Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Woodard Creek Health & Rehabilitation during CMS and state inspections, most recent first.
The facility failed to recognize and thoroughly investigate multiple abuse and neglect allegations, including reports of rough handling, rude staff behavior, missed incontinence care, delayed call light response, and missed bathing or hygiene care. A cognitively intact resident on continuous O2 reported prolonged waits for help and a malfunctioning call light, but the investigation did not include a resident interview or call light inspection. Another cognitively intact resident reported a CNA was rude and forced self-care despite limitations, and the facility’s investigation lacked key interviews and did not identify the alleged perpetrator. Similar grievances from other residents were handled as routine care concerns rather than abuse/neglect allegations.
Failure to assess, document, and treat pressure ulcers: Two residents had pressure injuries that were not properly monitored or documented. One resident with a pressure-related ear wound under oxygen tubing reported pain and said nursing had not assessed it; the chart had no wound assessment, provider notification, or treatment orders until surveyors identified the unstageable PU. Another resident with a coccyx PU had multiple blank TAR entries for ordered wound care, and leadership confirmed the missing documentation meant the care was not charted.
Failure to Protect Residents from Abuse and Neglect: A cognitively intact resident reported a CNA used a rude, dismissive tone, refused assistance, and made her try to care for herself, while a roommate corroborated the harsh treatment. Three other cognitively intact residents experienced delayed toileting or brief care, including prolonged waits after incontinence or call light use, and the facility later substantiated neglect tied to staffing-related delays. One incident was not documented in the incident log and was initially handled as a customer service issue rather than abuse.
PASRR assessments were not accurately completed for three residents with mental health diagnoses. Two residents were admitted under exempted hospital discharge status, but their Level I PASRRs were not updated to reflect current diagnoses and there was no documentation of Level II referral after they remained in the facility beyond the 30-day exemption. Another resident was admitted with generalized anxiety disorder, but the PASRR did not list anxiety and was not redone as expected.
Incomplete and outdated resident care plans affected multiple residents with needs related to nail care, podiatry, vision, bedside meds, foley catheter care, oxygen therapy, dialysis/fluid restriction, communication, nutrition, incontinence, mobility, pain, and falls. Staff acknowledged several plans were missing key details or were not updated to match current orders, conditions, or observed care needs, including an LPN noting that some items should have been care planned but were not.
Failure to assess and care for residents with bowel and bladder incontinence: Three residents had incomplete or absent bowel/bladder program evaluations, inconsistent incontinent care, and poor documentation of toileting and brief changes. One resident newly developed bowel incontinence after surgery and reported long waits for changes, another had continent/incontinent episodes with a diuretic order and family reports of urine odor and delayed care, and a third with severe dementia had no incontinent care plan, infrequent check-and-change documentation, and moisture-related skin breakdown.
A facility failed to follow ordered weights, accurately document meal intake and supplement use, and consistently provide ordered 1:1 meal assistance for two residents with nutritional concerns. One resident with severe protein-calorie malnutrition and dementia had delayed and missed weights, was repeatedly observed eating without the required help, and had meal and supplement records that did not match what surveyors saw. Another resident with DM, HF, and malnutrition had missed daily weights and was observed asleep with an untouched lunch tray even though the meal record showed most of the meal was eaten.
A resident with chronic respiratory disease was observed receiving oxygen at a higher flow than ordered while the humidifier bottle remained empty for an extended period, and the resident reported dry, scabbed nares and nosebleeds. Another resident with COPD and sleep apnea was left without oxygen after CPAP removal, with an SpO2 of 80% before oxygen was reapplied. A third resident’s oxygen tubing and humidifier were observed undated despite orders to date and maintain the equipment.
The facility failed to maintain enough nursing staff and a licensed nurse in charge on each shift, resulting in long delays for call light response and missed or delayed care. Residents reported waiting 30 minutes to several hours for help, including delayed brief changes and missed showers, while CNAs said staffing shortages made it difficult to complete showers and other assigned duties. Staff also reported that agency workers were often unprepared and that aides sometimes had to skip breaks or stay late to finish care tasks.
The facility failed to ensure NPIs were used and documented before PRN pain meds were given to several residents. Records showed PRN opioids and acetaminophen administered without documented repositioning, heat/cold, relaxation, or other NPI measures, and some pain orders lacked clear pain-score parameters or other required details. Staff interviews confirmed that NPIs were not consistently ordered, scheduled, attempted, or documented before pain medication administration.
A resident with HTN, ESRD on dialysis, and moderate cognitive impairment had a PRN hydralazine order for SBP over 160, but the MAR and BP record showed repeated elevated SBP readings with the medication given only 3 times. The Interim Administrator confirmed the PRN order was not followed 19 times during the identified period, including multiple elevated BP readings on one day when no hydralazine was administered.
Cross Contamination During Meal Plating: A Dietary Aide repeatedly handled multiple food items during lunch tray line plating with gloved hands and continued plating without changing gloves after touching food and environmental surfaces such as a spatula, thermometer, and containers. The Dietary Mgr stated staff should not touch food when serving and should have changed gloves after touching environmental surfaces.
Administration failed to oversee abuse/neglect reporting and investigation, despite facility policy requiring immediate identification, reporting, and investigation of allegations. Multiple resident grievances were later confirmed as abuse/neglect allegations or incidents the facility could not rule out, and leadership acknowledged the facility had missed the mark, with long call light wait times and a culture of poor urgency contributing to the failure to recognize and address these concerns.
Incomplete Hospice and dialysis records, along with an PHI privacy breach, were identified for multiple residents. A resident receiving Hospice had no current Hospice plan of care or visit documentation in the EHR or unit binder, and a resident with ESRD and cognitive impairment had missing dialysis communication, pre/post treatment records, and vital signs. In a separate event, a nurse went to another resident’s home to retrieve medication, which was acknowledged as a violation of that resident’s PHI.
A resident was not asked whether they had an AD, the facility did not attempt to obtain a copy, and there was no documentation that the resident was informed of the right to formulate one. The EHR contained no record of any AD discussion, and the Administrator confirmed there were no ADs or documentation that the topic had been discussed.
The facility failed to document and track multiple resident grievances raised through Resident Council and by a cognitively intact resident. Residents reported concerns about disrespectful CNA behavior, wipes being used on a roommate, agency staff wearing earbuds while providing care, loud staff conversations outside rooms, and roommate-related sleep disruption. Interviews with the SSD, Administrator, and DON confirmed these were care concerns that should have been entered on the grievance log, but they were not.
Inaccurate MDS coding affected multiple residents. A resident with PTSD, depression, and anxiety was incorrectly marked as not having a level II PASRR despite records showing PASRR level II findings and specialized services. Another resident with severe malnutrition had weight loss coded inaccurately on the 5-day MDS even though hospital records showed a significant recent loss and no facility baseline weight had been obtained before the assessment. Additional MDS errors included overcoding urinary incontinence for one resident and documenting a BIMS exception and a completed pressure injury risk tool for another resident without supporting documentation.
Medication and oxygen orders were not consistently followed or clarified for several residents. A resident's PRN morphine was not administered as ordered, another resident receiving oxygen for asthma and chronic respiratory failure was observed on 4 LPM despite an order for 1 to 3 LPM with no documented MD notification, and the MAR did not allow staff to record the actual oxygen dose delivered. The resident's humidifier order was also incomplete. For another resident on rifaximin, multiple doses were missed when the medication was unavailable, with progress notes showing the drug was pending, out of stock, or not available, but documentation of the required notification and order changes was inconsistent.
A resident with severe cognitive impairment, malnutrition, and weakness did not consistently receive ordered 1:1 meal assistance, and bathing records showed repeated missed showers with no POA notification or care plan updates for refusals. Another resident who needed substantial to maximal bathing help reported staff never came for showers, and records showed a 13-day gap between baths with no documentation of offers or refusals.
The facility failed to follow ordered bowel care for a resident with constipation, did not actually provide a resident’s ordered LE skin/lymphedema treatment despite charting it as done, and did not routinely assess and monitor another resident’s multiple wounds with weekly measurements and wound details. An LPN/unit manager and the DON confirmed the missed care and inaccurate documentation.
Failure to provide timely foot and nail care affected three residents with limited ability to manage toenail care. One resident with DM reported no assistance since admission, and observation showed thick, overgrown, yellow-discolored toenails curling around the toes; the care plan called for diabetic foot care but gave no frequency, and there was no MAR/TAR, POC, or EHR documentation of care. Two other residents also reported no nail trimming since admission, with observations showing long, brittle, jagged, or curling toenails, no care-plan direction for nail care, and no documentation that nail care had been provided; staff later said podiatry referral was needed and that podiatry services had not been in the building for a while.
A resident with HTN, ESRD, vision loss, blood thinner use, and repeated falls had several fall investigations that did not include key clinical factors such as elevated BP, weight gain, or all fall events, and one fall was not logged at all. In addition, three residents with mobility bars or bed positioning used for fall prevention lacked required orders, consent, and assessments to show the devices were safe and not restraints; one resident was observed with the head pressed against a mobility bar.
A resident with HTN, ESRD, and moderate cognitive impairment had incomplete dialysis records, missing facility-to-dialysis communication, and outdated care plans that still reflected an old dialysis schedule and fluid restriction. CNA fluid intake documentation was absent, water pitchers were found at bedside, and staff were unclear about tracking and sharing dialysis information. The resident also had repeated elevated BP readings with PRN hydralazine given outside ordered parameters, while dialysis staff reported the resident often arrived well above dry weight and sometimes needed extra dialysis treatments.
Failure to care plan dementia-related preferences and refusals: A resident with severe cognitive impairment and Lewy body dementia had no dementia-specific care plan, no documented family input on meal preferences or routines, and no care planning for repeated shower refusals. The record also lacked documentation that the POA was notified or reapproached regarding vaccine refusals, despite staff expectations for communication, reattempts, and family involvement.
A resident had eye drops, inhalers, and topical ointments at the bedside without an order, self-administration safety evaluation, or care plan, despite being cognitively intact. In the medication room, two expired influenza vaccine prefilled shots were found in the refrigerator, and staff stated they should not have been there and were to be returned to the pharmacy.
A resident with a terminal dx was receiving hospice services, but the facility did not maintain effective communication and coordination with the hospice provider. There was no current coordinated hospice POC in the chart, no designated IDT hospice liaison was clearly functioning in that role, and the hospice binder on the unit contained no current hospice paperwork. Staff could not show what hospice disciplines were ordered, when they visited, or what care they provided, and the social services director had not yet met with hospice reps about the resident’s care.
A resident with severe dementia, high fall risk, and on anticoagulant therapy experienced an unwitnessed fall in the dining room after apparently reaching for a dropped stuffed animal. Despite obvious signs of left hip and leg pain, including grimacing and yelping during movement, the resident was transferred from the floor to a wheelchair and then to bed with a Hoyer lift rather than being immobilized. Pain assessment and documentation were inconsistent, Eliquis was not held after the fall, and an x-ray confirming a left hip fracture was not obtained until later that evening. A family member reported the resident remained in significant pain, staff did not propose earlier hospital transfer, and the ambulance crew indicated staff lacked clear details about the fall, while the DON later acknowledged poor post-fall documentation and uncertainty about immobilization.
Surveyors identified a 23.5% medication error rate during an observed medication pass by an LPN, despite facility policy requiring timely administration, explanation of medications to residents, and immediate documentation. Multiple residents with conditions such as diabetes, metastatic prostate cancer, lumbar fracture, liver disease, and depression did not receive ordered medications, received partial doses, or received medications late, while the MAR and audit reports showed the medications as given at the scheduled times. The LPN frequently could not explain why medications were signed off before administration, why some ordered medications (including metformin, aspirin, torsemide, glycolax, amoxicillin, and topical lotion) were omitted or delayed, or why a reduced dose of abiraterone acetate was not documented, and one resident reported that medications were often not passed timely or at all.
