Above average — CMS composite of the measures below.
The next survey window likely opens around January 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 Wesley Homes Des Moines Health Center during CMS and state inspections, most recent first.
Resident Council concerns were not handled timely, verbal grievances were not identified or logged, residents were not routinely informed about rights, and anonymous grievance access was not available. Residents reported being unclear on how to file a grievance, did not know where Ombuds info was posted, and staff said grievance forms were kept at the nurse station with no anonymous drop box.
PASRR Level 2 determinations were not obtained for three residents after Level 1 screenings identified SMI or related conditions requiring further review. One resident had PTSD, a mood disorder, anxiety, and antidepressant use; another had PTSD, a mood disorder, hallucinations, delusions, disorganized speech, dementia, and antipsychotic use; and a third had dementia, psychosis, and antipsychotic use. Staff reported delays and limited documentation of follow-up while the referrals remained pending.
Medication storage and labeling were not maintained properly in the 300 East and 300 West med rooms. Refrigerator temp logs were incomplete, an open vial of TB testing solution was not dated, and expired meds and supplies were found in both storage areas and on a med cart. Staff stated the items should have been discarded and the refrigerator temps should have been monitored consistently.
Staff failed to follow TBP for a resident with C. diff, including posting and using the correct enteric precautions and ensuring hand hygiene and PPE use during meal service. Staff also failed to follow EBP during wound care for another resident by not performing hand hygiene when changing gloves and by using unsanitized scissors and returning them to the treatment cart without cleaning them.
Antipsychotic Used Without Adequate Behavioral Documentation: A resident with severe cognitive impairment, dementia, anxiety, depression, and a psychotic disorder received an AP medication for unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety. The MAR and progress notes did not consistently document the specific behaviors being treated, observations showed the resident calm and without distress, and staff stated the rationale for the AP order was not adequate and that orthostatic BP monitoring was important but not ordered.
Incomplete care plans were identified for several residents with complex needs, including post-surgical digestive care, COPD with oxygen therapy, heart failure with shortness of breath, blood thinner use, and psychotropic medication use. In some cases, the CPs and task sheets did not include required monitoring or staff directions, such as bowel monitoring, oxygen saturation checks, bleeding side effects, or goals related to medication benefit. Staff interviews confirmed the missing details were expected but were not included.
Unclarified medication and ostomy orders led to a deficiency for two residents. One resident with an ileostomy had orders that referred to a colostomy bag and did not specify wafer size, and the MAR did not include the ostomy care orders. Another resident with severe cognitive impairment had antipsychotic orders listing vascular dementia as the rationale, which the DON said was incorrect because the psychotic disorder should have been documented instead.
Failure to provide and document bathing assistance: A resident with impaired cognition, limited ROM, and dependence for transfers was assessed to need total assist for bathing and showering, yet was observed in bed unkempt and not dressed. The chart showed no showers, baths, bed baths, or refusals documented over the review period, despite an order requiring shower-day documentation and care plan directions for total assist with bathing.
A resident with heart failure, edema, and chronic cough was observed coughing repeatedly, short of breath, and reporting difficulty breathing when lying flat, but the record showed no respiratory assessment or provider notification for the change in condition. The resident also had an oxygen concentrator in the room despite no current oxygen order in the chart, and staff did not document oxygen monitoring or verify the order status.
A resident with dementia and a history of wandering and elopement was assessed as at risk for elopement and placed on a wander alarm. The care plan identified the alarm as a safety device, but the physician’s orders only directed staff to check the alarm’s placement, not its function. The resident was observed wandering on the unit, and the DON stated the alarm should be checked each shift and that an order to check its function should have been in place.
The facility failed to ensure that nurses and nurse aides had the necessary competencies to provide adequate care, as there was no system to evaluate staff skills. This deficiency was identified through interviews and record reviews, revealing that essential training and competency evaluations were not documented or implemented, placing residents at risk.
The facility failed to implement a comprehensive Antibiotic Stewardship program, as outlined in their policy. Key deficiencies included the lack of an accurate surveillance method to track infections, incomplete data collection, and failure to provide necessary reports. The Director of Nursing and Infection Control Preventionist were unable to provide complete documentation, and the Administrator acknowledged the program was not intact, placing residents at risk for adverse outcomes.
The facility failed to assist five residents with ADLs, resulting in poor hygiene and grooming. Residents dependent on staff for personal hygiene were observed with long fingernails, greasy hair, and unshaven facial hair. Despite being scheduled for showers, documentation showed that these residents did not receive the necessary care, and staff interviews confirmed the lack of adherence to care plans.
The facility failed to implement an effective infection prevention and control program, lacking a system for infection surveillance and failing to apply Enhanced Barrier Precautions (EBP) for two residents with specific medical needs. Additionally, a CNA improperly used PPE, wearing two masks due to an allergy and not being fit-tested for a new N-95 respirator. These deficiencies highlight significant lapses in infection control and PPE protocols.
The facility failed to ensure nurse aides completed required training, including dementia care and special needs management, as outlined in the facility assessment. Interviews revealed a lack of a structured system for verifying competency and tracking training completion, with missing documentation for required training. This deficiency placed residents at risk for less than competent care.
The facility failed to obtain informed consent for psychotropic medications for three residents, violating their policy and residents' rights. A resident with severe cognitive impairment received antianxiety medications without consent from their representative. Another resident's consent forms lacked signatures, and verbal consents were improperly documented. A third resident's consent forms were incomplete and lacked witness signatures. Staff acknowledged the failure to follow proper consent procedures, placing residents at risk for unwanted treatment.
