the nurse's station. The LPN also acknowledged that the cart should have been locked. These incidents were directly observed and confirmed through staff interviews, demonstrating a failure to maintain secure storage of medications as required.
Failure to Maintain Food Service Safety and Sanitation Standards
Penalty
Summary
The facility failed to store, prepare, and serve food in accordance with professional standards, as evidenced by multiple deficiencies in food service safety. Review of dishwasher temperature logs over several months revealed that temperatures were not consistently recorded in any of the dining rooms, with most logs left blank and only sporadic entries in one area. Staff interviews confirmed that signatures on the logs were used in place of actual temperature recordings, and staff could not verify if dishwashers were operating at required temperatures. Direct observation of the dishwashing process showed that the thermometers on the dishwasher did not register any temperature changes during test cycles, and staff were unable to confirm if dishes were being properly sanitized. During a tour of the produce cooler, expired and moldy food items were found, including lime juice and mustard past their expiration dates and containers of strawberries with visible mold. Staff acknowledged that these items should have been discarded and stated that cooler clean-outs were supposed to occur regularly, but the presence of expired and spoiled food indicated this was not consistently done. The food services manager confirmed that expired and moldy food should not be present and should have been thrown out. Observations of meal preparation revealed that staff were handling ready-to-eat food with gloved hands instead of utensils, repeatedly touching food items and plates without changing gloves or performing hand hygiene. When questioned, staff admitted that this practice was not appropriate and did not meet expectations for food safety. The food services manager confirmed that staff should not touch food that is served to residents and should change gloves to prevent cross-contamination.
Infection Control Deficiencies in PPE Use, Hand Hygiene, and Catheter Care
Penalty
Summary
Staff failed to maintain proper infection control practices in the COVID-positive unit, specifically regarding the donning and doffing of N95 masks. Multiple staff members, including a custodian and certified nursing assistants, were observed not changing their N95 masks after exiting rooms of residents on aerosol precautions for COVID-19. The N95 masks were located outside the unit, and staff reported changing masks only when entering or leaving the unit, rather than after each resident room as required. Signage on the unit doors instructed staff to change masks after exiting positive resident rooms, but this was not consistently followed. Hand hygiene practices were also deficient. A staff member was observed using hand sanitizer on gloved hands instead of removing gloves and performing hand hygiene as required. This practice was acknowledged by the infection preventionist and director of nursing as inappropriate and not in line with facility expectations. Urinary catheter care was not performed according to standards for two residents on Enhanced Barrier Precautions (EBP). One staff member donned PPE inside the resident's bathroom, which was identified as a potentially contaminated area, and another staff member failed to wear a gown during catheter care. Additionally, improper hand hygiene and glove changes were observed during catheter care, including touching multiple surfaces and resident items without changing gloves or performing hand hygiene between tasks. The staff also failed to use appropriate disinfectant techniques when disconnecting and reconnecting catheter tubing.
Failure to Timely Report and Log Allegations of Abuse, Neglect, and Theft
Penalty
Summary
The facility failed to report and log multiple allegations of abuse, neglect, and misappropriation of property to the state agency within the required five working days, as mandated by facility policy and state and federal regulations. Review of incident logs and progress notes revealed that several resident-to-resident altercations, as well as an allegation of theft by a staff member, were either not reported at all or were reported late. These incidents involved residents with varying levels of cognitive impairment, including those with severely impaired cognition, and included physical altercations resulting in injuries such as skin tears, bruising, and abrasions. Specific incidents included residents being struck, placed in headlocks, and sustaining injuries during altercations. In one case, a resident accused a nursing assistant of theft, but the allegation was not reported to the state agency in a timely manner. The incident logs did not reflect several of these events, and in some cases, there was no evidence that the incidents were reported to the appropriate authorities as required. Interviews with facility staff indicated a lack of awareness and inconsistent practices regarding the reporting and logging of such incidents. The investigation nurse acknowledged that some incidents were missed due to erroneous information and personal leave, and noted that direct care staff needed more support in reporting incidents. The DON and administrator were unaware of the reporting issues and expected that incidents would be investigated and reported promptly.
Failure to Investigate Resident-to-Resident Altercations
Penalty
Summary
The facility failed to thoroughly investigate allegations of resident-to-resident altercations involving two residents with severely impaired cognition. For one resident, progress notes documented two separate incidents: one where an unknown resident shouted at and nearly hit the resident, requiring staff intervention, and another involving a physical altercation with another resident over alleged theft, during which threats and physical contact occurred. For the second resident, progress notes described an incident where another resident leaned toward the resident's face, prompting the resident to push the other individual. In all cases, the facility was unable to provide evidence that investigations into these incidents were conducted. According to facility policy, all incidents of alleged or suspected abuse, neglect, or misappropriation of property are to be reported and investigated in accordance with state and federal regulations. However, interviews and record reviews confirmed that no investigations were completed for the incidents described, as acknowledged by the facility's investigation nurse. This lack of investigation was found to be inconsistent with the facility's own policies and regulatory requirements.