The facility failed to maintain complete and accurate medical records for three residents, including one with alcoholic cirrhosis who had physician orders for daily weights that were frequently not documented on the TAR, despite the resident reporting inconsistent monitoring of weights and VS and staff citing inconsistent assignments. Another resident with dementia and metabolic encephalopathy experienced a fall with a subsequent hip fracture; while the fall and x-ray results were noted, there was no documentation of the resident’s status prior to hospital transfer, and EMS records indicated staff could not provide clear fall details or confirm whether the resident hit their head while on anticoagulants. A third resident with a history of stroke and COPD had an unwitnessed fall documented on a fall report and SBAR as increased pain, but the fall itself was not recorded in progress notes or clearly communicated on hospital forms, and the DON acknowledged the absence of fall documentation in the record.
A resident with severe cognitive impairment, failure to thrive, severe protein-calorie malnutrition, and advanced kidney disease had a designated health care power of attorney, but the facility failed to involve this representative in care planning. The representative reported being unaware of the resident’s significant weight loss and observed the resident eating without needed assistance, prompting concerns about dietary care, pain, and poor communication. Progress notes indicated that staff told the representative a care conference would be held to discuss possible hospice and end-of-life care, but the DON later confirmed there was no follow-up and no care conference occurred, and the resident was not receiving hospice or end-of-life services.
A resident with alcoholic cirrhosis, esophageal varices, and alcohol dependence had a care plan that only generally directed staff to monitor for signs of cirrhosis and alcohol withdrawal, without specific guidance on daily weights, abdominal girth, or medication management. The resident reported that staff inconsistently obtained weights and vitals, administered medications, drew labs correctly, and applied prescribed skin creams, and felt the care plan lacked sufficient detail to guide care. A CNA stated that inconsistent staff assignments meant they did not always know when vitals or weights were needed, and the DON acknowledged the care plan should have been more personalized to the resident’s health conditions.
Two residents with indwelling urinary catheters were not properly assessed for continued catheter use or monitored according to provider orders. One resident with BPH and urinary obstruction had a catheter documented on admission and in the care plan, but there was no assessment of the need for ongoing use, no discussion of infection risk at care conference, and no documented provider decision to continue the catheter; the resident attempted to pull out the catheter, an outside provider later recommended removal due to high infection risk, and a voiding trial was only initiated at the receiving facility on the day of discharge. Another resident with urinary retention and prior UTI had a catheter care plan with no stated reason, incomplete documentation of ordered PVR scans and straight catheterization after catheter removal, and reinsertion of the catheter after failed voiding trials; later catheter removal occurred without a documented order or PVR monitoring, and the resident subsequently had difficulty voiding with high PVR before discharge, without documented urology referral or clear post-catheterization care planning.
A resident with alcoholic cirrhosis, esophageal varices, and ADHD experienced repeated omissions of ordered medications, including folic acid, eczema relief lotion, Adderall, and carvedilol, as documented on the MAR for January. The resident reported that daily medications, including liver-related supplements and Adderall, were not consistently given. During an observed med pass, an LPN failed to administer folic acid, thiamine, or eczema lotion and admitted he did not obtain missing folic acid, did not give the lotion, and had not administered Adderall on multiple prior days despite its availability. The DON confirmed that all ordered medications were expected to be administered as scheduled and that missing medications should be promptly obtained.
Surveyors found that staff did not follow required infection control practices, including entering EBP rooms and performing high-contact care with only gloves and without gowns, failing to disinfect shared equipment such as a mechanical lift, and leaving soiled linen and trash in room doorways. Multiple EBP and quarantine precaution rooms lacked necessary PPE (gowns, masks, disinfectant wipes) in door caddies, despite expectations that all staff restock them. The facility also lacked an effective respiratory protection program: there was no active process for N95 fit testing, and none of 21 newly hired staff had documentation of fit testing, with at least one NA unaware of what fit testing was and using whatever N95 was provided.
The facility failed to follow care plans and orders for meal assistance and weight monitoring for several residents. A resident with dementia, stroke, and swallowing difficulties, on aspiration precautions and ordered for 1:1 supervision with meals, was repeatedly observed eating independently in bed without staff present, while NAs cited staffing issues and gave conflicting statements about the resident’s need for assistance. Another resident, at risk for weight loss and with abdominal surgical wounds, experienced a notable weight decline over about two months without any assessment or interventions documented in the medical record, despite staff stating weight loss should be reviewed in weekly meetings. A third resident with dementia and CHF, ordered to receive tray setup, 1:1 and intermittent supervision, and bolt-upright positioning for meals, had a tray left unsetup, ate with the head of bed partially elevated and no staff present, and also had documented weight loss that was not addressed or recorded in the chart.
The facility did not submit complete results of abuse/neglect investigations to the State Agency Hotline within the required 5 working days for three residents. One resident with severe cognitive impairment and tube feeding allegedly went without food for an extended period, but the follow‑up report lacked resident interviews and no staff interviews were provided when requested. Another resident with a history of stroke reported staff were rude and unprofessional, yet the 5‑day report omitted staff interviews and none were later supplied. A third resident, who had requested only female caregivers, received care from a male staff member, and the follow‑up report lacked resident interviews, which also were not provided upon request. The DON and Administrator acknowledged that staff and resident interviews should be part of investigations reported to the State Agency.
A resident with severe cognitive impairment, sepsis, pneumonia, and a chronic NG tube was identified as being at elevated risk for pneumonia, with a care plan calling for nebulizer use and monitoring for respiratory symptoms. After the family reported respiratory concerns and the resident showed coughing and distress, a chest x-ray revealed right upper lung atelectasis versus consolidation, and albuterol nebulizers were ordered three times daily with a repeat chest x-ray. The resident received nebulizer treatments, but the ordered follow-up x-ray was not completed, and there was no progress note documentation for several days to reflect the resident’s respiratory status during this change in condition. When documentation resumed, the resident had increased congestion, required suctioning, had a fever, and was sent to the hospital, where records described progressive respiratory symptoms over two weeks and treatment limited to nebulizers, and facility leadership later acknowledged the lack of ongoing assessment and documentation.
The facility did not report an allegation of sexual abuse by a resident to law enforcement within the required two-hour window, and failed to log or notify APS or the State Agency when three residents left AMA, despite staff acknowledging these actions were necessary. These lapses involved residents with cognitive and physical impairments and were not documented or reported as required by policy.
The facility did not implement required interventions for two residents at risk of elopement, including failing to update care plans and use recommended safety devices. Additionally, two residents who left against medical advice did not receive proper discharge education, documentation, or completion of required Release of Responsibility forms, as outlined in facility policy.
A resident with cognitive impairment and a history of PTSD from prior abuse made an allegation of sexual abuse by a staff member. Despite physician orders to monitor and document the resident's psychosocial wellbeing after the allegation, staff did not perform or record the required monitoring.
The facility did not adequately assist two residents with discharge planning, resulting in incomplete arrangements for primary care and caregiver support, poor communication among staff, and missing documentation in the medical record. One resident with multiple medical conditions experienced delays and threatened to leave against medical advice, while another left the facility without a documented discharge plan. Staff interviews confirmed confusion and lack of coordination in the discharge process.
The facility did not complete a required discharge summary for a resident transferred to another LTC facility and failed to provide written bed hold notices to a resident who left on therapeutic leaves. Staff confirmed that discharge instructions were not always completed and that bed hold notices were not provided, as required.
Two residents' care plans were not updated to reflect their current needs: one resident's care plan lacked specific dietary and swallowing interventions despite physician and dietary assessments, and another resident's care plan was not revised after an allegation of sexual abuse by staff, even though the incident was documented elsewhere.
The facility did not have documentation showing that several agency and facility-employed nursing staff had received training on the use of mechanical lifts for resident transfers. Nursing assistants reported inconsistent practices and concerns about improper use of lifts, particularly by agency staff, and supervisors were unable to provide evidence of required training.
Four out of five sampled residents did not have documentation of assessment or offers for influenza and pneumococcal vaccines. In one case, a resident received a pneumococcal vaccine dose, but there was no evidence a second dose was offered. The DON confirmed the absence of vaccine history or offers in current records, and no further documentation was provided.
Three residents did not have documentation in their medical records showing assessment of vaccination history or that the COVID-19 vaccine was offered or administered. The DON confirmed the absence of this documentation, and no further records were provided.
The facility did not ensure proper monitoring, documentation, or justification for the use of psychotropic medications for several residents, including the absence of required diagnoses, lack of non-pharmacological interventions, missing stop dates for as-needed medications, and failure to act on pharmacist recommendations. Staff confirmed these deficiencies, and medication records showed inadequate documentation of behaviors and side effects.
The facility did not transmit required MDS assessment data to CMS within the mandated timeframe for multiple residents. This deficiency was identified through review of records and validation reports, and was attributed in part to a recent change in ownership and EHR systems, which led to delays in accessing and submitting the necessary assessment data.
Twelve residents did not have care plans that accurately reflected their medical needs, diagnoses, or physician orders. Omissions included missing plans for nutrition, catheter type and justification, daily or weekly weights, NPO status, mental health diagnoses, non-pharmacological interventions, advanced directives, and individualized safety measures. These deficiencies were confirmed by staff interviews and record reviews.
Facility staff did not consistently follow physician orders or document care as required, including missing or incomplete documentation for tube feeding equipment changes, nail and foot care, daily or scheduled weights for residents with heart failure, and monitoring for medication side effects. Staff also failed to properly document PICC line care and left resident information visible on unattended computer screens, contrary to facility expectations and professional standards.
Failure to Identify and Investigate Abuse and Neglect Allegations
Penalty
Summary
The facility failed to identify, report, and thoroughly investigate multiple allegations of abuse and neglect involving residents who reported verbal abuse, rough handling, delayed or missed incontinence care, long call light response times, and failure to provide bathing or hygiene care. The allegations were treated as routine grievances or care concerns rather than potential abuse or neglect, and the facility did not consistently obtain enough information to determine whether abuse or neglect had occurred. The report states this failure allowed alleged perpetrator(s) continued access to residents before the allegations were properly evaluated and constituted Immediate Jeopardy. Resident 131, who was cognitively intact, frequently incontinent of bowel and bladder, dependent on staff for toileting hygiene, and ordered continuous oxygen, reported sitting in a wet and soiled brief for hours and waiting over an hour for call light response. The resident also reported a later episode in which they felt shaky and needed oxygen, but the call light did not appear to function properly. The facility’s investigation into the reported two-hour wait did not include inspection of the call light, did not include an interview with the resident, and contained an incorrect account of who called the front desk for help. Staff later acknowledged the call light had not been inspected and that the resident should have been interviewed. Resident 78, who was cognitively intact, reported that a CNA abruptly pulled back the covers, laughed when told the resident was a check-and-change, and directed the resident to get up and clean themselves despite the resident’s limitations. A roommate corroborated the interaction. The grievance record only described the CNA as rude and disrespectful, and the facility’s investigation was left incomplete, with no interviews of the resident, roommate, or staff who may have witnessed the event and no identified alleged perpetrator. Resident 37, also cognitively intact and recently hospitalized for joint replacement surgery, reported being changed only twice a day and waiting hours for incontinence care. The investigation documented an extended delay in care but did not directly ask the resident about the reported wait, did not assess the resident’s cognition or medical history, did not interview the assigned nurse, and did not fully explore why the delay occurred. Similar grievances from other residents described long waits for call lights, missed brief changes, missed showers or hygiene care, rude or disrespectful staff interactions, and residents remaining in wet clothing or briefs for prolonged periods, but these were not consistently identified as abuse or neglect allegations or thoroughly investigated.