The facility failed to provide required written transfer notifications to residents or their representatives during hospital transfers. Despite a policy mandating such notices, staff interviews revealed a lack of awareness and adherence, affecting three residents. This oversight risked misalignment with residents' care goals.
A facility failed to complete the PASRR process for a resident with psychiatric mood disorder and confusion. The PASRR form was incomplete, lacking indicators for mood or anxiety disorders and a decision on the need for a Level II evaluation. The Social Services Director confirmed the oversight, noting the resident's increased antidepressant medication and nighttime wandering, indicating a potential need for further assessment.
A facility failed to conduct an accurate PASRR assessment for a resident with multiple mental health diagnoses, including psychotic and delusional disorders. Despite receiving antipsychotic medications, the resident's Level I PASRR did not indicate the need for a Level II evaluation, which was acknowledged as necessary by the Social Service Director.
The facility failed to develop comprehensive care plans for two residents, leading to unmet care needs. A resident with severe cognitive impairment and chronic pain lacked a pain management care plan, while another resident with a contracted hand due to a stroke had no care plan instructions for nail care. Staff interviews confirmed the absence of these essential care plans.
The facility failed to update care plans for three residents, leading to unmet care needs. A resident with a pressure ulcer was not repositioned as required, another resident at risk for wandering had an incomplete care plan, and a third resident had a transfer pole installed without proper assessment. Staff interviews confirmed these oversights.
A resident with a urinary catheter did not have their catheter care documented in their Care Plan, leading to a lack of awareness among staff and potential risks. The CP incorrectly noted bladder incontinence without mentioning the catheter, and the Kardex lacked care instructions. Interviews revealed staff were unaware of the catheter, highlighting a failure in communication and documentation.
A resident with multiple sclerosis and pressure ulcers experienced inadequate pain management during wound care, leading to treatment refusals. Pain medications were not administered as ordered, and the resident reported significant pain during treatments. Staff interviews highlighted the importance of pre-medicating for comfort and documenting treatment effectiveness.
The facility failed to ensure that two staff members, hired as Nursing Assistant Registered (NAR), completed the Certified Nursing Assistant (CNA) class and passed the state license exam within four months of hire. Both staff members continued to work with residents without obtaining their CNA licenses, as confirmed by the Washington State Provider Credential Search website. The facility's administrator acknowledged this oversight.
The facility failed to implement non-pharmacological interventions before administering psychotropic medications to three residents, as required by their policy. A resident with schizophrenia and depression received daily antidepressant and antipsychotic medications without prior non-pharmacological interventions. Another resident received antidepressant medication without documented interventions, despite no behavioral issues. A third resident, admitted with depression and anxiety, received antidepressant and narcotic pain medications without non-pharmacological pain interventions. Staff acknowledged the lack of documentation and the importance of these interventions.
A significant medication error rate of 68% was observed in an LTC facility due to late administration of medications to several residents. A registered nurse administered morning medications hours after the scheduled time without consulting providers, violating the facility's policy. Staff interviews revealed a lack of awareness of the policy, and the Director of Nursing highlighted the need for timely reporting and monitoring of residents.
The facility failed to follow dietary orders for three residents, leading to inappropriate food textures being served. A resident with dysphagia was given bread products, another with chewing difficulties received sandwiches, and a third on a mechanically altered diet was served the wrong meat texture. These errors occurred despite clear meal ticket instructions.
The facility failed to maintain food safety and sanitation standards. A cook improperly handled raw chicken without changing gloves or washing hands, leading to potential cross-contamination. Additionally, expired and undated food items were found in storage, and kitchen vents were observed with debris. Staff confirmed these practices were against policy.
The facility failed to maintain proper disposal and cleanliness of garbage and recycling dumpsters, leaving them uncovered and surrounded by debris. This was observed over several days, with sea gulls accessing the garbage. The Director of Environmental Services confirmed the need for covered dumpsters and a clean area to prevent pest attraction.
A resident with complex medical conditions reported two incidents of another resident entering their room at night, causing distress due to a history of domestic violence. Despite notifying staff and the Administrator, no grievance reports were filed, and the resident received no follow-up, violating the facility's policy on abuse and neglect.
The facility failed to maintain a safe environment for two residents, leading to potential accident risks. A resident with wandering behavior was not adequately monitored, and their care plan did not reflect their tendencies, resulting in frequent unsupervised wandering. Another resident had a transfer pole installed without proper assessment or consent, posing a risk of harm due to the lack of evaluation for safe usage.
Resident Council Grievances and Rights Not Properly Addressed
Penalty
Summary
The facility failed to ensure resident concerns were handled in a timely manner, verbal grievances were identified as grievances, resident rights were discussed periodically as required, and residents were given the opportunity to make an anonymous grievance for 1 of 1 Resident Council groups reviewed. Facility policy stated the Activity Director would facilitate Resident Council meetings, the facility would act on Council concerns and recommendations, grievance notices would be posted in prominent locations, and staff would make prompt efforts to resolve grievances and return grievance forms to the Grievance Official. However, review of six months of Resident Council minutes showed repeated concerns from Resident 13 about feeling like a prisoner and having a serious lack of freedom, and repeated concerns from Resident 75 about housekeeping issues, including their room not being tidied before visitors and their bed not being made until later in the day. None of the minutes reviewed showed discussion of residents’ rights. Review of the grievance log showed the facility did not log Resident 13’s concerns about lack of freedom or Resident 75’s housekeeping concerns from the Resident Council meetings. During a meeting with regular Resident Council attendees, all four residents, including Resident 13 and Resident 75, stated they were unclear on how to file a grievance, none recalled any discussion of residents’ rights during Council meetings, and none knew where information about the State Long-Term Care Ombuds office was posted. Observation showed no signs posted about the right to file a grievance, no grievance forms available for residents to complete without requesting one, and no box or receptacle for anonymous submission. Staff stated grievance forms were available at the nurse station, residents were not supposed to enter the nurse station, and staff were unsure how a resident could file an anonymous grievance if they had to ask for a form and had no place to leave it anonymously.