Failure to Implement and Monitor Fall Prevention Interventions
Penalty
Summary
The facility failed to consistently implement and monitor interventions for a resident at risk for falls, leading to multiple incidents. The resident, who has severe cognitive impairment, dementia, PTSD, and blindness, was admitted with a care plan that included hourly toileting, keeping items within reach, and maintaining room visibility. Despite these interventions, the resident experienced several falls, including incidents where they attempted to use the bathroom independently due to long wait times for assistance. The facility's documentation revealed that staff did not consistently assist the resident with toileting every hour as required, with only four out of 60 shifts showing compliance. The facility's incident reports and progress notes documented multiple falls and attempts by the resident to use the bathroom independently, resulting in injuries such as skin tears. The Director of Nursing acknowledged the lack of consistent documentation and the failure to determine effective interventions for the resident's behavior of disassembling their catheter. The facility's inability to ensure the effectiveness of fall interventions and the lack of consistent staff documentation contributed to the deficiency, placing the resident at risk for further accidents and injuries.
Failure to Monitor and Manage Indwelling Catheter Use
Penalty
Summary
The facility failed to adequately monitor and manage the use of an indwelling urinary catheter for a resident with severe cognitive impairment and multiple urologic issues, including an enlarged prostate and neurogenic bladder. The resident frequently disconnected their catheter, leading to urine spills and attempts to self-transfer to the toilet, which resulted in multiple falls and skin tears. Despite these ongoing issues, there was no follow-up with urology after the initial consultation, and no specific guidance or interventions were documented in the care plan to address the resident's behavior or the risk of infection. Staff interviews revealed a lack of communication and planning regarding the resident's catheter management and infection risk. Nursing staff were aware of the resident's frequent disassembly of the catheter but had not received specific instructions on how to manage the situation. The Director of Nursing confirmed the absence of a care plan addressing the catheter issues and infection control measures. The resident was hospitalized with septic shock due to a urinary tract infection, highlighting the facility's failure to prevent and manage catheter-associated complications.
Failure to Provide Consistent Oral Care for Dependent Resident
Penalty
Summary
The facility failed to consistently provide oral care for a resident who was dependent on staff for all activities of daily living (ADLs). The resident, who had severe cognitive impairment and was admitted with a care plan requiring oral care twice daily, did not receive documented oral care on multiple occasions across different shifts in April and May 2024. A dental hygienist noted severe oral hygiene issues, including dried mucus in the resident's mouth, indicating a lack of proper oral care. Photos taken in June 2024 further confirmed the poor condition of the resident's oral cavity. Interviews with staff revealed inconsistencies in the provision of oral care. A nursing assistant admitted to providing oral care every other day due to time constraints, while a registered nurse and unit care coordinator acknowledged the resident's resistance to oral care but did not report any refusals. The director of nursing was unaware of any issues with oral care refusals or staff challenges. The lack of adequate staffing and time was cited as a reason for the failure to provide the necessary oral care, particularly in a heavy care unit.
Insufficient Qualified Nursing Staff
Penalty
Summary
The facility failed to ensure sufficient qualified nursing staff were available to provide care and services, as evidenced by multiple resident and staff interviews. Residents reported long wait times for assistance, with some waiting up to an hour for staff to respond to call lights. Several residents also mentioned that they were unable to receive daily shaves or showers due to staff being too busy. Staff interviews corroborated these claims, with many staff members stating that they were unable to complete all their assigned tasks due to being short-staffed. This included essential activities of daily living (ADLs) such as shaving, oral care, and feeding residents. The shortage of staff also affected the timely delivery of meal trays, with some residents receiving cold food due to delays in service. Additionally, the facility's Restorative Nursing Program (RNP) was impacted, as aides from the RNP department were frequently pulled to cover direct care staff absences. This resulted in residents not receiving their required restorative programs. Staff members confirmed that this was a common occurrence, particularly on weekends. The facility's Director of Nursing Services and Administrator acknowledged the staffing issues, citing challenges in hiring CNAs and the impact of the pandemic on their staffing levels. Despite efforts to recruit and train new staff, the facility continued to struggle with maintaining adequate staffing levels to meet the needs of its residents.