Failure to Assess, Document, and Treat Pressure Ulcers
Penalty
Summary
The facility failed to ensure necessary treatment and services were provided to prevent avoidable pressure ulcers and to promote healing of existing pressure ulcers for two residents. Resident 11, who was cognitively intact and assessed as at risk for pressure ulcer development with a Braden score of 17, reported pain and an open area on the right ear that had developed under oxygen tubing and had been present for about 30 days. The resident stated staff aides had been applying an unknown ointment at her request, but she did not believe nursing staff had been aware of the area, and she said weekly skin checks had not been performed. Observation showed a moist reddish-brown crust on the right ear, later noted to involve the oxygen tubing, with the resident reporting soreness when the tubing was lifted. The electronic record contained no documentation identifying the right ear pressure injury, no wound assessment, no monitoring, no physician notification, and no treatment orders until surveyors and facility leadership observed and assessed the area on 05/20/2026. At that time, staff identified a 0.5 cm by 0.5 cm by 0.1 cm unstageable pressure ulcer with light drainage and a wound bed that was 100 percent slough. Orders were then obtained for cleansing, Medi Honey, a dry dressing, pressure-relieving foam on the oxygen tubing, shift skin monitoring, and referral to wound care. A later wound care note documented the wound as a stage 3 medical device-related pressure ulcer to the back of the right ear. For Resident 14, the record showed a coccyx pressure ulcer with wound care orders that required daily treatment, monitoring for infection or worsening, and notification of the provider. The April and May 2026 TARs contained multiple blank boxes with no documentation on several scheduled treatment dates. When asked about the blanks, the unit manager stated the orders were not charted and could not tell from the TAR whether care had been provided, and the DNS said she would expect staff to document if care was provided or refused. The report also noted the resident had moderate cognitive impairment and an unstageable pressure ulcer due to slough and/or eschar.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from verbal abuse and neglect, and the investigation findings identified failures involving four residents. The facility’s abuse policy stated residents had the right to be free from abuse and neglect, and neglect was defined as failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. The cited concerns involved Resident 78, Resident 131, Resident 94, and Resident 37, all of whom were reviewed for abuse and neglect concerns related to staff actions and delays in care. Resident 94, who was cognitively intact and on the 200 hallway, reported that while waiting for staff, they accidentally wet their pants and were told staff were caring for another resident. The facility later substantiated neglect and acknowledged the delay was related to staffing. Resident 37, who was cognitively intact and recently hospitalized for joint replacement surgery, reported going 2 to 3 hours without a brief change, and the facility substantiated neglect. Resident 131, who was cognitively intact, frequently incontinent of bowel and bladder, and dependent on staff for toileting hygiene, reported that it took two hours for a CNA to answer the call light after an incontinent episode; the facility later substantiated neglect and documented that abrupt staffing changes created delays in care delivery. Resident 78, who was cognitively intact, reported that an unfamiliar CNA abruptly pulled back the covers, laughed, refused assistance, told the resident to change herself, and ordered her to go to the bathroom despite the resident stating she was a check-and-change resident and could not adequately cleanse herself or fasten the brief tabs. The roommate corroborated that the CNA spoke harshly and treated Resident 78 like she was nothing. The resident reported feeling like she did not deserve assistance, and the record showed no documentation of the incident, no assessment or monitoring for psychosocial impact, and no entry in the incident log. The grievance was initially categorized as a customer service interaction, and the facility later substantiated verbal abuse even though the CNA suspended by the facility did not match the resident’s description of the alleged perpetrator and the alleged perpetrator had not been identified at the time of survey.
PASRR Assessments Not Accurately Completed for Residents With Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure PASRR assessments were accurately completed for 3 of 6 residents reviewed for PASRR. Resident 11 was admitted on an exempted hospital discharge with a physician certification that the resident would likely require fewer than 30 days of nursing facility services. The admission MDS showed the resident was cognitively intact, had a diagnosis of depression, and received antidepressant medication during the assessment period. The Level I PASRR dated 12/31/2026 identified suspected indicators of serious mental illness, including mood disorder and anxiety disorder, but the record showed the Level I PASRR was not updated to reflect current active diagnoses and there was no documentation of referral for a Level II evaluation after the resident remained in the facility beyond the 30-day exemption period. Resident 40 was also admitted on an exempted hospital discharge with diagnoses including depression and anxiety disorder and received antidepressant medication during the assessment period. The Level I PASRR dated 12/26/2026 identified suspected indicator of serious mental illness of anxiety disorder, but the record showed it was not updated to reflect the resident’s current active diagnoses and there was no documentation of a Level II referral after the resident remained in the facility beyond the 30-day exemption period. Resident 130 was admitted with generalized anxiety disorder, but the PASRR dated 05/14/2026 did not list anxiety disorder and documented that no Level II evaluation was indicated. During interview, the Social Services Director stated PASRRs were supposed to be checked against the diagnosis list on admission and acknowledged that Resident 130’s PASRR did not indicate anxiety disorder and should have been redone.
Incomplete and outdated resident care plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for multiple sampled residents, with deficiencies involving activities of daily living, advanced directives, vision, self-medication/medications at bedside, oxygen services/respiratory care, and fluid restrictions. The report states that 8 of 24 sampled residents were affected: Residents 10, 11, 78, 24, 7, 1, 2, and 100. The cited failures were identified through observation, interview, and record review. For Residents 10 and 11, the comprehensive care plans did not direct staff to assist with nail care or identify who was responsible for providing it, and neither care plan identified the need for podiatry services. Staff H stated that nail care should be care planned for diabetic residents because nursing assistants do not perform nail care on diabetic residents, and confirmed that nail care was not addressed in either resident’s care plan. Resident 78’s impaired vision care plan directed staff to ensure glasses were clean and worn as tolerated, but the resident reported that prescription glasses had gone missing from the bedside table after a room move and that the issue had been reported to staff. Resident 24 was observed with medications on the bedside table, including eye drops, inhalers, and topical ointments, and staff acknowledged that medications at the bedside should have been care planned but were not documented in the resident’s care plan. Resident 7 had a foley catheter and an order for catheter care every shift related to urine retention, but the catheter care plan had been resolved and was not active even though staff acknowledged it should have been care planned. Resident 1 had diagnoses including acute and chronic respiratory failure with hypoxia, interstitial pulmonary disease, and COPD, and had an order for oxygen as needed via nasal cannula at 1-3 liters per minute to maintain oxygen saturation above 92%. The care plan only stated to administer oxygen as ordered and did not include the reason for oxygen, saturation parameters, flow rate, delivery device, frequency, or monitoring expectations. Resident 2 had diagnoses including hypertension and end stage renal disease, moderate cognitive impairment, opioid and pain care plans without non-pharmacological interventions, conflicting fluid restriction care plans, an outdated dialysis care plan, a communication care plan that did not mention the translator tablet, and care plans that were not updated after hospitalization to reflect loss of vision, current blood clots, or the need for a sitter at dialysis. Resident 100 had severe protein-calorie malnutrition, neurocognitive disorder with Lewy bodies, and weakness, but the care plans did not include an incontinence care plan, dementia care plan, or mobility bar care plan; the nutrition plan did not reflect significant weight loss, supplements, or mirtazapine for appetite stimulation; the rehabilitation plan was not updated; the opioid plan still listed oxycodone after it was no longer being taken; and the fall plan was not updated after a fall.
Failure to assess and care for residents with bowel and bladder incontinence
Penalty
Summary
The facility failed to ensure residents with bowel and bladder incontinence were reviewed to determine whether they were appropriate for bowel or bladder retraining, and failed to provide appropriate incontinent care for three residents. The facility policy required residents with incontinence to be reviewed on admission, readmission, annually, quarterly, or with a change in status, and for the interdisciplinary team to determine whether retraining was appropriate and what type of incontinence was present. Resident 37 had been cognitively intact and previously continent of bowel, with only occasional urinary incontinence on the quarterly MDS. After a recent hospitalization for joint replacement surgery, records showed only 1-2 urinations a day documented and new bowel incontinence. The resident reported being changed only twice a day and sometimes waiting 2-3 hours for care. Staff confirmed the resident had not been evaluated for the bowel and bladder management program on readmission, and staff also acknowledged the documentation of only 1-2 voids did not meet expectations. Resident 94 was cognitively intact and had both continent and incontinent bowel and bladder episodes documented. The resident was ordered a diuretic twice daily, but staff did not evaluate the resident for a bowel and bladder program on admission and did not monitor whether voiding needs changed after the medication. Friends, family, and the POA reported the commode was full of stool, the resident had waited about 3 hours before wetting themselves, and the resident smelled strongly of urine with concerns about skin from sitting in urine. Staff confirmed the resident had not been evaluated as required. Resident 100 had severe cognitive impairment and was always incontinent of bowel and bladder. The resident did not have an incontinent care plan with interventions when reviewed, and urine and bowel records showed charting only 2-3 times a day rather than every 2 hours. During observation, the resident had a strong urine odor and was unaware of being wet. Staff later confirmed the resident should have been checked every 2 hours and changed when soiled, but the charting reflected end-of-shift documentation rather than each episode of care. Skin assessments were inconsistent, with documentation of a stage 2 pressure ulcer, then no skin concerns, then excoriation related to moisture, and staff observed redness and a small open area on the buttocks. Staff also confirmed there was no documentation that the resident had been evaluated for bowel and bladder retraining on admission.
Inaccurate nutrition monitoring and missed meal assistance
Penalty
Summary
The facility failed to ensure residents maintained acceptable nutritional status by not consistently following ordered weights, not accurately identifying or documenting weight loss, not accurately documenting meal monitors and supplement intake, and not consistently providing required meal assistance. The report cites deficiencies related to F641, F690, F656, and F610, and describes surveyor observations, interviews, and record review for Residents 100 and 94. Resident 100 was admitted with severe protein-calorie malnutrition, Lewy body dementia, and weakness. The record showed the resident had weighed 170 lbs in the hospital and 159 lbs 6.3 oz at hospital discharge, but the facility did not obtain an admission weight until after the MDS assessment had already been completed. The resident’s care plan called for 1:1 meal assistance, meal intake documentation, weights as ordered, and dietary preference review, and the dietary manager documented that staff should provide 1:1 oral intake assistance per family request. Speech therapy later observed the resident having difficulty with cups, utensils, and oral clearance, and recommended 1:1 assist, upright positioning, and increased oral care. Surveyors repeatedly observed Resident 100 eating without the ordered assistance or with incomplete assistance, including meals where the resident was slouched, spilled drinks on themselves, had trays untouched or only partially eaten, and had difficulty drinking or self-feeding without staff present. Meal monitor documentation and supplement records did not match observations: some meals were charted as 51-75% or 76-100% when the resident was observed eating little or none, and mighty shake intake was documented as fully consumed when staff observed the supplement still partially full. The resident’s weight loss was also not consistently tracked or recognized in a timely way, with missed or delayed weights and staff unable to locate or accurately report the most recent weight during interview. The resident’s POA and son reported that the resident was supposed to receive 1:1 assistance but rarely did, and they expressed concern that the resident was not being adequately helped to eat. Resident 94 had diagnoses including diabetes mellitus, heart failure, and malnutrition, and had an order for daily weights before breakfast. The record showed missed weights and no documented adjustment to the meal plan, communication with dietary, alert charting, IDT review, or updated care plan related to weight loss. During observation, Resident 94 was asleep when lunch was delivered, stated they would probably try to eat a few bites, then fell back asleep without eating; later the same tray remained untouched. Despite this, the meal monitor documented that the resident ate 51-75% of the meal, and a CNA confirmed the charting was incorrect and said CNAs are supposed to report to the nurse if residents have not eaten.
Failure to Provide Ordered Respiratory Care and Oxygen Documentation
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for residents receiving oxygen therapy. For Resident 11, who had diagnoses including asthma and chronic respiratory failure and required oxygen therapy, surveyors observed the resident receiving oxygen at 4 LPM via nasal cannula while the refillable humidifier bottle attached to the concentrator was empty. The bottle remained empty across multiple observations, and the resident reported the lack of humidification caused dry, scabbed nares, difficulty breathing, and nosebleeds. The resident also stated staff repeatedly did not know how to fill the humidifier bottle and that the bottle had been empty for an extended period. Record review for Resident 11 showed physician orders for oxygen within a specified range and weekly documentation that oxygen tubing, humidification bottle, and filter had been changed or filled and dated. However, the medication administration record did not provide a location for staff to document the actual oxygen flow rate administered, and staff acknowledged the resident had been receiving oxygen at 4 LPM, which exceeded the ordered range. Staff also acknowledged there was no documentation showing physician notification when oxygen exceeded the ordered limit, and the humidifier order did not specify what solution was to be used. For Resident 131, who had COPD, obstructive sleep apnea, chronic respiratory failure with hypoxia, and severe obesity with alveolar hypoventilation, surveyors observed the resident without oxygen in place after CPAP was removed. The resident reported feeling shaky and needing oxygen, and an oximeter showed an SpO2 of 80% before oxygen was reapplied. Staff later stated the CPAP had been removed without ensuring oxygen was placed back on the resident, and staff acknowledged they did not know at the time that oxygen needed to be reapplied after CPAP removal. For Resident 1, who had acute and chronic respiratory failure with hypoxia, interstitial pulmonary disease, and COPD, surveyors observed oxygen tubing and a humidifier attached to the concentrator without dates on either item, despite an order to change and date the tubing weekly and date the humidifier when placed.