PASRR Level 2 Determinations Not Obtained
Penalty
Summary
The facility failed to ensure Level 2 PASRR determinations were obtained for 3 residents whose Level 1 screenings identified mental disorder or intellectual disability-related concerns requiring further review. Facility policy stated residents with a mental disorder, intellectual disability, or related condition must be referred for a Level 2 PASRR evaluation, and the Social Services Director was responsible for tracking screening status and referrals. Review of records showed Resident 3 had PTSD, a mood disorder, anxiety, and antidepressant use, and a corrected Level 1 PASRR indicated a Level 2 evaluation was needed, but no Level 2 determination was found until many months later in the record. Staff stated there were delays in processing Level 2 PASRR evaluations and could not provide emails or documentation showing follow-up during the period when the referral was pending. Resident 9’s records showed PTSD, a mood disorder, another mental health condition with hallucinations, delusions, and disorganized speech, dementia, and antipsychotic use. A Level 1 PASRR indicated SMI indicators and dementia requiring Level 2 referral, but no corresponding Level 2 evaluation or invalidation was found in the chart, and staff could not provide documentation of follow-up beyond stating a call was made. Resident 63’s records showed dementia, psychosis, and antipsychotic use, and the most recent Level 1 PASRR identified psychotic and delusional disorders with dementia and required Level 2 referral. No Level 2 evaluation or invalidation was found in the chart, and although staff later produced evidence that the referral was received and one email was sent with clinical documentation, there was nothing to show follow-up after that communication.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Medications and biologicals were not stored and labeled in accordance with accepted professional standards in the 300 East and 300 West medication storage areas. In the 300 East medication room, the refrigerator temperature log showed 5 of 17 required temperature checks were not documented between 02/01/2026 and 02/09/2026, and Staff J stated the temperatures should have been monitored consistently. During the same observation, an open vial of tuberculosis testing solution was found without a date showing when it was opened or when it should be discarded. In the 300 East medication storage room, expired medications and medical supplies were observed, including insulin syringes, blood collection syringes, blood collection tubes, anticlotting test kits, specimen collection kits, a urine drainage bag, oxygen tubing, and a full bottle of Vitamin D tablets, with expiration dates ranging from 2019 to 2025. In the 300 West medication storage area, the refrigerator temperature log had no readings documented on 02/01/2026 and 02/08/2026, and the medication cart contained expired magnesium supplement, pain reliever, and non-steroidal anti-inflammatory drug bottles. Staff H and Staff F stated expired medications should not have been available on the cart and that refrigerator temperatures should be checked daily, while the DON stated medications should be labeled with the date opened and supplies should be discarded before expiration.
Infection Control Failures During C. diff Precautions and Wound Care
Penalty
Summary
The facility failed to ensure staff posted and followed the correct Transmission Based Precautions for a resident with C. diff. Resident 40 had multiple medically complex diagnoses, including C. diff infection, and had completed vancomycin treatment but continued to have loose stools. A physician ordered stool testing to re-check for C. diff, and the resident’s room initially displayed a Contact Precautions sign that instructed hand sanitizer use, glove and gown use, and reusable equipment disinfection. Staff later stated that standard Contact Precautions were not appropriate for C. diff and that Contact Precautions Specific Enteric should have been used, but the incorrect signage remained posted during the observed meal service. During meal delivery, a nursing student entered Resident 40’s room without performing hand hygiene or putting on a gown or gloves, placed the meal tray on the bedside table, adjusted the bed, removed the tray lid, left the room without hand hygiene, and later re-entered the room without hand hygiene or PPE to finish setting up the meal. The tray was handled with reusable dishware, and the student also handled items at the nursing station between room entries. Staff later stated they expected students to follow the precaution signs and that nursing staff should have coordinated with kitchen staff to provide disposable dishware that could be discarded inside the room, but this did not occur. The facility also failed to ensure appropriate PPE and hand hygiene during wound care for another resident on Enhanced Barrier Precautions. Resident 44 had venous insufficiency and a surgical wound to the right ankle requiring wound care every other day. While providing wound care, an RN changed from soiled to clean gloves without performing hand hygiene, cut foam dressing with scissors that had not been sanitized, then picked up soiled wound dressings with the same hand holding the scissors and returned the scissors to the treatment cart without sanitizing them. The RN stated hand hygiene and sanitizing the scissors should have been done but were not, and the Infection Preventionist stated equipment should be sanitized before and after use to prevent spread of infections.
Antipsychotic Used Without Adequate Behavioral Documentation
Penalty
Summary
The facility failed to ensure one resident’s medication regimen was free of chemical restraints when an antipsychotic medication was continued without an adequate documented rationale and without consistent documentation of the behaviors being treated. Resident 11 had severely impaired cognition and diagnoses including dementia, anxiety, depression, and a psychotic disorder, and the physician’s orders included antipsychotic medication for unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety. The facility’s psychotropic medication policy required a specific, diagnosed, and documented condition and ongoing evaluation of the resident’s response, but the record did not show a clear rationale supporting the medication use as documented. The resident’s care plan for dementia with psychosis focused on improved mood and monitoring for depression, anxiety, and sadness, while the MAR documented behaviors described only as delusional thinking, hallucinations, or agitation on limited shifts across several months. The October 2025 MAR did not identify which behavior was observed, and progress notes from admission through the time of review did not document delusions or hallucinations, only agitation and wandering. Survey observations showed the resident sitting with a spouse, walking toward the spouse’s room, and leaving the bedroom without signs of distress or diminished mood. Staff also stated there was no adequate rationale for the antipsychotic order as written and acknowledged that orthostatic blood pressure monitoring was important for residents taking antipsychotic medications, yet no order directed staff to monitor for orthostatic hypotension.