Failure to Investigate Allegations of Abuse and Implement Interventions
Penalty
Summary
The facility failed to thoroughly investigate three out of four allegations of abuse, neglect, and/or misappropriation for two residents, leading to deficiencies in ensuring resident safety and proper documentation. For Resident 97, there were multiple incidents involving threats and aggressive behavior from roommates. The investigations did not include interviews with all relevant staff members, failed to establish a clear timeline of events, and incorrectly updated Resident 97's care plan with information that should have been attributed to the roommate. This lack of thorough investigation and documentation detracted from the ability to ensure Resident 97's safety and address the incidents appropriately. In one incident, Resident 97 reported that his roommate threatened to kill him and smeared feces and urine in the bathroom. The investigation concluded that the roommate's delusions were exacerbated by the new environment, but there was no documentation of interviews with staff who were present during the incidents. Another incident involved Resident 97's roommate threatening to beat him, but the investigation was deemed unsubstantiated without interviewing direct care staff or providing a clear explanation for the conclusion. Additionally, Resident 97's care plan was incorrectly updated to reflect delusions and vivid dreams attributed to the roommate. For Resident 105, the facility failed to document and implement behavior monitoring after an altercation where Resident 105 was punched by another resident. Although the other resident was care planned for behavior monitoring, there was no documentation of this intervention being implemented. The Director of Nursing Services acknowledged that the expectation for immediate intervention and accurate care plan updates was not met, leading to a deficiency in ensuring resident safety and proper documentation.
Failure to Honor Resident Bathing Preferences
Penalty
Summary
The facility failed to offer and honor bathing choices for three residents, leading to a deficiency in promoting and facilitating resident self-determination. Resident 97, who had moderate cognitive impairment, expressed that he was not given a choice about his bathing frequency and preferred three showers a week. His electronic health record showed no documentation of his preferences, and he was only provided one shower per week instead of the scheduled two. Staff confirmed that residents scheduled for more than one shower a week were sometimes informed it would not be provided due to staffing issues. Resident 102, who was cognitively intact, also indicated he was not given a choice about his bathing frequency and preferred three showers a week. His electronic health record similarly lacked documentation of his preferences, and he was only provided one shower in a 20-day period instead of the scheduled one per week. Resident 125, who was cognitively intact, stated he was not allowed to choose his bathing frequency and preferred at least two showers a week. His care plan scheduled him for one shower a week, but he was not provided a shower on one of the scheduled days. The Director of Nursing confirmed that staff failed to provide bathing at the frequency care planned for these residents and was unsure who was responsible for identifying and documenting resident care preferences. This lack of adherence to resident preferences and care plans led to the deficiency in promoting resident self-determination and choice.
Failure to Provide Required Restorative Services
Penalty
Summary
The facility failed to provide the necessary care and services to ensure residents' ability to participate in activities of daily living did not diminish. This deficiency was observed in three residents who were assessed to require specific restorative programs. Resident 102, who was cognitively intact but had limited range of motion, did not receive the restorative ambulation program at the required frequency. The resident's restorative flowsheets showed the program was offered only 15 out of 25 times, with no documentation explaining the shortfall. Similarly, Resident 48, who had severe cognitive impairment and limited range of motion, did not receive the restorative transfer and standing exercise programs as frequently as required. The flowsheets indicated the transfer program was offered only 12 out of 25 times, again with no documentation explaining the discrepancy. Resident 97, who had moderate cognitive impairment and no limitations in functional range of motion, also did not receive the required frequency of restorative programs. The resident's lower extremity exercise program was offered only nine out of 12 times, and the ambulation program was offered only four out of 12 times. Staff interviews revealed that restorative aides were frequently pulled from their duties due to staffing issues, which was confirmed by both the Restorative Aide and the Restorative Nurse. This frequent reassignment of restorative aides was identified as the primary barrier preventing the provision of restorative programs at the assessed frequency.