Insufficient Nursing Staffing and Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff every day to meet resident needs and to have a licensed nurse in charge on each shift. Surveyors reviewed staffing data and found the facility was triggered for a one-star staffing rating and excessively low weekend staffing. Interviews with residents showed repeated delays in response to call lights and care requests, with residents reporting waits ranging from 30 minutes to several hours, including instances where staff turned off call lights and said they would return but did not come back. Residents also reported missed or delayed care tasks tied to staffing shortages. One resident said the nighttime was especially bad and that staff knew how long call lights were left on because the front office could see it. Another resident reported being left in bed for long periods and said weekend call lights were harder to get answered. A resident stated scheduled showers were not provided because staff did not show up, and another said they were changed only twice a day because two staff members were required and they had to wait hours. Staff interviews supported the resident reports. A CNA said the facility was not fully staffed one to two days a week, which made it difficult to complete morning showers because aides also had to serve meals, assist residents with meals, attend appointments and care conferences, help residents get dressed for visits, and manage admissions and discharges. Another CNA said they often skipped breaks and lunches and sometimes stayed late to finish showers. The Interim DON stated staffing challenges remained after the building was sold and senior staff transferred, leaving many positions open, and that union negotiations had recently been completed with wage increases intended to improve recruiting and retention.
Failure to Document and Use Non-Pharmacological Pain Interventions Before PRN Analgesics
Penalty
Summary
The facility failed to ensure that residents received non-pharmacological interventions (NPI) for pain management before receiving as-needed pain medications for six sampled residents. The report cites the facility’s pain management policy, which states that non-pharmacological interventions may be used alone or with medications and includes examples such as repositioning, massage, cold or heat application, ambulation or movement, and relaxation or calming activities. The deficiency was identified through record review and staff interviews and involved residents who were receiving scheduled and PRN pain medications, but whose records did not consistently show NPI use or documentation before PRN analgesics were administered. For one resident, the record showed multiple PRN pain medication orders, including oxycodone, aspirin-acetaminophen-caffeine, and diclofenac gel, along with an order for NPI documentation, but the April and May 2026 MARs did not show where NPIs were documented when PRN pain medications were given. A LPN/unit manager stated the order for NPIs had not been scheduled and was just fixed so staff could document it, while the interim DON said staff would be expected to reposition, provide hot or cold packs, and use imagery before giving a narcotic and that NPIs should be scheduled and offered before pain medications. For another resident, PRN acetaminophen was administered for a pain score of 3 without any NPI documentation, and the nurse stated there was no order to document NPIs and that NPIs were only given depending on whether pain was severe. Additional residents had similar issues with pain medication administration and missing NPI documentation. One resident had PRN acetaminophen and oxycodone-acetaminophen given without pain parameters or NPI documentation, and staff could not find documentation of NPIs. Another resident’s MAR showed PRN acetaminophen, oxycodone, and tramadol orders with multiple administrations outside ordered pain parameters and no NPI documentation. A resident with a scheduled lidocaine patch and PRN acetaminophen had no listed patch location or pain scale attached to the PRN order. Another resident received PRN oxycodone on several occasions, and review of the MAR showed no non-pharmacological interventions were identified or attempted before those administrations. Staff interviews confirmed the lack of documented NPIs and, in some cases, the absence of ordered pain parameters.
Medication Error With PRN Hydralazine for Elevated BP
Penalty
Summary
The facility failed to ensure that Resident 2 was free from significant medication errors related to an as needed hydralazine order for elevated systolic blood pressure. Resident 2 was admitted with hypertension and end stage renal disease requiring dialysis, and the Medicare 5 Day MDS assessment dated 03/24/2026 showed moderate cognitive impairment. The April 2026 MAR showed an as needed hydralazine order in place from 04/04/2026 through 04/25/2026 for systolic blood pressure over 160, with the medication available every 8 hours, and the record showed it was administered only 3 times. Review of Resident 2's blood pressure record from 04/04/2026 through 04/25/2026 showed the systolic blood pressure was regularly over 160. On 04/11/2026, the resident had multiple elevated readings, including 170/86, 202/98, and 164/82, and no as needed hydralazine was given per the administration record. The Interim Administrator stated on 05/29/2026 that a medication error investigation was being conducted for the timeframe when the parameter was only systolic blood pressure, and later provided confirmation that the as needed hydralazine order was not followed 19 times during the identified period.
Cross Contamination During Meal Plating
Penalty
Summary
The facility failed to prevent cross contamination during meal preparation services in the kitchen. During observation of lunch tray line plating, Staff D, a Dietary Aide, repeatedly handled food items with gloved hands and continued plating without changing gloves after touching different foods and equipment. Staff D was observed touching garlic bread, green beans, grilled cheese sandwiches, spaghetti noodles, meatballs, a hamburger patty, bread rolls, and toasted bread while continuing to plate multiple meals. Staff D also handled environmental items during the plating process, including a spatula and a food thermometer, and did not change gloves after touching those items. At one point, Staff D grabbed the whey powder protein container and mixed it with gravy in a cup, then continued plating without changing gloves. Later, Staff D obtained food holding temperatures of foods on the steam table with the thermometer and again did not change gloves after touching the thermometer. The tray line plating continued from late morning until 1:40 PM, with repeated instances of touching food and equipment while wearing the same gloves. When interviewed, the Dietary Manager stated staff should not touch food when serving and should use gloves and utensils. The Dietary Manager also stated staff should have changed gloves after touching environmental surfaces such as containers, the spatula, and the thermometer.
Failure to Investigate and Report Abuse/Neglect Allegations
Penalty
Summary
Administration failed to provide oversight and monitoring of facility personnel, systems, and practices related to abuse and neglect, and failed to ensure compliance with identifying, reporting, protecting, and thoroughly investigating allegations of abuse and neglect. The facility policy required staff to identify, correct, and intervene in situations where abuse, neglect, or misappropriation of resident property was more likely to occur, and to immediately report any allegation or observation of abuse to supervisory leadership. The administrator job summary also included responsibility for ensuring resident concerns and complaints were responded to with tact and urgency and for reporting allegations of resident abuse, neglect, and misappropriation of resident property. A review of annual and complaint surveys over the prior 22 months showed repeated citations for failure to report and thoroughly investigate allegations of abuse and neglect. Grievances filed by multiple residents between 04/05/2026 and 05/19/2026 were reviewed with the administrator, who confirmed each grievance was an allegation of abuse or neglect, or that the facility had not obtained enough information to rule out abuse or neglect. The administrator later stated the facility had "dropped the ball" and had only then begun reviewing those grievances as potential abuse and neglect allegations. The interim administrator later stated call lights were an issue, long wait times were evident in call light records, and many grievances involved long call light times that could be neglect allegations. The interim administrator also stated staff did not understand the gravity of what residents reported and that this had become culturally accepted; when asked whether prior administrative actions or inactions contributed to the failure to identify alleged abuse or neglect, the interim administrator said yes.
Incomplete Hospice and Dialysis Records; Unprotected Resident PHI
Penalty
Summary
The facility failed to ensure resident medical records were complete, accurate, and readily accessible, and failed to protect resident-identifiable information for three residents reviewed. For Resident 17, who had a terminal diagnosis and was receiving Hospice services during the assessment period, the electronic health record contained no Hospice documentation for the current certification period. There was no documentation of re-certification with a terminal illness, no current coordinated plan of care, no record of what Hospice services were to be provided or at what frequency, and no documentation showing whether Hospice disciplines had visited, when they visited, or what care was provided. A Hospice communication binder was present on the unit, but it contained no Hospice paperwork for the resident, and the unit manager stated the binder had fallen out of regular use and that the facility had no copy of the current Hospice plan or visit documentation. For Resident 2, who had hypertension, end stage renal disease, and moderate cognitive impairment, the dialysis record was incomplete. The resident’s dialysis schedule changed, but the chart lacked a complete record of dialysis treatments, pre/post dialysis evaluations, and communication forms between the facility and dialysis center for multiple dates. Several forms did not include vital signs, one form had no information from the dialysis center, and staff could not determine from the EHR whether the resident had gone to dialysis during part of the period reviewed. Staff also stated the facility lacked documentation showing assessment after dialysis, medications given during dialysis, or increased fluid removal needs. In a separate incident, Resident 142’s personal health information was not protected when a nurse was sent to Resident 127’s home after discharge to retrieve Resident 142’s medication, and the interim DON acknowledged this was a violation of Resident 142’s PHI.
Failure to Ask Resident About Advance Directive
Penalty
Summary
The facility failed to ask Resident 11 whether they had an advance directive or to attempt to obtain a copy, and failed to notify the resident of the right to formulate one. Resident 11 was admitted to the facility on [DATE], and review of the electronic health record showed no documentation that the resident was asked about an advance directive or informed of the right to create one. On 05/18/2026 at 3:44 PM, the surveyor requested documentation from the Administrator showing that Resident 11 had been asked about an advance directive and/or informed of the right to formulate one. On 05/18/2026 at 4:27 PM, the Administrator responded by email that there were no advance directives or documentation that the topic had been discussed.
Failure to Log Resident Grievances
Penalty
Summary
The facility failed to initiate grievances for resident concerns raised during the April 2026 Resident Council meeting for Resident 139, Resident 47, and Resident 25. The meeting minutes documented Resident 139’s concerns that CNAs were disrespectful, did not listen, argued with residents about their care, and did things their own way instead of meeting resident needs. Resident 47 reported that CNAs were taking packages of wipes and using them on the roommate, creating an infection control concern. Resident 25 reported that agency staff were wearing earbuds while on the floor providing care and that the morning shift was loud and talked outside residents’ doors. During interviews, the SSD, SS, and Administrator each reviewed these concerns and stated they were care concerns that should have been documented on the grievance log, but they were not. Resident 80, who was cognitively intact on the 04/17/2026 MDS, also reported concerns about a previous roommate. Resident 80 stated they had filled out a grievance and that the Administrator and top nurse came and talked to them. However, review of the grievance log did not show Resident 80’s roommate concerns, and the Administrator stated they were not seeing a grievance for those concerns, though the room transfer had occurred. Resident 80 later stated they had filled out a grievance and gave it to staff who said they would give it to the Administrator. A nursing progress note dated 04/24/2026 documented Resident 80’s statement that the roommate had been loud at night, kept them awake talking about family members in the past, and that they wanted a room change. The Interim DON later stated she did not see a grievance for Resident 80’s roommate concerns and would expect a grievance to be done if the issue could not be handled immediately and tracked. The deficiency was cited under WAC 388-97-0460.
Inaccurate MDS Assessments for PASRR, Weight Loss, Incontinence, and Cognitive/Pressure Injury Items
Penalty
Summary
The facility failed to accurately assess Resident 4’s PASRR status on the annual MDS. Resident 4 had diagnoses of PTSD, depression, and anxiety disorder. The annual MDS documented that the resident was not currently considered by the state level II PASRR process to have a serious mental illness or intellectual disability, and nothing was checked for serious mental illness, even though the resident’s PASRR Level I identified mood disorders and anxiety disorders as serious mental illness indicators. The resident’s EHR also contained a Level II PASRR evaluation summary with recommendations for the nursing facility, and the care plan stated the resident was determined to need specialized services related to a PASRR level II evaluation. The facility also failed to accurately assess Resident 100’s weight loss on the Medicare 5-day MDS. Resident 100 was admitted with severe protein-calorie malnutrition, neurocognitive disorder with Lewy bodies, and weakness. The MDS showed the resident as severely cognitively impaired and did not assess significant weight loss over the prior 30 days or 6 months. However, the resident did not have a weight taken at the facility until after the MDS was completed. Hospital records showed the resident weighed 170 pounds on hospital admission and 159 pounds, 6.3 ounces shortly before the MDS, reflecting a 6.18% weight loss in less than 2 weeks. The facility further failed to accurately code Resident 94’s urinary incontinence and Resident 17’s cognitive pattern and pressure injury risk assessment items. Resident 94’s 5-day MDS coded the resident as frequently incontinent of urine, but the documented urinary episodes showed only two episodes of urinary incontinence and continence at other times during the assessment period. Resident 17’s quarterly MDS indicated that a BIMS should not be conducted because the resident was rarely or never understood, yet the mood interview and preferences interviews were completed. The MDS also coded that a formal pressure injury prediction tool was completed, but the EHR contained no documentation that such a tool, such as a Braden or Norton scale, had been completed during the assessment period.