Incomplete Care Plans for Multiple Residents
Penalty
Summary
The facility failed to ensure comprehensive care plans were developed and implemented for 5 of 20 sampled residents. The deficiency involved residents with varied medical needs, including recent digestive surgery, COPD with oxygen therapy, heart failure with shortness of breath, blood thinner use, and psychotropic medication use. In each case, the care plans or related task sheets did not fully reflect the residents’ current conditions, ordered monitoring, or staff directions needed to guide care. For one resident admitted after a digestive surgery, the comprehensive care plan did not include directions for post-surgical digestive care or bowel monitoring. The resident reported abdominal pain, recent bowel movements that were not as expected, and uncertainty about whether staff were monitoring bowel function. Staff interviews confirmed bowel monitoring should have been included in the care plan but was not. For another resident with COPD and oxygen therapy, the pneumonia care plan directed oxygen use per physician orders but did not include monitoring oxygen saturation levels, and documentation showed oxygen saturation was not recorded on multiple days. The resident was observed without oxygen at one point and stated the tubing bothered them. For a resident with heart failure and edema, the altered respiratory status care plan directed staff to monitor for respiratory distress and report abnormal breathing, but the resident was observed coughing repeatedly, reported coughing all night, and had shortness of breath and dizziness, with no provider notification documented. For a resident on a daily blood thinner, the care plan and February task sheet did not identify the medication or the side effects staff should observe and report. For a resident receiving antipsychotic medication, the psychotropic medication care plan only addressed avoiding drug-related complications and did not include a goal related to potential benefit from the medication.
Unclarified medication and ostomy orders
Penalty
Summary
The facility failed to ensure care and services were provided within professional standards of nursing for 2 of 5 residents whose medication regimen was reviewed. For Resident 8, the record showed diagnoses including a stroke history, intestinal obstruction, and prior digestive surgery, and the Quarterly MDS indicated the resident had an ileostomy. Physician orders dated 11/19/2025 included an order to change the resident’s colostomy bag and an order to change the ileostomy wafer, but the wafer order did not specify the wafer size and the bag order referred to a colostomy rather than an ileostomy. The February 2026 MAR did not include either order, and there was nowhere for nurses to document the care provided. Staff G stated nurses would review the order to see what size wafer to use, and Staff B stated the wafer order should have specified the size and the bag order should have been changed to an ileostomy bag, but neither issue was identified by nursing staff. For Resident 63, the Quarterly MDS showed severely impaired cognition and altered level of consciousness, with diagnoses including vascular dementia and a psychotic disorder. The physician’s orders dated 09/26/2025 directed two antipsychotic medications, one in the morning and one in the evening, with the stated rationale of vascular dementia. Staff B stated the rationale was incorrect and that the orders should have identified the resident’s psychotic disorder as the reason for the medication, but nursing staff did not identify the error.
Failure to Provide and Document Bathing Assistance
Penalty
Summary
The facility failed to ensure that Resident 78 received the assistance with ADLs that was assessed and care planned, specifically bathing and grooming. Resident 78 had moderately impaired cognition, limited range of motion in the left arm and leg, was dependent on staff for transfers, and was always incontinent of bowel and bladder. The resident also stated they were unable to do much for themselves. At the time of observation, Resident 78 was in bed in a gown with unkempt hair and a stained pink neck pillow supporting their head; a later observation showed the resident still in bed watching television, not dressed, with the same stained neck pillow and messy hair. The physician’s order required shower day documentation for showers, bed baths, or refusals, and the care plan directed total assistance from one staff member for bathing and showering. Review of bathing records from 01/23/2026 through 02/12/2026 showed no showers, baths, or bed baths provided and no documented refusals for Resident 78. Review of progress notes also showed no documentation that bathing was provided during that period and no documentation of bathing refusals. The DON stated Resident 78 should be provided bathing as ordered and care planned, and that staff were expected to document care provided and any refusals.
Failure to Monitor Fluid Overload and Oxygen Therapy
Penalty
Summary
The facility failed to provide adequate monitoring for fluid overload and edema for Resident 38, who had diagnoses including heart failure, high blood pressure, and generalized edema. The resident’s care plan directed staff to monitor, document, and report symptoms of fluid overload such as edema, coughing, shortness of breath, and difficulty breathing while lying flat. On observation, Resident 38 was repeatedly coughing, stated they had a deep cough they could not get rid of, and said they could not sleep the prior night because of coughing and shortness of breath. The resident also stated they had raised the head of the bed to breathe better because lying flat made them cough more, and reported dizziness and lightheadedness during the night. The record showed staff gave cough medication and documented it as effective, but there was no further documentation of a respiratory assessment or other interventions for the cough. The resident’s record also did not show that the provider was notified of the increased coughing or shortness of breath. Staff interviews confirmed the resident had chronic heart failure, edema, and a long-term cough, and that the cough should have been assessed because of the resident’s medical conditions. Staff stated the resident should have been assessed for cough and edema and the provider notified of a change in condition related to fluid overload, but this was not done. The facility also failed to monitor oxygen therapy for Resident 38. The resident had a discontinued oxygen order for 2 liters per minute as needed, but there was no current oxygen order in the medical record and the February 2026 MAR did not show an oxygen order or oxygen saturation monitoring. Despite this, an oxygen concentrator was observed in the resident’s room, and the resident stated they used oxygen only at night and had used it the previous night. Staff acknowledged the resident had oxygen in the room and breathing treatments, and stated nurses should have checked for oxygen orders, assessed the resident, monitored oxygen saturations, and notified the provider, but did not.
