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
The facility failed to provide enough nursing staff to meet resident needs, with staff and residents reporting frequent short staffing, long call light delays, missed showers, and rushed care. During meal observations, a resident spilled food while waiting for help, another could not reach a breakfast tray until a NA repositioned them, and a resident with a paralyzed arm had the tray placed on the wrong side. The report also cited inadequate wound care for a resident with a surgical hip wound and a pressure injury that developed in the facility.
A facility failed to keep 4 hallways clean and comfortable, with stained carpets, food debris, urine odor, and cluttered resident rooms observed. Residents reported rooms were not cleaned routinely, one said a spill was left sticky after being wiped but not mopped, and a grievance showed food spills remained for days before cleaning. Staff said housekeeping could not always complete daily room cleaning and that staffing was limited.
A resident admitted after a hip hemiarthroplasty had ordered surgical wound assessments and daily dressing changes, but the record showed missed dressing changes after showers and missing wound documentation, including wound characteristics, measurements, and appearance. Staff interviews confirmed the hip dressing could get wet during showers, that nursing should have assessed and documented the wound after wet dressings, and that the wound care orders were not clarified or followed as expected.
Failure to Provide Bed-Hold Notice at Hospital Transfer: The facility did not provide the required written bed-hold notice when three residents were transferred to the hospital. Records showed one resident had a broken leg, anxiety, and vision loss with impaired cognition; another had metabolic encephalopathy, kidney disease, and severe cognitive impairment; and a third had respiratory failure, diabetes, and heart failure with intact cognition. Transfer records and interviews with two representatives confirmed the notices were not received, and the DON stated the process was not followed.
A hydration deficiency occurred on the dementia unit when 11 residents did not have a water pitcher or any fluids available at their bedside after lunch trays were collected and before the evening shift returned clean pitchers. The Unit Manager acknowledged the facility's hydration process, but confirmed the residents had no water available in their rooms at the time of observation.
A facility failed to consistently serve meals according to resident meal tickets, dislikes, and preferences. One resident received the wrong breakfast and a lunch tray without a meal ticket, while other residents were served eggs, chicken, bacon, or missing fruit despite those items being crossed out or listed as dislikes. Dietary staff and CNAs reported that meal tickets were not always followed on the tray line, and the DNM acknowledged that some staff needed additional training.
Insufficient Nursing Staffing and Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet resident needs and to have a licensed nurse in charge on each shift. Survey findings cited failures related to resident rights, quality of care, and pressure injuries for 13 residents reviewed for staffing concerns. Interviews with residents, staff, and resident council members described frequent short staffing, delayed call light response times, rushed care, missed showers, and staff working extended shifts, while the nursing scheduler stated staffing was based on census rather than resident acuity and that many residents required two staff members for care. During meal service observations, Resident 54 was seen trying to eat while seated too far from the table and spilling food on themselves and the floor until a NA assisted 25 minutes later. Resident 35 had a breakfast tray placed out of reach and remained unable to access the meal until a NA repositioned them 15 minutes later. Resident 4, who had a paralyzed left arm, was observed attempting to eat with the tray positioned on the left side, causing food to fall on their clothing and the floor. A NA stated they were the only one working in the assisted dining room and were also passing meal trays on the south hallway. The report also described inadequate wound and skin care. Resident 3 had a surgical wound on the right hip that was not adequately assessed, monitored, or treated according to professional standards. Resident 79 developed a pressure injury on the right hip in the facility. Residents and a resident representative reported call lights taking up to an hour or longer to be answered, staff appearing rushed, and concerns about cleanliness and missed care. Staff interviews confirmed frequent shortages, pulled bath aides, missed breaks, and the DON stating the facility often had to work the floor due to a lack of licensed nurses.