Medication and Oxygen Orders Not Followed or Clarified
Penalty
Summary
The facility failed to ensure services met professional standards of practice for 4 of 24 sampled residents by not obtaining, following, or clarifying physician orders when indicated, by signing for tasks that were not fully documented as completed, and by not notifying the physician or pharmacy of missed doses when medications were unavailable. The report identified deficiencies involving Residents 17, 10, 11, and 119, with the cited findings focused on medication administration and order management issues. Resident 17 had orders for morphine sulfate 0.25 mL by mouth every 4 hours as needed for pain level 1-4 or air hunger, and morphine sulfate 0.50 mL by mouth every 4 hours as needed for pain level 5-10 or air hunger. Review of the April 2026 MAR showed that on the listed occasions, the resident's morphine dose was not administered in accordance with the physician orders. Resident 11 had diagnoses including asthma and chronic respiratory failure and required oxygen therapy. The resident had an order for oxygen at 1 to 3 LPM continuously via nasal cannula, titrated to maintain oxygen saturation between 90% and 95%, with notification of the physician if oxygen exceeded 3 LPM. The resident was observed receiving oxygen at 4 LPM on three occasions, but there was no documentation that the physician was notified. The MAR allowed staff to initial that oxygen at 1 to 3 LPM was given, but it did not provide a place to record the actual LPM delivered. The resident also had an order to change oxygen tubing, the humidification bottle if used, clean the concentrator filter weekly, and label supplies, but the order did not identify what fluid should be used to refill the humidifier bottle; the humidifier bottle was observed empty and dated. Staff acknowledged the order was incomplete and that the order should have been clarified.
Failure to Provide Ordered Feeding Assistance and Scheduled Bathing
Penalty
Summary
The facility failed to ensure dependent residents received assistance with activities of daily living related to nutrition and hygiene. Resident 100 was admitted with severe protein-calorie malnutrition, neurocognitive disorder with Lewy bodies, and weakness, and the MDS showed the resident was severely cognitively impaired and dependent on staff for care. The resident’s diet order required a soft and bite sized regular diet with 1:1 assist for oral intake, but observations showed the resident without 1:1 meal assistance on multiple occasions. The resident’s POA stated the resident was supposed to have 1:1 eating assistance and rarely received it, and also reported finding food under the resident’s fingernails. Staff stated they expected residents needing 1:1 assist to receive it every meal and to remain with the resident until the meal was consumed. Resident 100’s bathing record showed only two showers in a 30-day period despite eight scheduled opportunities, with four refusals and two not applicable entries, and there was no documentation that the POA was notified of the refusals. The care plan was not updated to address the refusals or the resident’s dementia-related needs. Resident 30, who was cognitively intact and required substantial to maximal assistance with bathing, stated the resident was supposed to be showered twice weekly and at least once weekly was necessary, but staff never came. The care plan did not address the resident’s preferred bathing frequency, and the bathing record showed the resident was scheduled twice weekly but went 13 days between showers, with no documentation that bathing was offered or refused during that interval.
Missed bowel protocol, unperformed skin treatment, and incomplete wound monitoring
Penalty
Summary
The facility failed to ensure bowel care was provided according to physician orders for a resident with significant constipation concerns. Resident 78, who was cognitively intact, reported having a lot of trouble with constipation. The resident had standing as-needed bowel protocol orders beginning with Miralax if no bowel movement occurred after 72 hours, followed by additional steps if ineffective. The bowel record showed periods of four days without a bowel movement on two separate occasions, and the March 2026 MAR showed nurses did not administer the ordered Miralax after three days without a bowel movement as required by the order. The unit manager confirmed that bowel care was not provided in accordance with the physician orders and bowel protocol. The facility also failed to provide and document ordered treatment for a resident with congenital lymphedema and dry, flaky lower-extremity skin. Resident 10 had a daily treatment order for ammonium lactate lotion to both lower extremities, kerlix wrapping, and ace wrap application every evening shift. The resident’s husband reported that staff had not been applying lotion or performing the daily wraps, and the resident was observed with tan tubular gauze on both lower extremities without underlayment. When the gauze was pulled down, the skin was very dry and flaking bilaterally. Although the May 2026 TAR showed the evening shift nurse signed that the treatment had been completed on multiple dates, the DON and administrator observed that the ordered treatment was not actually provided, and the DON confirmed the nurse signed for care that was not performed. The facility further failed to assess and monitor multiple non-pressure skin conditions for a resident with several wounds. Resident 17 had a lesion to the right upper chest, a deep tissue injury to the left buttock, and an open area to the right outer ankle, with wound orders and weekly skin observation interventions documented. The record showed no further documentation that these wounds were routinely assessed weekly with measurements, wound bed description, drainage amount and character, or response to treatment after identification. A later weekly skin observation still noted the wounds were present, and the unit manager acknowledged that weekly wound assessments, including measurements for each wound, should have been completed but were not.
Failure to Provide Timely Foot and Nail Care
Penalty
Summary
The facility failed to provide necessary foot care and treatment, including nail care and podiatry services, for three residents reviewed for activities of daily living. The deficiency was identified through observation, interview, and record review, and involved residents with limited ability to manage their own toenail care. The report states that the failure to provide timely toenail care placed the residents at risk for negative health outcomes. One resident was cognitively intact, had diabetes, and was independent with most activities of daily living. The resident reported that no one had assisted with trimming toenails since admission and that the nails needed to be cut. Observation showed multiple toenails on both feet were long, thick, untrimmed, yellow-discolored, and curling around the toes. The resident’s diabetes care plan directed licensed staff to provide diabetic foot care and checks as indicated, but the care plan did not identify a frequency for the care, and the April and May MAR/TARs, Point of Care charting, and EHR contained no documentation that foot or nail care had been provided. A second resident was cognitively intact with range-of-motion limitations in both upper and lower extremities and required partial/moderate assistance with lower body dressing. The resident reported that toenails had not been trimmed since admission. The care plan contained no direction for nail care or assignment of responsibility, and there was no MAR/TAR or Point of Care documentation showing nail care had been provided. Observation by the LPN/Unit Manager showed multiple toenails were long, untrimmed, brittle, and jagged, and the resident stated the nails sometimes got caught on the bedding. A third resident was moderately cognitively impaired, had range-of-motion limitations to both lower extremities, and was dependent for lower body dressing. The resident’s husband reported that no one had trimmed the toenails since admission, and observation showed multiple toenails on both feet were long, untrimmed, yellow-discolored, and beginning to curl around the toes. The care plan lacked direction for nail care, and the MAR/TARs, Point of Care charting, and EHR contained no documentation that nail care had been provided. Staff later confirmed the toenails were long, thick, and untrimmed and stated the resident needed a podiatry referral; staff also indicated the facility had recently signed a podiatry contract and that it had been a while since podiatry services had been in the building.
Incomplete fall investigations and missing bed rail documentation
Penalty
Summary
The facility failed to ensure that falls were investigated thoroughly for a resident who had repeated falls and hospital-related documentation. Resident 2 was admitted with hypertension and end stage renal disease and had moderate cognitive impairment. The resident also had chronic loss of vision, was on a blood thinner, and had an as-needed hydralazine order for elevated systolic blood pressure. The resident experienced falls on multiple dates in April 2026, including a fall on 04/10/2026 that was not logged or investigated in the facility’s accident and incident log. The fall investigations that were completed for Resident 2 did not include the resident’s clinical picture. The investigation for the 04/11/2026 fall did not address elevated blood pressures or the resident’s weight gain, including a 20.1-pound increase between weights taken after dialysis and the next recorded weight. The investigation for the 04/12/2026 fall also did not include the resident’s elevated blood pressures or weight gain, and it incorrectly identified the event as the second fall in a row rather than the third. The investigations for the 04/19/2026 and 04/29/2026 falls likewise did not include the resident’s ongoing elevated blood pressures. The resident later reported at dialysis that they had fallen the prior week, but this was not logged or investigated in the May 2026 accident and incident log. The pharmacy review related to the falls was not completed until 05/15/2026. The facility also failed to ensure that residents with mobility bars or bed positioning used for fall prevention had the required documentation and assessment to determine safety and whether the device was being used as a restraint. Resident 100, who had severe cognitive impairment, was observed lying on their side with their head pressed against the mobility bar, yet there was no order, no care plan entry, and no assessment showing the mobility bar was safe or not a restraint. Resident 37, who was cognitively intact, had bilateral mobility bars but the record lacked an order, consent, and assessment. Resident 50 had the bed against the wall for fall prevention, but the record lacked an order, consent, and assessment, and there was no documentation that risks and benefits had been reviewed. Staff interviews confirmed these documentation elements were missing for all three residents.
Incomplete dialysis coordination, outdated care plans, and unmanaged BP trends
Penalty
Summary
The facility failed to coordinate and manage dialysis care for a resident with HTN and ESRD who had moderate cognitive impairment. The resident was admitted on a dialysis schedule of Tuesday, Thursday, and Saturday, but the schedule later changed to Monday, Wednesday, and Friday. The record contained an incomplete dialysis treatment history, with a pre/post dialysis form completed on 04/30/2026 and not another until 05/20/2026. The paper communication forms between the facility and the dialysis center were also missing after 04/30/2026 until the resident’s 05/27/2026 appointment, and several forms lacked vital signs or dialysis center information. The resident’s care plans were not kept current with the resident’s treatment needs. The fluid restriction order required 1500 ml in 24 hours, with specific amounts assigned to kitchen and nursing, but the fluid restriction care plan still reflected 1800 ml/day and the dialysis care plan also continued to show the older fluid restriction and the prior dialysis schedule. The dialysis care plan did not include a goal dry weight or note that the resident required a sitter for dialysis. CNA task documentation did not show any fluid intake, and during observation the resident had two water pitchers at bedside, including one that had spilled on the floor. The resident also had abnormal blood pressure trends that were not consistently addressed. The April MAR showed PRN hydralazine for elevated SBP, later revised to include DBP parameters, but several doses were administered outside the ordered parameters and one administration lacked a charted BP at the time. Staff interviews showed uncertainty about dialysis documentation, fluid tracking from the kitchen, and communication with the provider regarding blood pressure trends. A later coordination summary documented that the resident frequently arrived at dialysis 5-11 kg above dry weight, often required maximum fluid removal, and had needed additional dialysis treatments because of ongoing fluid overload concerns.
Failure to Care Plan Dementia-Related Preferences and Refusals
Penalty
Summary
The facility failed to ensure a resident with dementia received appropriate care and services. Resident 100 was admitted with severe protein-calorie malnutrition, neurocognitive disorder with Lewy bodies, and weakness. The Medicare 5-day MDS assessment showed the resident was severely cognitively impaired and dependent on staff for care. Review of the resident’s care plans showed there was no dementia care plan and no other care plans addressing resident preferences with family involvement, including meal preferences, the time, duration, and severity of expressions or refusals, or non-pharmacological approaches to care when refusals occurred. The dietary profile showed the resident was interviewed about likes and dislikes, but family was not involved, and no other dietary profile documenting family input was found. The resident’s electronic health record showed multiple refusals related to showering and bathing, including four recorded refusals over the last 30 days reviewed. The resident also refused pneumococcal and COVID vaccinations, but there was no documentation that the Power of Attorney was notified or that reattempts were made. During interview, the Unit Manager could not locate a dementia-specific care plan and stated the resident’s daytime/nighttime routine had not been care planned. The Interim DON stated staff expectations for residents with dementia included communication the resident could understand, reapproaching refusals, using different staff or approaches, involving family in routines, and documenting interventions and preferences, but these elements were not found in Resident 100’s care planning or records.