Wander Alarm Not Fully Ordered or Monitored
Penalty
Summary
The facility failed to ensure a resident assessed as at risk for elopement received the supervision and safety measures identified in the resident’s assessment and care plan. Resident 11 had a diagnosis of dementia, severely impaired cognition, and behavior including wandering. The resident’s elopement risk assessment stated the resident could ambulate independently, verbalized a desire to go home, had an elopement history at a prior residence and at the facility, and took medications that altered mental status. The physician’s orders included checking the placement of a wander alarm on the resident’s ankle, but there was no order to check the alarm’s function. The resident’s care plan identified goals of not leaving the facility unattended and maintaining safety, and included a wander alarm as a safety device. During observation, Resident 11 was seen wandering on the unit near the spouse’s room without any clear purpose. The DON stated that when a resident required a wander alarm, the device should be checked each shift to ensure it was working correctly, and stated Resident 11 should have had an order for staff to check the alarm’s function, but no such order was in place.
Lack of Staff Competency Evaluation in LTC Facility
Penalty
Summary
The facility failed to ensure that nurses and nurse aides possessed the necessary competencies and skills to provide adequate care and services to residents. This deficiency was identified during interviews and record reviews, which revealed that the facility did not have a process in place to evaluate the competency of its staff, including medication pass evaluations. The lack of a structured evaluation system for Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Nurse Aides (NAs) meant that staff were not assessed for their ability to perform essential job functions, such as medication management, emergency response, and personal care skills. The facility's 2024 Facility Assessment outlined the training and education needs for RNs, LPNs, and NAs, but these were not implemented or documented for the staff reviewed. During an interview, the Human Resources Director and Administrator admitted that the Administrator, Director of Nursing, and Staff Development Specialist were new to their roles and acknowledged the absence of a system to evaluate staff competencies. This oversight placed residents at risk for medication errors, accidents, injuries, infections, and a diminished quality of life and care.
Deficiency in Antibiotic Stewardship Program Implementation
Penalty
Summary
The facility failed to implement a comprehensive Antibiotic (ABO) Stewardship program, which is essential for optimizing infection treatment and reducing adverse events associated with antibiotic use. The facility's policy outlined a detailed ABO Stewardship program, including the use of national standard surveillance tools, monthly antibiotic reviews by the pharmacist, and documentation of assessments and ABO use protocols. However, the facility did not adhere to these guidelines. Interviews and record reviews revealed that the facility lacked an accurate surveillance method to track resident infections, identify infection sources, and ensure correct ABO treatment. Additionally, there was no data collection analysis or summary for resident infections for August and September 2024, and the facility was unable to provide necessary data reports as per the ABO stewardship policy. The Director of Nursing and the Infection Control Preventionist were unable to provide complete surveillance logs or documentation of analysis for resident ABO use. The ABO Stewardship binder for September and October 2024 contained incomplete data, with many blanks in critical columns such as infection etiology, evaluation, laboratory results, and whether the infection met the criteria for ABO treatment. The Administrator acknowledged the deficiencies, noting that the ABO stewardship program was not intact and did not meet policy requirements. This lack of implementation placed residents at risk for potential adverse outcomes associated with inappropriate or unnecessary ABO use and increased the risk for ABO-resistant organisms.
Failure to Provide ADL Assistance
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADL) for five residents, leading to issues with cleanliness and grooming. Resident 2, who had weakness on the right side due to a stroke, required maximal assistance with personal hygiene but was observed with long facial hair and fingernails. Staff interviews confirmed that Resident 2 did not refuse care, and staff were expected to provide the necessary grooming assistance. Resident 3, dependent on staff for personal hygiene due to poor balance and vision impairment, was observed with long fingernails and greasy hair. Despite being scheduled for showers twice a week, no showers were documented for Resident 3 in the past 30 days. Resident 24, who required total assistance with personal hygiene, was observed with long fingernails and greasy hair, and no showers were documented for the past 30 days. Resident 35, who needed one-person assistance, reported not receiving a shower for a month. Resident 37, totally dependent on staff for personal hygiene, was observed with greasy hair and had not received scheduled showers. Staff interviews confirmed that these residents did not refuse care, and the facility's policy required staff to provide ADL assistance according to residents' needs and preferences. The failure to adhere to these policies resulted in poor hygiene and diminished quality of life for the affected residents.
Inadequate Infection Control and PPE Use
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by the lack of a system for surveillance to identify and control infections and communicable diseases. The facility's policy outlined a comprehensive infection surveillance system, but during interviews, the Director of Nursing and the Infection Control Preventionist were unable to provide data for infection tracking and monitoring for several months. The Administrator confirmed that the infection control systems were not intact, indicating a significant gap in the facility's infection prevention efforts. Enhanced Barrier Precautions (EBP) were not implemented for two residents who required them. One resident had open pressure ulcers and an indwelling catheter, while another had an indwelling urinary catheter. Observations revealed that neither resident's room had EBP signage or readily available supplies for staff use. The Infection Control Preventionist acknowledged that residents with certain conditions should be on EBP precautions, but this was not executed for the residents in question. The facility also failed to ensure proper use of Personal Protective Equipment (PPE). A Certified Nursing Assistant was observed wearing two masks due to an allergy to the N-95 respirator and did not clean their face shield after exiting an isolation room. The CNA later used a different N-95 respirator without being fit-tested, contrary to facility policy. The Infection Control Preventionist confirmed that staff should not wear two masks simultaneously and should be fit-tested for N-95 respirators, highlighting a lapse in adherence to PPE protocols.
