Citations in Washington
Statistics, citations and compliance trends for long-term care facilities in Washington.
Statistics for Washington (Last 12 Months)
Financial Impact (Last 12 Months)
Latest citations in Washington
Medication administration records and narcotic tracking logs did not match for 3 residents receiving opioid pain meds. A resident with chronic pain had multiple hydrocodone removals that were not documented on the MAR, and some MAR entries showed doses given before the narcotic log showed the med was removed. Two other residents also had discrepancies between opioid removal logs and MAR documentation, and staff acknowledged the mismatches.
A resident with impaired judgment had medication cups left unattended on an overbed table in the room, with tablets exposed and not fully contained. The resident had not been evaluated for self-administration, and the DON stated meds should not be left on residents’ tables or in their rooms if not given immediately.
Failure to Protect Residents from Resident-to-Resident Abuse: A resident with vascular dementia, severe cognitive impairment, poor impulse control, and a history of aggression was involved in three physical altercations with three other residents within a 24-hour period. The resident knocked snacks from one resident’s hands and hit and kicked them, kicked another resident near the nurses’ station, and struck a third resident in the leg/ankle while agitated. One resident said the aggressor scared them and another said they did not feel safe around the aggressor; staff later stated the incidents constituted abuse.
A resident with dementia and MS was admitted for respite care and was dependent on staff for eating and drinking. The care plan directed staff to encourage fluids, but intake records showed repeated low fluid intake over several days, and there was no documentation that the MD or resident representative was notified. The DON acknowledged the resident’s poor intake and progressive decline, and that no change of condition was sent per usual procedure.
A resident with obesity, a T-11 to T-12 SCI, multiple rib fractures, and a dislocated elbow was discharged to another SNF, but the facility did not provide recent information about a non-injury fall and an abuse-related sexual behavior allegation. Staff acknowledged no verbal report was given before discharge, and the receiving facility reported the resident arrived without authorization, report, or orders.
Failure to Provide Bed Hold and Transfer/Discharge Notices: The facility did not document providing bed hold notices for four residents who were transferred or discharged to the hospital, including one resident who was unresponsive at transfer. The facility also did not document a written transfer/discharge notice for one resident. Staff interviews and record review confirmed the notices were not found in the EHR, despite facility policy requiring written notice of bed-hold rights and appeal rights when a resident is transferred or discharged.
Medication Administration and Narcotic Documentation Discrepancies
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured accurate dispensing and administration of medications for 3 of 3 sampled residents reviewed for medication administration. The facility policy on medication administration required staff to follow the 10 rights of medication administration, including verifying the medication against the provider order and MAR and promptly documenting administration in the resident’s medical record. For Resident 1, who had chronic pain and was receiving hydrocodone as needed, the narcotic tracking log showed multiple removals of hydrocodone from the resident’s supply, but the June 2026 MAR did not document administration for several of those removals. The MAR also showed hydrocodone administrations occurring before the medication was documented as removed from the resident’s supply on several occasions. For Resident 2, the narcotic tracking log showed hydrocodone was removed from the resident’s supply on multiple dates, but the MAR did not document administration for several of those removals. For Resident 3, the narcotic tracking log showed oxycodone was removed from the resident’s supply on multiple dates, but the MAR did not document administration for several of those removals. Staff B acknowledged there were numerous discrepancies between the narcotic tracking logs and the MAR documentation, and Staff A stated staff were expected to administer medications per provider orders and ensure accurate documentation in the resident’s medical record.
Unsecured Medications Left in Resident Room
Penalty
Summary
The facility failed to ensure medications were secured when two clear plastic medication cups containing tablets were observed left unattended on Resident 1’s overbed table in the resident’s room, with the cups on their sides and the contents not fully contained in the bottom cup. Resident 1 was admitted with multiple diagnoses, and the Minimum Data Assessment dated 06/02/2026 documented impaired judgment and the need for staff assistance with activities of daily living. The resident’s record also showed they had not been evaluated to determine whether they were a candidate for self-administration of medications. When the medications were later observed with the DON, the DON stated medications should not be left on residents’ tables or in their rooms and should be removed if not given immediately.