Improper bedside medication storage and expired vaccines in medication room
Penalty
Summary
Drugs and biologicals were not properly managed for one resident who was observed with medications on the bedside table, including eye drops, inhalers, and topical ointments. The resident was documented as cognitively intact on the Quarterly MDS dated 02/13/2026. The facility policy on self-administration of medications and treatments stated residents may self-administer only if the interdisciplinary team determined it was clinically appropriate and safe. During interviews, an LPN/unit manager stated there was no order in the chart, no self-administration safety evaluation, and no care plan for self-administration for the resident, and the medications were to be removed until there was a doctor’s order. The DON also stated there should have been an assessment for resident safety, an order allowing independent administration, and care planning for bedside medications. Expired influenza vaccine prefilled shots were found in the medication room refrigerator. Two single-dose influenza vaccine shots were observed expired on 05/13/2026, and the LPN/unit manager stated they should not have been in the refrigerator and should be placed in the return box to the pharmacy. The same staff member said the infectious disease nurse usually monitored this, but that person was out on leave. The DON was asked about the expectation for expired vaccines and said they would find the policy and later stated they would send the vaccines back to the pharmacy.
Hospice coordination and documentation were not maintained for a resident receiving hospice services
Penalty
Summary
The facility failed to maintain effective communication, collaboration, and coordination of care with the hospice provider for Resident 17, who had a terminal diagnosis and was receiving hospice services during the assessment period. The facility did not designate a member of the interdisciplinary team as the hospice liaison, and there was no current coordinated hospice plan of care in the resident’s electronic health record. The only hospice document located was an Episode Summary Report for a prior certification period, which listed hospice visits from chaplain, master social work, and RN disciplines, but no current certification-period hospice documentation was present. Review of the resident’s record and the hospice communication binder showed no documentation of the current hospice plan of care, no record of what hospice services were to be provided or at what frequency, and no documentation of whether hospice disciplines had visited, when they visited, or what care they provided. Staff B acknowledged the absence of current hospice documentation and stated there could be a hospice communication binder on the unit. The binder was found, but it contained no hospice paperwork for Resident 17. Staff H stated the binder had previously been updated regularly but had recently fallen off, and Staff I stated she had recently been informed she was responsible for coordinating hospice care for all hospice residents and had not yet met with hospice representatives regarding Resident 17’s care and services.
Failure to Adequately Assess and Manage High-Risk Resident After Unwitnessed Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a known high fall-risk resident was adequately assessed and provided with appropriate supervision and resident-specific fall prevention interventions following a fall. The resident had severe cognitive impairment, dementia, metabolic encephalopathy, was dependent for ADLs, and was on Eliquis, an anticoagulant. The care plan identified the resident as at risk for falls related to advanced dementia, with interventions including non-skid socks, bed in lowest position, and staff reminders to use the call light. A fall risk assessment documented the resident as high risk due to a history of falls, incontinence, and anticoagulant use. On the date of the incident, nursing progress notes documented that the resident had an unwitnessed fall to the floor in the dining room, apparently after dropping a stuffed animal and reaching to retrieve it. It was unclear whether the resident hit their head, and staff were aware the resident was on Eliquis. After the fall, the resident reported or demonstrated pain in the left hip and thigh, with redness noted to the left hip in one note, and later documentation that no bruising or redness was seen. The resident, who had severe dementia and difficulty verbalizing pain, showed obvious pain through facial grimacing and yelping when attempts were made to place a Hoyer sling and when being rolled onto the left side. Despite these signs, the resident was transferred from the floor to a wheelchair and then to bed using a Hoyer lift, rather than being immobilized in place. Progress notes and the MAR showed that Eliquis 5 mg was administered later that day and was not held after the fall. Pain documentation was inconsistent, with pain levels recorded as 0/10 throughout much of the day, no pain score documented when Tylenol 650 mg was given, and later administration of oxycodone 5 mg for pain rated 7/10. A stat x-ray was ordered, but the radiology report confirming a left hip fracture was not completed until that evening. The resident’s family member reported that the resident was in pain for an extended period, that staff did not suggest sending the resident to the hospital sooner, and that the ambulance crew stated staff did not know details about the fall. The DON later acknowledged there was a lack of documentation on the resident’s status after the fall and stated the resident should have gone to the hospital if there was concern about a head injury or increased pain, and could not confirm whether the resident’s injury had been immobilized.
High Medication Error Rate and Inaccurate MAR Documentation During LPN Medication Pass
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying an error rate of 23.5% (8 errors out of 34 observed medication administration opportunities). Facility policy dated 01/2023 required that medications be explained to residents, administered within 60 minutes of the scheduled time, and documented immediately after administration. During an observed medication pass on 01/21/2026 by Staff G, an LPN, multiple discrepancies were noted between medications actually administered and those documented on the Medication Administration Record (MAR) and Medication Admin Audit Reports. For Resident 15, who had spina bifida and diabetes mellitus and required supervision with ADLs, the scheduled metformin for diabetes was not administered during the observed pass, although the MAR and audit report showed metformin, Jardiance, and duloxetine as signed off as given earlier that morning. Staff G later acknowledged realizing the metformin had been missed and could not explain why it had been signed off as given. For Resident 16, who had influenza and diabetes and was dependent for ADLs, the medication abiraterone acetate, ordered as four tablets for metastatic prostate cancer, was administered as only two tablets because no additional packets were available. The shortage was not explained to the resident, and the MAR and audit report documented the dose as fully given without notation of the partial dose. For Resident 14, with lumbar fracture and diabetes and independent in ADLs, the observed pass included several medications but omitted aspirin and torsemide, both due at 6 AM. The audit report showed multiple medications, including aspirin, signed off as given earlier, and torsemide signed off later, while Staff G stated he did not give the torsemide and did not know what happened with the aspirin, acknowledging the medications were late. Resident 1, with alcoholic cirrhosis, esophageal varices, and ADHD, reported that medications were not passed timely or at all, and during observation did not receive ordered eczema lotion or amoxicillin; documentation showed amoxicillin signed off as given earlier and the lotion documented later, with Staff G unable to locate the cream and unsure about the antibiotic. For Resident 17, with lumbar fracture and diabetes and requiring substantial assistance with ADLs, several cardiac and psychiatric medications were administered, but aspirin and glycolax were not observed to be given, despite the audit report and MAR indicating they had been administered at the scheduled time. Staff G could not explain these discrepancies and stated that medications due at 6 AM were always going to be late because of his start time.
Incomplete and Inconsistent Medical Record Documentation for Weights, Vitals, and Falls
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete, accurate, readily accessible, and systematically organized medical records for multiple residents. For one resident with alcoholic cirrhosis, esophageal varices, and alcohol dependence, the quarterly MDS documented no cognitive impairment and partial to moderate dependence for ADLs, and an order summary showed daily weights were to be taken. However, the TAR for December showed daily weights missing on 5 of 31 days, and the TAR for January showed daily weights missing six times. The resident reported that staff did not understand the importance of monitoring weights and vital signs, that they personally tracked vitals, and that weights and vitals were missing when they went to outside appointments, stating that staff performed these tasks inconsistently or not at all. A nursing assistant stated staff had inconsistent assignments and did not always know which residents needed vitals or weights, and the DON stated staff should be aware of when to take weights and vitals. For a second resident with dementia and metabolic encephalopathy, the admission MDS documented severe cognitive impairment and total dependence for ADLs, and the care plan identified fall risk with interventions such as non-skid socks, low bed position, and reminders to use the call light. The resident experienced a fall, was found on the floor with left lower extremity pain, and an x-ray later confirmed a left hip fracture. Progress notes documented the fall, pain, and x-ray results, but the record did not include documentation of the resident’s status before transport to the hospital. EMS notes indicated facility staff could not articulate details of the fall, only stating it occurred around midday, and that they were unable to obtain a mobile x-ray until the evening and did not have a copy of the x-ray. EMS documentation also noted uncertainty about whether the resident hit their head while on an anticoagulant, and described significant swelling and pain in the left leg and the resident’s verbal distress. A staff member later acknowledged they could not determine the resident’s status while waiting for hospital transfer from the record and that documentation was missing, and the DON confirmed a lack of documentation on the resident’s status after the fall and could not speak to whether the injury was immobilized due to missing documentation. For a third resident with a history of stroke and COPD, the MDS documented no cognitive impairment and partial to moderate dependence for ADLs, and the care plan identified fall risk with interventions similar to the other resident at risk for falls. A fall report documented that this resident was found lying on the right lateral side of the bed, with no injuries noted, stable vital signs, complaints of head and left shoulder pain, and subsequent transport to the hospital. However, progress notes did not reflect the fall event. An SBAR communication form to the hospital documented the onset of increased chronic pain to the scalp and right shoulder but did not document that a fall had occurred. The DON stated that staff did not document the fall in the medical record or on the hospital communication forms. These omissions across multiple residents demonstrate incomplete and disorganized documentation of ordered monitoring, fall events, and resident status in the medical record.
Failure to Involve Resident Representative in Care Planning and Hospice Discussion
Penalty
Summary
The facility failed to ensure that a resident and/or their representative were offered the opportunity to participate in the development and implementation of a person-centered plan of care. Resident 5, admitted with failure to thrive, severe protein-calorie malnutrition, and advanced kidney disease, had a quarterly MDS dated 10/30/2025 documenting severe cognitive impairment and dependence on staff for eating. A Durable Power of Attorney for Health Care designated a family member (CC5) as the decision maker if the resident could no longer make decisions. CC5 reported being shocked by the resident’s significant weight loss, which had not been communicated to him, and observed the resident eating without assistance, leading to concerns that the resident was not receiving needed care. CC5 raised concerns with the provider about the resident’s dietary status, pain, and communication with staff, and was told a care conference would be scheduled to further discuss these issues. Progress notes dated 11/19/2025 documented that a call was made to CC5 and that a care conference would be held the following week to determine if hospice was appropriate. However, during an interview on 03/02/2026, the DON (Staff B) stated there was no follow-up with CC5 after the 11/19/2025 note and confirmed that no care conference took place. Staff B also stated that the resident was not receiving end-of-life or hospice services and that end-of-life or hospice care needed to be discussed to address the potential for further weight loss and pain. This lack of follow-through on the planned care conference and failure to involve the designated representative in care planning constituted the deficiency under WAC 388-97-0300(3)(a).
Non-individualized Care Plan for Resident With Liver Disease and Alcohol Dependence
Penalty
Summary
Surveyors identified a failure to develop a comprehensive, person-centered care plan for one resident with alcoholic cirrhosis, esophageal varices, and alcohol dependence. The resident’s quarterly MDS showed no cognitive impairment and partial to moderate dependence for ADLs. The existing care plan, initiated on 10/24/2025, addressed cirrhosis only generally by directing staff to monitor for yellowing of the eyes/skin, abdominal ascites, and changes in mental status, and to obtain labs and diagnostics as ordered. A subsequent care plan entry dated 12/13/2025 instructed staff to monitor for alcohol withdrawal and check vitals as needed. The care plan did not include more specific interventions such as monitoring daily weights, monitoring abdominal girth, or addressing medications used to manage the resident’s liver disease and alcohol dependence. During interview, the resident reported that staff did not always understand the tasks needed to manage liver disease and alcohol dependence and stated, "I don't think they understand liver disease." The resident described inconsistent performance of key tasks, including obtaining weights and vitals, passing medications on time or at all, drawing laboratory samples correctly, and applying prescribed skin creams, all of which the resident identified as part of managing her condition. The resident felt the care plan lacked the detail staff needed to care for her health conditions. A nursing assistant reported that staff had inconsistent assignments and therefore did not always know if the resident needed vitals or weights and that staff did not always know residents well. The DON acknowledged that the resident’s care plan should be more personalized to address the resident’s health conditions.