Deficiency in Nurse Aide Training and Competency Verification
Penalty
Summary
The facility failed to develop, implement, and maintain an in-service training program for nurse aides, which resulted in four nurse aides not completing the required training, including dementia care management and training for the special needs of residents. The facility assessment indicated that nurse aides required training in various areas such as basic personal care skills, vital signs monitoring, and dementia management, among others. However, the facility did not ensure that nurse aides received at least 12 hours of continuing education annually, nor did they conduct annual performance evaluations to identify areas needing additional training. Interviews with facility staff revealed a lack of a structured system for verifying nurse aide competency and tracking training completion. The Human Resources Director and Administrator acknowledged that the training program was incomplete and that documentation for the required training was missing. The Director of Nursing confirmed the absence of a system for annual evaluations, and the Staff Development Specialist admitted to not tracking the completion of training checklists. Consequently, the facility did not meet the regulatory requirements for nurse aide training and competency verification, placing residents at risk for receiving less than competent care.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent before administering psychotropic medications to three residents, which is a violation of their policy and residents' rights. Resident 53, who was severely cognitively impaired and had a designated Resident Representative (RR) for healthcare decisions, was administered antianxiety medications without obtaining consent from the RR. Similarly, Resident 212 was prescribed multiple psychotropic medications, but the consent forms lacked signatures, and verbal consents were improperly documented. Resident 213, who was moderately cognitively impaired, also had psychotropic medications administered without proper consent documentation, as the consent forms were incomplete and lacked witness signatures for verbal consents. The facility's policy requires collaboration with residents or their representatives and proper documentation of informed consent, including signatures and witness verification for verbal consents. However, the records for these residents showed significant lapses in following these procedures. Staff E, a Registered Nurse and Resident Care Manager, acknowledged the failure to obtain consent for Resident 53 and explained the expected process for obtaining and documenting consent, which was not followed in these cases. This oversight placed the residents at risk for unwanted treatment, as they were not fully informed or involved in the decision-making process regarding their psychotropic medication regimens.
Failure to Provide Written Transfer Notifications
Penalty
Summary
The facility failed to provide required written notices to residents or their representatives at the time of transfer or discharge to an acute care hospital. This deficiency was identified for three residents who were reviewed for hospitalizations. The facility's policy, revised on 08/08/2024, mandates that a notice of transfer or discharge must be provided to the resident or their representative, including the specific reason for the transfer, the date, and the name of the hospital. However, for Residents 16, 35, and 46, there was no documentation that such notifications were provided. Interviews with facility staff revealed a lack of awareness and adherence to the policy. Staff F, a Resident Care Manager, admitted to not knowing about the process for written notification, and Staff B, the Director of Nursing, acknowledged the importance of providing written transfer notifications but confirmed that the facility did not follow its policy. This oversight placed residents at risk for discharges that might not align with their stated goals for care and preferences.
Incomplete PASRR Process for Resident with Mental Health Needs
Penalty
Summary
The facility failed to ensure the Preadmission Screening and Resident Review (PASRR) process was properly followed for a resident with complex conditions, including a psychiatric mood disorder and confusion. Upon admission, the Minimum Data Set (MDS) indicated these conditions, and subsequent reviews showed diagnoses of depression and anxiety. The resident's Cognitive Care Plan included interventions for impaired cognitive function and thought processes, with goals to prevent delirium. However, the PASRR Care Plan did not indicate a Level 2 referral, and the PASRR form was incomplete, lacking necessary indicators for mood or anxiety disorders and missing a decision on the need for a Level II evaluation. The clinical record revealed that the admission PASRR was signed by hospital staff but was incomplete, with no updates since the initial assessment. During an interview, the Social Services Director confirmed the PASRR I form was not fully completed and acknowledged the resident's increased antidepressant medication and nighttime wandering, suggesting a potential need for a PASRR II. The incomplete PASRR process placed the resident at risk of not receiving necessary specialized mental health services.
Inaccurate PASRR Assessment for Resident with Mental Disorders
Penalty
Summary
The facility failed to ensure an accurate Pre-Admission Screening and Resident Review (PASRR) assessment for a resident, identified as Resident 14, who was reviewed for mental disorders or intellectual disabilities. Resident 14, who was admitted to the facility with diagnoses including non-Alzheimer's dementia, seizure disorder, psychotic disorder, delusional disorders, and an unspecified mental disorder, was receiving antipsychotic medications. Despite these conditions, the Level I PASRR conducted on 08/06/2021 did not indicate the need for a Level II evaluation, which should have been triggered by the presence of serious mental illness indicators such as psychotic and delusional disorders. This oversight was confirmed during an interview with the Social Service Director, who acknowledged that a Level II PASRR referral was necessary but not made.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, leading to deficiencies in meeting their care needs. Resident 53, who was admitted with severe cognitive impairment and chronic pain, did not have a care plan addressing pain management despite having a physician's order for scheduled pain medication. This oversight was acknowledged by Staff F, a Registered Nurse and Resident Care Manager, who confirmed the absence of a pain care plan and emphasized the importance of individualized care plans for providing necessary care. Similarly, Resident 2, who had right-side weakness due to a stroke, was observed with a contracted right hand and long fingernails over several days. Staff interviews revealed that there were no care plan instructions for managing the contracted hand, making it difficult for nursing assistants to provide appropriate nail care. Staff F confirmed the lack of a care plan for Resident 2's contracted hand, acknowledging that such a plan should have been in place to guide staff in providing necessary care.