Failure to Protect Residents from Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure freedom from abuse during resident-to-resident altercations involving one resident with vascular dementia and severe cognitive impairment who was able to communicate needs and independently propel a wheelchair. The resident had a care plan noting potential verbal or physical aggression, poor impulse control, and a history of altercations with other residents, with interventions including redirection, activities, and calm intervention before agitation escalated. A discharge plan had also been developed for transition to a higher level of care due to increasing cognitive and behavioral needs. Within a 24-hour period, the resident was involved in three separate physical altercations with three different residents. In one incident, the resident cornered another resident in a room with a vending machine, knocked snacks from that resident’s hands, kicked the resident, and then struck the resident on the left chest with pointed straight fingers. In another incident, the resident became agitated near the nurses’ station, kicked a wheelchair-bound resident’s leg out of the way, and used profanities. In the third incident, while agitated over staff attempting to collect a urine sample and while verbally abusive toward staff, the resident wheeled down the hall, approached another resident seated in a wheelchair, and hit that resident in the right leg/ankle. The other residents involved had varying levels of impairment and mobility. One resident was alert, oriented, and able to walk with a walker; another had severe cognitive impairment, used a wheelchair, and depended on staff for mobility and daily care; and the third had memory problems and could recognize room location and staff names and faces. During interview, one victimized resident stated the aggressor scared them and that staff warned them when the aggressor was nearby so they could avoid them. Another resident indicated they did not feel safe around the aggressor. Staff later stated the physical altercations constituted abuse.
Failure to Notify Provider of Poor Fluid Intake
Penalty
Summary
The facility failed to assess, implement interventions, and notify the medical provider of inadequate fluid intake for one resident who was admitted for respite care and later discharged. The resident had diagnoses including dementia and multiple sclerosis, and the discharge MDS showed severe cognitive impairment with dependence on staff for eating and drinking. The resident’s care plan identified the resident as a total assist with eating and directed staff to encourage fluid intake and assist to keep skin hydrated. The resident’s fluid intake record showed very low daily intake on multiple days during the stay, including 240 cc, 600 cc, 170 cc, 402 cc, 111 cc, and 60 cc. Review of the electronic medical record found no documentation that the medical provider or resident representative was notified about the low fluid intake. The DON reviewed the record and acknowledged the resident had poor fluid intake, that the resident showed progressive decline during the stay, and that no change of condition was sent to the medical provider per the facility’s usual procedure.
Failure to Communicate Recent Fall and Abuse Allegation at Discharge
Penalty
Summary
The facility failed to ensure discharge planning included providing recent information related to an abuse allegation and a recent fall for one resident who was being discharged to another skilled nursing facility. The resident was admitted with diagnoses including obesity, a T-11 to T-12 spinal cord injury, multiple fractured ribs, and dislocation of the right ulnohumeral joint. The admission MDS documented the resident was cognitively intact, had no behaviors, was dependent on staff for bathing and transfers, and was frequently incontinent of bladder and bowel. A social services note documented that the accepting facility had been contacted and discharge was planned. However, progress notes documented the resident had a non-injury fall in the activity room and later exhibited inappropriate sexual behavior toward female residents, including exposing his genitalia and making unwanted sexual propositions, after which he was placed on 1:1 observation. Staff later acknowledged the accepting facility was not contacted to provide a verbal report before discharge, and the accepting facility reported the resident arrived without authorization, without a report, and without orders. Staff also acknowledged they were unsure whether the accepting facility had been notified of the fall or the sexual abuse allegation prior to discharge.
Failure to Provide Bed Hold and Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide bed hold notices for 4 of 4 residents reviewed for discharge process. Facility policy stated that residents and/or their representatives are to receive written information about bed-hold policies in advance of transfer and again at the time of transfer, or within 24 hours if the transfer is an emergency. For Residents 1, 2, 3, and 4, record review showed each was transferred or discharged to a short-term general hospital, but there was no documentation in the EHR that a bed hold notice was provided to the resident and/or their representative. Resident 1 was unresponsive when transferred to the hospital, and the discharge MDS documented discharge to a short-term general hospital. Resident 2 was transferred to the hospital, and Resident 3 was sent to the ER for evaluation and treatment and later discharged to a short-term general hospital. Resident 4 was transferred to the hospital for evaluation and also discharged to a short-term general hospital. Interviews with the residents and staff confirmed that no bed hold notice could be found in the records for these residents, and staff stated that the notices should have been provided. The facility also failed to provide a written transfer/discharge notice to Resident 4 and/or the resident's representative when the resident was transferred to the hospital. Facility policy stated that upon notice of transfer or discharge, the resident is to be provided a statement of the right to appeal the transfer or discharge, including appeal contact information, instructions for completing and submitting an appeal form, assistance with the appeal process, and the facility bed-hold policy. Record review showed no documentation that Resident 4 received a transfer/discharge notice, and staff from social services, medical records, and administration stated that the notice should have been completed and provided.
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Compliance trends in Washington
Data through May 2026Comparisons below measure the most recent period Jun 2025 – May 2026 against the prior period Jun 2024 – May 2025 (two equal 12-month windows). The most recent 2 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 2-month reporting lag.
Frequency movers
Biggest change in how often each tag is cited, as a rate per 100 inspections (so it isn't skewed by survey volume): Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. The number is the average severity on the A–L scale (A=0…L=11); the letter is the band it falls in. A rise means the same tag is being cited at a more serious level — note the average can move enough to rank here while staying within the same letter. Same 20-citation minimum applies.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 2 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025; the most recent 2 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 2 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
Trusted data from CMS and state health departments
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