Failure to Assess and Manage Indwelling Urinary Catheters and Voiding Trials
Penalty
Summary
The deficiency involves the facility’s failure to monitor and justify the continued use and removal of indwelling urinary catheters for two residents, and to follow ordered protocols for voiding trials and post-void residual (PVR) monitoring. For one resident with a history of left hip fracture, diabetes mellitus, benign prostatic hyperplasia, and urinary obstruction, the admission MDS and care plan documented the presence of an indwelling catheter and general catheter care tasks, but there was no assessment addressing possible removal of the catheter. Hospital transition orders recommended temporary catheter management per nursing protocol for urinary retention, yet the facility did not document evaluation of the ongoing need for the catheter. During a multidisciplinary care conference with the family, staff reviewed the resident’s care needs but did not address the indwelling catheter or infection risk related to its continued use. Subsequent nursing notes for this resident documented that blood was noted in the catheter because the resident was trying to pull it out, and an outside orthopedic provider later expressed concern that the catheter had remained in place since hospitalization, recommending removal when medically acceptable due to high infection risk and noting the resident had not received the care specifically needed. The facility’s alleged neglect investigation, initiated after the family reported concerns that staff refused to remove the catheter, concluded there was no abuse or neglect but did not address the continued use of the catheter. Staff interviews revealed that LPNs waited for direction from the nurse manager for catheter removal, that the supervising LPN was unsure whether the provider had been contacted about removal for this resident, and that if a provider chose to keep a catheter in place this decision would not be documented. The supervising LPN agreed there was no justification for continued catheter use and acknowledged that a voiding trial was only started on the day of discharge at another facility, and the DON confirmed there was no documentation of assessment for appropriateness of continued catheter use. For a second resident admitted with a lower leg fracture and urinary retention, the care plan documented an indwelling catheter but left the reason for the catheter blank, and the admission assessment noted no factors related to urinary incontinence and no justification for continued catheter use. Provider notes indicated the resident had a UTI and urinary retention in the hospital, had failed a voiding trial, and was started on medication for urinary retention. Later provider notes ordered removal of the catheter and initiation of bedside commode use, with specific orders to scan the bladder every shift for 72 hours, perform straight catheterization if bladder volume exceeded a set threshold, and replace the indwelling catheter after a third failed attempt. The record showed the catheter was removed and that the resident subsequently failed a voiding trial and required reinsertion of an indwelling catheter, but there was no documentation of PVRs during the initial ordered monitoring period. When the catheter was later removed again, there was no corresponding provider order in the record and no PVR monitoring to ensure the resident could tolerate removal. Staff interviews confirmed that PVRs were not done when ordered, that no urology consultation was obtained despite ongoing urinary retention, and that PVR monitoring before discharge was inconsistent. Discharge documentation noted the resident would need catheter replacement upon discharge and later documented difficulty voiding and high PVR with straight catheterization, without mention of post-catheterization care, further PVRs, or urology follow-up.
Repeated Medication Omissions and Inconsistent Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered as ordered, resulting in repeated omissions of multiple prescribed drugs for one resident. The resident had diagnoses including alcoholic cirrhosis, esophageal varices, and ADHD, and was assessed as having no cognitive impairment with partial to moderate dependence for activities of daily living. The resident reported that staff did not pass all daily medications, including liver-related supplements, and that Adderall was not administered consistently, which the resident stated affected decision-making and increased stress. A January Medication Review Report listed folic acid, Sarna eczema relief lotion, Adderall, and carvedilol among the resident’s prescribed medications. The January MAR documented numerous missed doses: folic acid was missed 15 of 21 times, the eczema relief lotion 9 of 41 times, Adderall 8 of 21 times, and carvedilol 11 of 41 times. During an observed medication pass, an LPN did not administer folic acid, thiamine, or the eczema relief lotion to the resident. The LPN later stated he could not find the folic acid and did not retrieve more, acknowledged that thiamine was given but not at the scheduled time, and confirmed the lotion was not given. He also stated the resident had 16 tablets of Adderall available and verified that Adderall had not been administered the previous day or on many prior days, without being able to explain why it was not given. These observations and record reviews showed that ordered medications were not consistently administered as prescribed.
Failure to Implement PPE, EBP, and Respiratory Protection Requirements
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to improper use of personal protective equipment (PPE) and implementation of enhanced barrier precautions (EBP). In one EBP room, a nursing assistant entered to assist a resident with a mechanical lift transfer, donned only gloves, and then exited the room carrying used gloves in the hallway while seeking assistance, before returning to dispose of them and don new gloves. The PPE caddy on that room’s door lacked gowns and disinfectant wipes, and the registered nurse who entered to assist with the transfer also wore only gloves, stating she typically wore gowns only for wound care. Facility policy and state guidance required gowns and gloves for high-contact resident care activities in EBP rooms and disinfection or dedicated use of equipment, but the mechanical lift used for the transfer was not wiped down after use. Additional observations on two halls showed multiple EBP and quarantine precaution rooms without required PPE stocked in the door caddies and improper handling of soiled linens and trash. Several rooms designated for EBP had no gowns available in the PPE caddies, and rooms on quarantine precautions had no gowns or masks available. Surveyors also observed bagged and unbagged dirty linen and a bag containing a soiled brief placed on the floor in resident doorways. The DON, infection preventionist, and other staff acknowledged that PPE caddies were expected to be stocked and that dirty linen and trash should not be left in doorways, and stated that all staff were responsible for restocking PPE. The facility also failed to implement a complete respiratory protection program as required by state guidance and its own policy. The Washington State Department of Health guidance and the facility’s Respiratory Protection Program policy required medical evaluation, respirator training, and initial and annual fit testing for N95 respirators before use. The infection preventionist and DON reported there was no current process in place for fit testing staff, that it had likely stopped when the facility changed ownership, and that newly hired staff had not been fit tested. A newly hired nursing assistant reported working about a month, was unfamiliar with fit testing, and stated they used whatever N95s were provided before entering rooms requiring an N95. Review of records for 21 staff hired in the past 90 days showed no documentation that any had been fit tested, and the administrator confirmed they did not have a good plan in place to protect residents from staff who may not have been fit tested for an appropriate N95.
Failure to Provide Required Meal Assistance and Address Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to provide required assistance and supervision with meals and to promptly identify and address weight loss for multiple residents. One resident with dementia, a history of stroke, swallowing difficulties, and documented aspiration precautions was care planned and ordered to receive 1:1 assistance and supervision with meals, including cues to eat and encouragement to go to the dining room. Despite this, meal observation on two separate dates showed the resident eating independently in bed without staff present or assisting, and staff interviews revealed inconsistent understanding of the resident’s need for 1:1 supervision. Nursing assistants reported that staffing levels made it difficult to supervise residents who required it and, at times, the resident was left to eat independently, contrary to the care plan, dietary ticket, and physician orders. Another resident, admitted with a colostomy and hypothyroidism and care planned as at risk for weight loss due to advanced age, experienced a significant decline in weight over approximately two months, from about 167 pounds to about 155 pounds. The nutritional assessment had set a goal of no weight loss through the review period and noted surgical abdominal wounds, but the medical record contained no documentation addressing this weight loss. Staff interviews confirmed that weight loss was supposed to be addressed at a weekly weight loss meeting and that findings were entered into a computer system rather than the medical record, resulting in no documented assessment or interventions in response to this resident’s weight loss. A third resident with dementia and congestive heart failure, care planned and ordered to receive assistance with tray setup, 1:1 and intermittent supervision, and to be positioned bolt upright for meals, was observed with a meal tray left on the bedside table without setup and with the head of bed at about 45 degrees. The resident initially made no attempt to eat and later had to pull their body toward the tray to reach the food due to the bed position, with no staff present during the observation period. The dietary ticket and order details documented the need for 1:1 assistance and upright positioning, but a nursing assistant stated the resident did not require assistance with meals. Weight records showed this resident had notable weight loss over several months, and staff acknowledged that the weight loss should have been addressed at weekly meetings and documented in the medical record, but no such documentation or response was present.
Failure to Submit Complete Abuse/Neglect Investigation Results to State Agency
Penalty
Summary
The facility failed to ensure that results of abuse and neglect investigations were fully developed and reported to the State Agency Hotline within 5 working days for three residents. For a resident with sepsis, pneumonia, severe cognitive impairment, and dependence in ADLs, an investigation dated 09/23/2025 addressed an allegation that staff did not change the resident's tube feeding and the resident was without food for an extended period. The 5‑day follow‑up investigation submitted to the State Agency lacked interviews of sample residents, and when surveyors requested staff interviews on 12/11/2025 and 12/18/2025, none were provided. For a resident with a stroke, left‑side weakness, no cognitive impairment, and dependence in ADLs, an investigation dated 10/02/2025 documented that the resident reported staff were rude and unprofessional. The 5‑day follow‑up investigation submitted to the State Agency was missing staff interviews, and requested interviews on 12/11/2025 and 12/18/2025 were not provided. For another resident with a urinary tract infection, morbid obesity, no cognitive impairment, and dependence in ADLs, an investigation dated 11/04/2025 documented that the resident received care from a male staff member after requesting only female caregivers. The 5‑day follow‑up investigation submitted to the State Agency lacked interviews of sample residents, and requested resident interviews on 12/11/2025 and 12/18/2025 were not provided. The DON and the Administrator both stated that staff and resident interviews should be included in facility investigations.
Failure to Monitor and Follow Up on Resident Respiratory Change in Condition
Penalty
Summary
The facility failed to assess, monitor, and intervene appropriately when a resident experienced a change in respiratory status. The resident, who had severe cognitive impairment, sepsis, pneumonia, and a chronic nasogastric tube, was care planned as being at elevated risk for pneumonia, with interventions including administering nebulizers as ordered and observing for signs and symptoms of pneumonia. On one date, progress notes documented that the resident’s family inquired about the need for nebulizer treatments, and the resident was observed to be uncomfortable, coughing, and making a distressing facial expression, prompting an order for a chest x-ray. The x-ray showed right upper lung atelectasis versus consolidation related to pneumonia. Subsequent progress notes documented that the resident was to receive albuterol nebulizer treatments three times a day for four days with a repeat chest x-ray, and that the family reported the resident was short of breath, although staff did not find concerns upon assessment. The family later requested a nebulizer treatment, and the medication record showed the resident received albuterol nebulizers three times a day over several days. Despite the order to repeat the chest x-ray after the nebulizer course, no follow-up x-ray was completed, and there was no progress note documentation for a several-day period to show the resident’s status following the identified change in condition. When documentation resumed, notes indicated the resident had increased congestion, required airway suctioning, had a fever of 101.4 degrees, and was transferred to the hospital, where records described progressive respiratory symptoms over two weeks, shortness of breath, altered breath sounds over the prior week, and fevers occurring the previous night and a few days earlier. The family reported that the resident had respiratory symptoms for two weeks and had no treatment besides nebulizers. The DON later acknowledged that there was no documentation from the gap period to show the resident’s status and that staff should have been documenting the resident’s condition given the change, and the Administrator confirmed there was no follow-up chest x-ray in the medical record.
Failure to Timely Report Abuse Allegations and AMA Discharges
Penalty
Summary
The facility failed to ensure that allegations of abuse were reported to law enforcement within the required two-hour timeframe. Specifically, a resident with moderate cognitive impairment and significant dependence on staff for activities of daily living made an allegation of sexual abuse by a staff member. The incident was not reported to law enforcement within two hours as required by facility policy, and staff could not provide a reason for the delay, despite acknowledging the requirement. Additionally, the facility did not properly log or report residents who left against medical advice (AMA) to Adult Protective Services (APS) or the State Agency. Three residents with varying medical conditions, including congestive heart failure, cirrhosis, hip fracture, anxiety disorder, and chronic obstructive pulmonary disease, left the facility AMA. In these cases, there was no documentation of the incidents in the facility's log, nor evidence that APS was contacted, even when residents' whereabouts were unknown or their safety was potentially at risk. Staff interviews confirmed that these discharges should have been reported to APS, but this was not done.
Failure to Prevent Elopement and Ensure Safe AMA Discharges
Penalty
Summary
The facility failed to implement appropriate interventions to prevent elopement and did not act effectively when elopement occurred for two residents identified as at risk. One resident, with a history of leaving healthcare facilities against medical advice (AMA) and documented risk factors for elopement, expressed a desire to leave upon admission. Despite recommendations to implement care plan interventions and consider a wander bracelet, these measures were not put in place, and the care plan did not address the resident's elopement risk. The resident subsequently eloped from the facility. Another resident, admitted for a hip fracture and anxiety disorder, was not assessed for elopement risk and was found missing after signing out to retrieve a wheelchair. The resident did not return as expected, and staff were initially unaware of their whereabouts, with staff later acknowledging that elopement protocol should have been followed. The facility also failed to ensure safe discharges for residents leaving AMA. For one resident with congestive heart failure and cirrhosis, documentation showed the resident left AMA without receiving their stored medications or having them sent to a pharmacy. The medical record did not reflect efforts to encourage the resident to stay, nor was there a completed Release of Responsibility form as required by facility policy. Another resident, dependent on oxygen and diagnosed with chronic obstructive pulmonary disease, requested to leave AMA, but the medical record lacked the required Release of Responsibility form and did not document actions taken to ensure a safe discharge. Facility policy requires that residents leaving AMA be educated on the risks, that the attending physician be notified, and that all efforts to ensure a safe discharge be documented, including completion of a Release of Responsibility form. In the cases reviewed, these steps were not consistently followed, and documentation was incomplete or missing, failing to demonstrate that the facility made reasonable efforts to ensure the safety of residents leaving AMA.