Care Plan Deficiencies and Unmet Resident Needs
Penalty
Summary
The facility failed to ensure that care plans were accurately reviewed and revised to reflect the current status and needs of residents, leading to unmet care needs and diminished quality of life for three residents. Resident 24, who had a pressure ulcer on their sacrum, required repositioning every two hours and needed to be laid back in bed after meals to relieve pressure. However, observations showed that the resident was left sitting in their wheelchair for extended periods, and the care plan was not updated to reflect the necessary interventions. Staff interviews confirmed the oversight in revising the care plan to address the resident's current needs. Resident 213, admitted with medically complex conditions, was at risk for wandering due to memory impairment and dementia. Despite documented behavior issues, the care plan did not reflect the resident's wandering risk. Staff interviews revealed that the care plan needed timely updates to reflect the necessary care services. Additionally, Resident 212, who was at risk for falls, had a transfer pole installed without a corresponding assessment or consent documented in the care plan. Staff acknowledged the absence of a transfer pole assessment, highlighting a potential risk of harm if not used properly.
Failure to Document and Provide Catheter Care
Penalty
Summary
The facility failed to provide appropriate care for a resident with a urinary catheter, as evidenced by the lack of documentation and awareness among staff. Resident 212, who was admitted with muscle weakness, Parkinson's disease, and a urinary catheter, did not have the catheter documented in their Care Plan (CP). The CP incorrectly indicated that the resident had urge and functional bladder incontinence, with no mention of the indwelling catheter or instructions for its care. Additionally, the resident's Kardex did not include any instructions for catheter care. Interviews with facility staff revealed a lack of awareness and oversight regarding the resident's catheter care. Staff E, a Registered Nurse and Resident Care Manager, was unaware of the catheter's presence and acknowledged that it should have been included in the CP. Staff B, the Director of Nursing, emphasized the importance of addressing the indwelling catheter in the CP to ensure all caregivers had access to the necessary care instructions. This oversight placed the resident at risk for infections, skin breakdown, and diminished quality of care.
Inadequate Pain Management During Wound Care
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as Resident 33, during wound care, which led to avoidable pain and refusal of treatments. Resident 33, who was admitted with conditions including multiple sclerosis and pressure ulcers, had a care plan that required evaluation of pain and administration of pain medication prior to wound therapy. However, the Medication Administration Records indicated that pain medications were not administered on several occasions, and the resident refused wound care on multiple days due to pain. Interviews with Resident 33 revealed that they experienced significant pain during wound treatments and suggested that earlier treatment times might be more tolerable. Despite this, no discussions about changing treatment times were documented. Staff interviews confirmed the importance of pre-medicating residents for comfort and documenting refusals and treatment effectiveness. The Director of Nursing expected treatments and medications to be administered as ordered, with proper documentation of wound conditions and treatment outcomes.
Failure to Ensure CNA Licensure for NAR Staff
Penalty
Summary
The facility failed to ensure that staff with a Nursing Assistant Registered (NAR) certificate completed a Certified Nursing Assistant (CNA) class and passed the state license exam within four months of hire. This deficiency was identified for two staff members, Staff J and Staff L, who were both hired as NARs on April 9, 2024. As of October 28, 2024, both staff members were still working as NARs without having obtained their CNA licenses. The Washington State Provider Credential Search website confirmed that neither Staff J nor Staff L had transitioned from NAR to CNA status, despite having worked at the facility for more than four months. The facility's daily schedules for October 2024 showed that both staff members were actively working with residents in their NAR capacity. During an interview, the facility's administrator acknowledged that both staff members had been employed for longer than four months without obtaining the necessary CNA licensure.
Failure to Implement Non-Pharmacological Interventions Before Psychotropic Medications
Penalty
Summary
The facility failed to ensure that three residents were free from unnecessary psychotropic medications, as required by their policy. Resident 3, diagnosed with schizophrenia and depression, received antidepressant and antipsychotic medications daily without documentation of non-pharmacological interventions being attempted prior to medication administration. Staff F, the Resident Care Manager, confirmed the lack of documentation and acknowledged that non-pharmacological interventions should have been attempted and recorded. Similarly, Resident 35, who received antidepressant medication, had no documented non-pharmacological interventions prior to medication administration, despite being assessed with no behavior or rejection of care. Staff C, the Social Services Director, and Staff B, the Director of Nursing, both admitted that non-pharmacological interventions were not attempted as required. Resident 53, admitted with depression and anxiety, received antidepressant medications and narcotic pain medication without any non-pharmacological pain interventions ordered. Staff E, a Registered Nurse, confirmed the absence of non-pharmacological interventions, emphasizing their importance in preventing unnecessary medication use.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a significant error rate of 68% during a medication pass observation. This deficiency was observed in the administration of medications to four residents, where 28 out of 35 medications were not administered according to the prescribed schedule. Staff G, a registered nurse, administered morning medications several hours later than the times specified in the Medication Administration Record (MAR) for Residents 54, 6, 44, and 163. The medications included antibiotics, blood pressure medications, antidepressants, and pain medications, which were given without consulting the residents' providers for approval of the delayed administration. Interviews with staff revealed a lack of awareness and adherence to the facility's medication administration policy, which requires medications to be given within a 60-minute window of the scheduled time unless otherwise directed by a physician. Staff G admitted to not knowing the policy regarding late medication administration and did not report the delay to management or the residents' providers. The Director of Nursing emphasized the importance of notifying management and the provider if medications are administered outside the designated time frame and monitoring residents for adverse effects. This oversight placed residents at risk of not receiving the intended therapeutic effects of their medications.