Failure to Follow Bowel Management and Fluid Restriction Protocols
Penalty
Summary
The facility failed to provide necessary care and services to maintain the highest practicable level of well-being for several residents. Specifically, the facility did not follow the bowel management protocol for five residents, leading to extended periods without bowel movements and lack of administration of prescribed medications. For instance, Resident 239 went four days without a bowel movement, and no PRN bowel medication was administered despite the protocol requiring it after 72 hours. Similar failures were noted for Residents 91, 155, 175, and 82, where the bowel protocol was not followed, and necessary medications were not administered as per the orders. Additionally, the facility failed to adhere to a fluid restriction order for Resident 125, who was on a 1500 ml/day fluid restriction due to hyponatremia. The resident's fluid intake exceeded the prescribed limit on multiple occasions, and there was no documentation or calculation of the 24-hour total fluid intake by the nursing staff. The Medication Administration Records (MARs) did not provide a place for nurses to record the resident's fluid intake, and the staff failed to monitor and record the intake accurately. Interviews with staff confirmed these deficiencies. Staff H, a Charge Nurse, acknowledged that the fluid intake was not recorded or tallied, making it impossible to determine if the resident adhered to the fluid restriction. Staff B, the Director of Nursing, confirmed that the fluid restriction orders were incomplete and that the bowel protocol was not followed for the residents reviewed. These failures placed residents at risk for fluid and electrolyte imbalances, nausea, vomiting, pain, discomfort, and other health complications related to untreated constipation.
Failure to Ensure Resident Safety from Falls
Penalty
Summary
The facility failed to ensure residents were safe from falls, specifically for Resident 171, who had multiple falls documented. Resident 171, diagnosed with dementia, experienced falls on several occasions, including 11/22/2023, 11/23/2023, 03/29/2024, 04/09/2024, and 04/15/2024. Despite a care plan intervention dated 04/01/2024 to install bilateral assist bed handles for security and mobility, these were not observed to be installed. Additionally, a safety assessment for a recliner chair was conducted on 04/05/2023, but no further assessments were found, and the recliner was identified as a potential cause of falls without being removed or replaced promptly. On 04/15/2024, Resident 171 reported falling out of the recliner and hurting their left side and thigh. Staff confirmed the resident had slid out of the recliner a week prior. The Neighborhood Coordinator acknowledged a plan to replace the electric chair with a manual one, but this would take two weeks. The Director of Nursing Services stated that interventions like bedrails should have been implemented immediately and that the recliner should have been removed when identified as a root cause. The lack of communication between departments led to the bedrails not being installed, and safety assessments for the recliner were not conducted quarterly as expected.
Medication Management Deficiencies
Penalty
Summary
The facility failed to ensure medications were properly dated when opened and expired drugs and biologicals were discarded according to professional standards. During an audit, it was observed that two medication carts (G2 & G1) and two medication rooms (G2/H2 & A2/B2) contained undated and expired medications. Specifically, an opened and undated multiuse vial of tubersol was found in the G2/H2 medication room refrigerator, and an expired bottle of bismuth was found in the A2/B2 medication room. Additionally, the G2 medication cart contained undated bottles of fluticasone propionate nasal spray and Refresh eye drops, while the G1 cart had undated bottles of latanoprost and timolol maleate eye drops. Staff confirmed that these medications should have been dated upon opening and discarded after their respective expiration periods. Furthermore, the facility did not secure medications in locked storage for two residents. Resident 116 was observed with a bottle of TUMS on their bedside table on multiple occasions, and Resident 125 had a Dulera inhaler in a plastic bin on their bedside table. Staff confirmed that these medications should have been secured and not left at the bedside. These lapses in medication management placed residents at risk for accidentally taking another resident's medication and/or receiving expired or outdated medications and biologicals.
Failure to Serve Food at Appetizing Temperatures
Penalty
Summary
The facility failed to provide food at appetizing temperatures, which was observed during a review of kitchen services. During the lunch meal service, it was noted that none of the items on the steam table had their temperatures taken prior to being served. Additionally, plates were not being warmed within the plate holder, and only the top insulator was used for plating food. Staff EE admitted to not taking the food temperatures due to being in a rush and assuming another staff member had done it. The Dietary Manager, Staff FF, confirmed that temperatures should be taken before placing food on the steam table and thirty minutes into the meal service, and that both insulated plate bases and lids should be used to maintain food quality. The Administrator, Staff A, mentioned that new plate insulators had been ordered but had not yet arrived, and reiterated the expectation for staff to take food temperatures to ensure safe and palatable delivery to residents. Two residents who received meals in their rooms reported that their food, particularly breakfast, was often delivered cold. Resident 97 stated that the eggs were cold every morning, leading to them not eating breakfast. Resident 2 also complained about receiving cold breakfast. Observations showed that room trays were passed after the dining room service, causing delays. Staff H and Staff I confirmed that aides from certain halls were able to get in line for room trays first, resulting in delays for other residents. This process led to the food being cold by the time it was delivered to residents who ate in their rooms, particularly affecting the residents on G2 hall who had to wait longer for their meals.