Failure to Monitor Psychosocial Wellbeing After Abuse Allegation
Penalty
Summary
The facility failed to monitor and document the psychosocial wellbeing of a resident following an allegation of sexual abuse by a staff member. The resident, who had a history of post-traumatic stress syndrome due to previous physical and emotional abuse, was admitted with moderate cognitive impairment and was dependent on staff for many activities of daily living. Physician orders required staff to monitor the resident for psychosocial wellbeing, including observing and charting progress notes for behavior, refusal of care, social isolation, and pain management, and to notify the provider of any concerns, with monitoring to occur every shift for five days. However, a review of progress notes showed no documentation of such monitoring related to the abuse allegation, and staff confirmed that this monitoring was not performed.
Failure to Ensure Safe and Timely Discharge Planning
Penalty
Summary
The facility failed to adequately assist residents with discharge planning, resulting in unmet discharge needs for two residents. For one resident admitted with blood clots in the lungs and chronic obstructive pulmonary disease, the care plan indicated a short-term stay and required coordination with the physician and community referrals. However, the resident’s power of attorney (POA) repeatedly requested assistance in setting up a primary care provider (PCP) and home caregivers, but was told by staff that this was not the facility’s responsibility. Documentation showed ongoing communication issues, incomplete discharge planning assessments, and a lack of coordination among staff, leading to delays and the resident threatening to leave against medical advice due to feeling unprepared for discharge. For another resident with congestive heart failure and cirrhosis, the care plan documented a long-term stay, but there was no evidence of a discharge evaluation, care conference notes, or progress notes regarding discharge goals. The social service evaluation was incomplete, with key sections left blank, including the resident’s wishes for discharge and anticipated length of stay. Although social services staff reported working on community housing for the resident, this was not documented in the medical record or reflected in the care plan. The resident ultimately left the facility against medical advice, and staff acknowledged the absence of a documented discharge plan or reassessment. Interviews with staff, including the Director of Nursing and social services, confirmed confusion and lack of communication regarding discharge planning for both residents. Staff admitted that necessary services, such as arranging a PCP and caregiver support, were not set up, and that discharge planning was not properly documented or coordinated. These failures resulted in delayed or unsafe discharges and were not aligned with the residents’ needs or preferences.
Failure to Complete Discharge Summaries and Provide Bed Hold Notices
Penalty
Summary
The facility failed to complete a discharge summary for one resident who was reviewed for discharge planning. Specifically, the medical record for this resident, who had diagnoses including dementia and dysphasia and was admitted for a short-term stay, did not contain a completed discharge summary or discharge instructions. Although the resident's medications and belongings were reviewed and sent with the resident upon transfer to another LTC facility, the required discharge summary was not prepared or sent. Staff confirmed that they did not always complete the discharge summary or instructions as required. Additionally, the facility did not provide written bed hold notices to a resident who left on therapeutic leaves of absence. The medical record for this resident, who had diagnoses of congestive heart failure and cirrhosis and was independent with activities of daily living, showed multiple instances of leaves of absence without documentation that a bed hold was offered. Staff in social services stated they were not aware of the requirement to provide bed hold notices for therapeutic leaves and did not provide them to residents.
Failure to Update and Revise Care Plans for Resident Needs
Penalty
Summary
The facility failed to ensure that care plans were reviewed, revised, and accurately reflected the care needs of two residents. For one resident with dementia and dysphagia, the care plan did not include specific dietary needs as indicated by physician orders and a nutritional assessment, such as the requirement for moderately thick liquids, thin water between meals, small bites of food, and specific swallowing techniques. Despite these needs being documented in other records, the care plan was not updated to reflect them. For another resident with Parkinsonism syndrome and chronic pain, the care plan documented a history of post-traumatic stress syndrome due to past abuse but was not revised to include a new allegation of sexual abuse by a staff member. The incident was documented in an incident report, but the care plan was not updated to address this significant event. These omissions were confirmed by facility staff during interviews.
Lack of Documented Mechanical Lift Training for Nursing Staff
Penalty
Summary
The facility failed to ensure that both agency and facility-employed nursing staff demonstrated competency in the use of mechanical lifts for resident transfers. Specifically, five staff members, including both agency and facility staff, did not have documentation of mechanical lift training in their personnel files. Interviews with nursing assistants revealed inconsistent practices regarding the number of staff required for mechanical and standing lift transfers, with some staff expressing concerns about agency staff using improper techniques, such as attempting transfers with only one staff member. These concerns were reported to supervisors, but no documentation of required training was found for the identified staff. During interviews, staff members described varying practices and acknowledged intervening when improper transfer methods were observed. The Administrator and DON were unable to provide evidence of mechanical lift training for the staff in question, despite further attempts to locate such documentation. No additional documentation was provided to demonstrate that the staff had received the necessary training to safely operate mechanical lifts, as required by facility policy and state regulations.
Failure to Assess and Document Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that four out of five sampled residents received appropriate assessment and documentation regarding influenza and pneumococcal vaccinations. For three residents, there was no documentation in their medical records indicating that their vaccination history was assessed or that they were offered the influenza or pneumococcal vaccines. One resident had documentation of receiving a dose of the pneumococcal vaccine, but there was no evidence that a second dose was offered as required. The Director of Nursing confirmed that there was no documentation of vaccine history or vaccine offers in the current medical records, and no additional documentation was provided from previous record systems.
Failure to Document and Offer COVID-19 Vaccination
Penalty
Summary
The facility failed to ensure that the COVID-19 vaccine was provided or offered to three out of five residents reviewed for immunizations. For these residents, there was no documentation in their medical records indicating that their vaccination history had been assessed or that the COVID-19 vaccine was offered or administered. The Director of Nursing confirmed that there was no documentation of vaccine history or vaccine offers in the current medical records, and was unable to provide further documentation from previous record systems. This lack of documentation and action resulted in the deficiency identified during the survey.
Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure proper management and monitoring of psychotropic medications for multiple residents, resulting in deficiencies related to unnecessary medication use, lack of documentation, and failure to implement non-pharmacological interventions. For one resident with bipolar and depressive disorders, antipsychotic and antianxiety medications were administered without clear documentation of target behaviors, clinical rationale for medication duration beyond 14 days, or evidence that non-pharmacological interventions were attempted prior to medication administration. The care plan did not address all relevant diagnoses or specify the symptoms being treated, and staff interviews confirmed these omissions. Another resident was prescribed multiple psychotropic medications, including antianxiety, antipsychotic, and antidepressant drugs, without corresponding diagnoses documented in the medical record or care plan. The Director of Nursing Services acknowledged the lack of appropriate diagnoses and justification for these medications. Additionally, for several residents, as-needed psychotropic medications were ordered without required stop dates or re-evaluation, and pharmacist recommendations regarding medication duration and documentation were not acted upon in a timely manner. For residents on hospice or palliative care, as-needed psychotropic medications were ordered for periods exceeding regulatory limits without documented clinical justification or end dates. Medication administration records showed instances where medications were given without documentation of target behaviors or attempted non-pharmacological interventions. Staff interviews confirmed that monitoring for side effects and behaviors was not consistently ordered or documented, and that medication orders often lacked appropriate diagnoses or rationale.
Failure to Timely Transmit MDS Assessment Data
Penalty
Summary
The facility failed to transmit required Minimum Data Set (MDS) assessment data to the Center for Medicare and Medicaid Services (CMS) within 14 days of completion for eight out of nine residents reviewed. According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, MDS assessments, including Admission, Significant Change, Quarterly, and Annual assessments, must be completed no later than 14 days after the Assessment Reference Date (ARD) and submitted to the CMS database within 14 days of completion. Review of the electronic health records (EHR) for the identified residents showed no MDS data was present for assessments with ARDs in March 2025, and there was no indication that these MDSs had been scheduled, completed, or transmitted as required. The deficiency was further substantiated by the facility's March 2025 MDS Final Validation Report (FVR) from CMS, which showed that for each of the eight residents, the most recent MDS assessments were submitted more than 14 days after their completion dates. The administrator explained that a recent change in facility ownership and EHR systems resulted in an inability to access the data for MDS assessments completed in March 2025, which contributed to the delay in submission. The lack of timely MDS transmission was identified through both record review and staff interview.
Failure to Develop and Implement Comprehensive, Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that accurately reflected the care needs of twelve residents. For several residents, care plans did not address critical medical conditions or physician orders, such as malnutrition, use of ace/compression wraps, specific catheter types and justifications, daily or weekly weights with notification parameters, and NPO status. In multiple cases, the care plans omitted essential details about the residents' diagnoses, treatments, and monitoring requirements, despite these being documented in the residents' medical records and confirmed by staff interviews. Residents with complex medical histories, including severe cognitive impairment, heart failure, kidney disease, malnutrition, and those on hospice or palliative care, were affected by these omissions. For example, one resident with severe cognitive impairment and malnutrition did not have a nutrition care plan, and another with a suprapubic catheter did not have the catheter type or justification documented in the care plan. Additionally, care plans failed to address specific interventions such as daily weights for residents on diuretics, non-weight bearing status affecting bathing routines, and individualized smoking safety plans. Further deficiencies included the lack of person-centered care planning for mental health diagnoses, such as anxiety and PTSD, and the absence of non-pharmacological interventions for psychotropic medication use. Care plans for residents on hospice did not specify advanced directives, goals of care, or the hospice provider. Other omissions included not updating continence care plans to reflect current status, not care planning for bed placement against the wall, and not specifying respiratory care details such as oxygen saturation targets and delivery methods. These failures were confirmed through staff interviews and record reviews, indicating a systemic issue in care plan development and implementation.
Failure to Follow Physician Orders, Document Care, and Protect Resident Information
Penalty
Summary
Facility staff failed to ensure that services provided met professional standards for multiple residents, as evidenced by incomplete or missing documentation, failure to follow physician orders, and improper record-keeping. For example, one resident who was cognitively impaired and received tube feeding had a physician order for daily syringe changes, which was not properly documented or initialed, despite staff signing off as completed. Another resident, also cognitively impaired and dependent on staff, had orders for weekly fingernail trimming and daily foot checks, but observations and record reviews showed these tasks were not performed as documented, with staff signing off on tasks that were not completed. Additional deficiencies included failure to record and monitor daily or scheduled weights for residents with heart failure and diuretic therapy, as ordered by physicians. In several cases, weights were not recorded for extended periods, and significant weight variances that required physician notification were not documented or communicated. Staff interviews confirmed that these tasks were not optional and should have been completed, but issues with order entry into the electronic health record (EHR) or task administration records (TAR/NTAR) may have prevented nurses from seeing the required tasks. Other deficiencies included blank documentation on medication administration records (MARs) for required monitoring of side effects and behaviors related to psychotropic medications, lack of documentation and proper timing for PICC line dressing changes and measurements, and failure to protect resident information by leaving computer screens with resident data visible and unattended. Staff interviews consistently confirmed that these actions did not meet facility expectations or professional standards.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 544 citations issued within 25 miles in the last 12 months — including the 1 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 Olympia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Olympia Transitional Care And Rehabilitation | 0.1 mi | ★★★★★ | 19 | 0 |
| Panorama City Conv & Rehab Ctr | 1.4 mi | ★★★★★ | 6 | 0 |
| Regency Olympia Rehabilitation And Nursing Center | 2.4 mi | ★★★★★ | 15 | 0 |
| Crystal Cove Post Acute | 2.7 mi | — | 43 | 0 |
| Lacey Post Acute & Rehabilitation | 3.5 mi | ★★★★★ | 11 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Woodard Creek Health & Rehabilitation.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.