Unclean hallways and inconsistent room cleaning
Penalty
Summary
The facility failed to maintain a clean and comfortable environment in 4 of 4 hallways reviewed for physical environment, including hallways 100, 200, 300, and 400. Observation showed a large brown stain on the carpet near the nurses station on 100 hall, multiple large dark stains on the carpet on 200 hall, dark brown spots on the floor in rooms on 200 hall, dark stains with hardened substance on the carpet on the back side of 200 hall, dark stains in front of the nurses station between 200 and 300 halls, a large dark grayish spot in a doorway, a strong odor of urine at the end of 300 hall, and food particles under a table and in the sink of the dining area on 400 hall. The observation also noted multiple items on the floor in a resident room, including pillows, socks, bags, shoes, towels, books, cups, wheelchair legs, and the call light, as well as breakfast trays left on bedside tables in two rooms. Resident interviews and record review showed concerns about routine cleaning. One resident reported orange juice had been spilled on the floor and wiped with a paper towel but not mopped, leaving a sticky residue. Other residents said their rooms were not cleaned routinely, with one stating the room had been cleaned only once in two weeks and another saying the room was not cleaned on a routine basis. A resident council minute noted a request for more frequent sweeping, and a grievance documented food spills remaining on the floor for several days before the room was cleaned. Staff interviews confirmed housekeeping could not always complete daily room cleaning, that each housekeeper had about 19 to 20 rooms per shift, that only two housekeepers were working at the time, and that dining rooms should be swept and mopped after meals.
Incomplete Surgical Wound Assessment and Dressing Care
Penalty
Summary
The facility failed to ensure wound care treatment and management were provided according to orders and professional standards for a resident with a right femoral neck fracture treated with hemiarthroplasty. The resident was admitted cognitively intact and able to make needs known, with hospital transfer orders directing follow-up with orthopedics in two weeks, keeping the wound covered while bathing, and following current wound care recommendations. The facility’s wound care order required the right surgical hip incision to be assessed twice daily starting on 06/19/2026, then cleansed with wound cleanser and normal saline, skin prep applied to the peri-wound area, and covered with a bordered dressing starting on 06/20/2026, with dressing changes daily or if soiled or displaced. Record review showed the resident had showers on multiple dates in June and July 2026, and the shower documentation identified the right hip surgical incision wound. However, the record showed no additional dressing changes after several showers, including on 06/20/2026, 06/23/2026, 06/26/2026, 06/30/2026, and 07/07/2026. The treatment record also showed missed dressing changes on 06/26/2026, 06/29/2026, 06/30/2026, and 07/06/2026. In addition, the wound documentation did not include descriptions of wound characteristics, measurements, or appearance on 06/28/2026 and in the July 2026 record, and there was no documentation that the wound had required a dressing change because it was soiled or displaced. Staff interviews confirmed the wound care process was not followed as expected. A nursing assistant stated the surgical hip dressing would get wet during showers and sometimes become brown stained, and that nursing staff were notified when a dressing change was needed after showering. The Resident Care Manager stated that if a wound dressing got wet during a shower, the nurse needed to assess the wound and document the assessment and dressing change. The DON stated the surgical dressing was usually intended to remain in place for 14 days, but also acknowledged that the resident’s wound care orders should have been clarified and that no assessment of the surgical site other than hospital wound characteristics was found. The DON, Resident Care Manager, and Regional Administrator/RN all stated the resident’s surgical wound care treatment and management were not followed as required.