Failure to Maintain Current Hospice Plan of Care
Penalty
Summary
The facility failed to develop and maintain a current hospice Plan of Care (POC) in collaboration with hospice for four residents receiving hospice services. This deficiency was identified through interviews and record reviews, revealing that the facility did not have documentation of hospice services being provided for the residents. For instance, Resident 137, who was admitted with diagnoses including Parkinson's disease and Lewy Body Dementia, had no documentation of hospice services in the electronic health record since the day after admission to hospice. Staff members, including the Resident Care Manager and Director of Nursing Services, were unaware of the hospice visits and could not locate the necessary documentation in the electronic medical record or hospice binder. Similarly, Residents 118, 37, and 87, all of whom had significant changes in condition and were receiving hospice services, had no hospice POC documented in their electronic health records. Staff members, including the Neighborhood Coordinator and Assistant Director of Nursing Services, were unable to locate the hospice POCs in both the electronic health records and the hospice binders. The Director of Nursing Services acknowledged the issue and indicated that the Neighborhood Coordinators and MDS Coordinator were responsible for obtaining the hospice POCs, but the necessary documentation was still missing for these residents.
Failure to Provide Dignified and Respectful Care
Penalty
Summary
The facility failed to ensure care and services were provided in a respectful and dignified manner for Resident 87, who was admitted with diagnoses including hemiplegia, depression, and polyneuropathy. Observations over several days revealed that Resident 87 was consistently left in an unkempt state, with unbrushed hair, stubble on his face and neck, discharge in his left eye, and food particles around his mouth. The resident was also observed wearing a dirty shirt protector for extended periods, and his Ensure drink was placed out of reach. Staff interviews confirmed that there was insufficient time to provide necessary care such as shaving, oral care, and feeding due to staffing constraints, leading to neglect of these essential tasks. The facility's admissions packet stated that residents have the right to be treated with respect and dignity, yet the observations and staff interviews indicated a failure to uphold this standard. Both the Assistant Director of Nursing Services and the Director of Nursing Services acknowledged that the expectation was for shirt protectors to be removed and oral care to be provided after meals, but this was not being consistently practiced. This deficiency placed residents at risk of being treated with a lack of dignity and respect, thereby diminishing their quality of life.
Failure to Accurately Assess Resident for Significant Change in Condition
Penalty
Summary
The facility failed to accurately assess Resident 137 for a significant change in condition. Resident 137, who was admitted with Parkinson's disease, Lewy Body Dementia, and a UTI, was noted to be cognitively intact and required supervision with ADLs according to the Quarterly Assessment MDS dated 02/28/2024. However, the resident was admitted to hospice care on 03/20/2024, which was not reflected in the Significant Change in Status Assessment MDS. Staff V, the MDS Coordinator, confirmed that hospice care should have been marked in the MDS, as it was the primary reason for the significant change. Staff B, the RN and Director of Nursing, acknowledged that the MDS had been corrected but confirmed that the hospice section should have been marked initially.
Care Plan Deficiencies
Penalty
Summary
The facility failed to ensure resident care plans were reviewed, revised, and accurately reflected residents' care needs for four residents. Resident 239's care plan did not include the type, location, and care instructions for a Peripherally Inserted Central Catheter (PICC) despite being readmitted with this device. The Director of Nursing acknowledged the omission and stated the care plan needed to be updated. Resident 97's care plan did not include a referral for a Level II Pre-Admission Screening and Resident Review (PASRR) assessment for serious mental illness (SMI) despite the assessment indicating the need. Additionally, the care plan included instructions for administering oxygen, but there was no corresponding order in the electronic health record. The Director of Nursing confirmed these discrepancies and stated the care plan needed revision. Resident 116's care plan required the use of sage boots at all times, but observations showed the resident without the boots while in bed. The Director of Nursing stated the boots were not required while the resident was in an Envella air fluidized bed but should be used when in a wheelchair. Resident 87's care plan was outdated and did not reflect the resident's current hospice care needs, including mobility and continence. The care plan also lacked specific instructions provided by hospice staff for skin care and positioning. The Director of Nursing and MDS Coordinator acknowledged the inaccuracies and the need for updates.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 1,385 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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 Pt Orchard
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Port Washington Post Acute | 2.6 mi | ★★★★★ | 15 | 0 |
| Belmont Terrace | 2.7 mi | ★★★★★ | 22 | 0 |
| Life Care Center Of Port Orchard | 2.7 mi | ★★★★★ | 20 | 0 |
| Avamere Rehabilitation At Ridgemont | 2.8 mi | ★★★★★ | 16 | 0 |
| Bremerton Trails Post Acute | 2.8 mi | ★★★★★ | 55 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.