Failure to Implement Dietary Orders for Residents
Penalty
Summary
The facility failed to implement dietary orders for three residents, leading to the provision of inappropriate food textures that could pose risks such as choking. Resident 34, diagnosed with oral phase dysphagia, was observed being fed a sandwich and dinner roll, despite a dietary order excluding bread due to swallowing difficulties. The meal ticket for Resident 34 did not list bread products, and the Certified Nursing Assistant acknowledged the oversight in reviewing the meal ticket before serving the meal. Similarly, Resident 37, who had a dietary order for no bread due to chewing difficulties, received a lunch tray with two sandwiches, contrary to the instructions on the meal ticket. Resident 45, on a mechanically altered diet, was served a sandwich with chopped meat instead of the required ground meat, as per the dietary order. The Registered Nurse confirmed that the kitchen staff did not adhere to the meal ticket instructions. In all cases, the dietary expediter supervisor was responsible for ensuring the correct meal components were served according to the residents' diet orders, but errors occurred, resulting in the residents receiving inappropriate food items.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to food service safety standards, as observed during a survey. Staff AA, a cook, was seen wearing plastic gloves over knitted safety gloves while washing raw chicken at the prep sink. Without removing the contaminated gloves or washing their hands, Staff AA proceeded to touch various kitchen items, including a large spoon used to stir soup, soup warming pans, and a plastic bag of frozen corn. This improper hand hygiene and glove use were confirmed by Staff AA and Staff S, the Executive Chef, who acknowledged that gloves should be removed and hands washed after handling raw chicken. Additionally, the facility did not comply with its policy for food storage, which requires foods to be covered, labeled, and dated. Observations revealed expired foods in the walk-in refrigerator and undated items in both the dry storage and freezers. Staff Q, the Lead Cook, confirmed that expired food should be discarded and that opened food items should be labeled with open and use-by dates. Furthermore, the kitchen's sanitation was compromised by thick grey debris on overhead vents, which were located above the clean dish area and the food prep and serve area. Staff T, the Hospitality Manager, acknowledged that the vents should be clean and that kitchen staff should notify maintenance for cleaning needs.
Improper Disposal and Maintenance of Dumpsters
Penalty
Summary
The facility failed to ensure proper disposal and maintenance of garbage and recycling dumpsters, as observed over several days. Specifically, 2 of 3 garbage dumpsters and 1 of 2 recycling dumpsters were left uncovered, and the surrounding areas were not kept clean, with trash and food scraps scattered on the concrete. This situation was observed on multiple occasions, with sea gulls seen flying over the dumpsters and opening garbage bags for food scraps. During an observation and interview, the Director of Environmental Services acknowledged that the dumpsters should be covered and the area should be free of debris to prevent attracting pests.
Failure to Investigate Resident's Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate and address allegations of abuse or neglect concerning a resident, identified as Resident 31. Resident 31, who has complex medical conditions including kidney insufficiency, high blood pressure, and heart failure, reported that another resident entered their room on two separate occasions during the early morning hours. Despite communicating these incidents to the staff and leaving a message for the Administrator, Resident 31 did not receive any follow-up or feedback regarding their concerns. The resident expressed feeling scared due to a history of domestic violence and felt neglected by the staff. Interviews with facility staff, including the Director of Nursing and the Social Services Director, revealed that no grievance reports were filed for Resident 31's complaints. The Administrator acknowledged being unaware of the initial incident and confirmed that a grievance report was only being initiated after the second occurrence. This lack of immediate response and failure to document and investigate the resident's concerns violated the facility's policy on abuse, neglect, and exploitation, which mandates thorough investigation and feedback to residents.
Failure to Ensure Safe Environment for Residents
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for two residents, leading to potential risks of accidents and injuries. Resident 213, who was admitted with conditions including high blood pressure, urinary tract infections, and muscle weakness, exhibited wandering behavior that was not adequately addressed in their care plan. Despite frequent behavior issues documented by staff, the care plan did not reflect the resident's wandering tendencies. Interviews with staff revealed a lack of awareness and communication regarding Resident 213's behavior, with staff needing to check the resident's location every 15 minutes due to their confusion and tendency to wander into other residents' rooms. Resident 212, admitted with muscle weakness and unsteadiness, had a transfer pole installed in their room without proper assessment or consent. The care plan did not document the presence of the transfer pole, and staff interviews confirmed the absence of a necessary assessment and consent form. This oversight posed a risk of harm if the transfer pole was not used correctly, as there was no evaluation to ensure a safe distance between the pole and the bed to prevent the resident from getting wedged between them.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 1,598 citations issued within 25 miles in the last 12 months — including the 6 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 Des Moines
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Puget Sound Transitional Care | 1 mi | ★★★★★ | 32 | 0 |
| Judson Park Health Center | 1.2 mi | ★★★★★ | 50 | 0 |
| Valley View Skilled Nursing And Rehabilitation | 5.6 mi | ★★★★★ | 22 | 0 |
| Benson Heights Rehabilitation Center | 5.6 mi | ★★★★★ | 30 | 0 |
| Life Care Center Of Federal Way | 5.6 mi | ★★★★★ | 1 | 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.