Failure to Provide Bed-Hold Notice at Hospital Transfer
Penalty
Summary
The facility failed to provide a written bed-hold notice at the time of hospital transfer for 3 of 3 residents reviewed for hospitalization. The facility policy titled, Bed-Hold Policy, revised 08/05/2025, stated the bed-hold policy should be given upon admission and upon transfer to the hospital, including within 24 hours for an emergency transfer, so the resident or representative is informed of the bed-hold and reserve bed payment policy before and upon transfer. Resident 1 was admitted with diagnoses including healing of a broken leg, anxiety, and vision loss in both eyes, and the 07/23/2026 assessment showed dependence on one to two staff for ADLs and moderately impaired cognition. Nursing progress notes showed Resident 1 was transferred to the hospital for a change in condition, but there was no documentation that a written bed-hold notice was provided. Resident 2 was admitted with metabolic encephalopathy, kidney disease, and generalized muscle weakness, and the 06/17/2026 assessment showed partial assistance/dependence for ADLs and severely impaired cognition; a transfer form showed an unplanned hospital transfer for uncontrollable pain, and there was no documentation of the required bed-hold notice. Resident 2's representative stated they were present during the transfer and did not receive a bed-hold notice. Resident 3 was admitted with respiratory failure, diabetes, and heart failure, and the 07/14/2026 assessment showed dependence on one to two staff for ADLs while the 07/20/2026 cognitive assessment showed intact cognition; a transfer form showed an unplanned hospital transfer for fever, altered mental status, and pain, and there was no documentation that the required bed-hold notice was provided. Resident 3's representative also stated they did not receive a bed-hold notice. Staff A, the DON, stated nurses were responsible for ensuring the notice was provided upon transfer or within 24 hours for an emergent transfer, and stated the process was not followed.
Lack of Fluids at Bedside on Dementia Unit
Penalty
Summary
The facility failed to provide adequate fluids within reach for residents on the dementia unit. Review of the facility's Hydration Rounds Procedure showed that day shift was to collect water pitchers when collecting lunch trays and evening shift was to retrieve clean water pitchers from the kitchen, fill them with ice water, and pass them out to residents on the hall. During observation on 07/29/2026 at 3:20 PM with the Unit Manager, 11 residents on the dementia unit did not have a water pitcher or any fluids available to drink at their bedside. In interview, the Unit Manager acknowledged the facility's process for removing dirty pitchers at lunch and returning clean pitchers later, but stated she was unsure why the pitchers had not been replaced and confirmed that 11 residents did not have water available in their rooms at that time. The Administrator later acknowledged the facility had completed corrective actions related to hydration in the dementia unit and stated his expectation was that residents always have access to water or fluids at their bedside.
Meals Not Consistently Matched to Resident Preferences
Penalty
Summary
The facility failed to ensure that residents received meals that matched their documented dietary preferences and dislikes. The facility policy stated that each resident should be provided a nourishing, palatable diet that considers resident preferences, and that food service staff should inspect trays to ensure the correct meal is provided. During observation, interview, and record review, surveyors found that dietary staff did not consistently follow meal tickets or resident preferences for several residents. Resident 3 reported that a breakfast ticket listed scrambled eggs, bacon, a cinnamon roll, and fruit, but the resident was served pancakes and sausages instead. Later, when lunch trays were delivered, Resident 3 had not yet received lunch, and when a tray was finally brought to the room, it contained grilled cheese sandwiches and zucchini with no meal ticket attached. Staff G stated the lunch had not been sent from the kitchen and that they did not know how to verify it was the correct meal. Resident 3 stated they had not requested the meal that was served. Resident 4's meal tickets showed items crossed out and listed eggs and chicken under dislikes, yet a breakfast tray with scrambled eggs was placed on the tray line and a lunch tray with orange glazed chicken breast was also served, despite the ticket indicating chicken was a dislike. Resident 5's breakfast ticket listed fruit, but the tray was sent without fruit, and Staff K stated, 'I do not have fruit for everybody.' Resident 6's breakfast ticket showed scrambled eggs and bacon crossed out and listed as dislikes, yet a tray with scrambled eggs and bacon was placed on the tray line. Resident 6 stated the facility continued to serve those items despite the resident's medical condition and that this had happened several times. Staff interviews confirmed that dietary staff were not consistently following meal tickets and resident preferences.
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Compliance trends in Washington
Data through Jun 2026Comparisons below measure the most recent period Jul 2025 – Jun 2026 against the prior period Jul 2024 – Jun 2025 (two equal 12-month windows). The most recent 1 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 1-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): Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 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: Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 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 Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 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 1 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025; the most recent 1 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 1 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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