Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Agility Health And Rehabilitation during CMS and state inspections, most recent first.
The facility failed to thoroughly investigate incidents involving two residents, including a fall with major injury and an unexpected death due to choking, by not interviewing all relevant staff, omitting key timeframes, and not reporting significant injuries as required. Another resident with severe vision impairment experienced an unwitnessed fall, and the investigation did not address prolonged periods without staff contact or include all necessary witness statements.
The facility failed to ensure safe and appropriate respiratory care for several residents with COPD and other respiratory conditions by not consistently following physician orders for oxygen administration, not documenting actual oxygen flow rates, and delaying the provision of prescribed respiratory equipment. Staff also inconsistently changed and documented respiratory equipment, and there was confusion regarding the correct procedures for respiratory care.
A resident with respiratory needs repeatedly refused oxygen therapy, BiPAP/CPAP, and other care, but the facility did not involve social services or update the care plan to address these refusals. Nursing staff documented the refusals and informed the resident's representative, but social services was unaware and did not explore the reasons or participate in care planning.
The facility did not follow up on concerns raised by residents during multiple council meetings about staff using cell phones, chatting at the nurse's station, and delayed responses to call lights. These issues were documented in meeting minutes but were not entered into the grievance log or otherwise addressed, as confirmed by both the Activities Supervisor and the Administrator.
Licensed nurses failed to consistently follow provider orders for holding blood pressure medication based on parameters and did not document non-pharmacological interventions prior to administering PRN pain medications for several residents. Facility policy required such actions and documentation, but medication records and staff interviews confirmed these steps were not taken.
Staff failed to date multiple food items and did not consistently monitor or record meal and beverage temperatures before service. The dietary manager confirmed that beverage temperatures were not taken and food temperatures were checked out of view, which did not meet regulatory expectations.
A resident prescribed olanzapine for delirium with agitation did not have an accurately completed informed consent form, as the form incorrectly listed a diagnosis of psychotic disorder, which was not present in the medical record. Both an LPN Supervisor and the DON confirmed the documentation was inaccurate and did not meet expectations.
A resident with heart failure and diabetes did not have an advance directive (AD) documented in the EHR, despite care plan notes indicating an AD was in place and that education was provided. The resident believed the facility had the AD paperwork, but both the Social Services Director and Administrator confirmed that no AD was on file and that required documentation and review did not occur as expected.
The facility did not properly identify or report allegations of abuse involving two residents. In one instance, a resident involved in a verbal altercation had no documented report to the state agency, despite claims it was reported. In another case, a resident's grievance about inappropriate staff behavior during care was not investigated or reported as potential abuse, and only customer service training was provided to the staff member.
A resident with multiple health conditions was involved in an altercation when another resident operating an electric scooter bumped their chair, causing distress. The facility did not conduct or document a thorough investigation of the incident, nor did it implement or record any interventions for the resident operating the scooter, contrary to facility policy. The DON indicated the lapse was due to a new staff member's lack of training.
Two residents were not consistently monitored according to their care plans, resulting in lapses in elopement precautions for a resident with dementia and in fall prevention measures for another resident with a history of multiple falls. Required documentation of 15-minute night checks was missing for one resident, and fall prevention signage and supervision were not maintained for the other. Staff interviews confirmed that care plan interventions were not consistently followed.
A resident with an indwelling urinary catheter was not properly monitored by nursing staff, despite care plans and orders requiring regular assessment for complications. Over several days, the resident's catheter drainage bag showed abnormal findings, and the resident experienced discomfort and urinary retention, but these issues were not documented or addressed until a provider intervened and replaced the non-functioning catheter, resulting in symptom relief.
A resident with chronic respiratory failure and COPD received oxygen at a higher flow rate than ordered, with staff administering 4.5 LPM instead of the prescribed 3 LPM via nasal cannula. Staff interviews confirmed the oxygen setting was changed without a provider's order, contrary to facility policy and the resident's care plan.
A resident with chronic kidney disease and diabetes, who was able to express needs, had broken and missing bottom teeth and reported waiting for dental care. Although an oral exam recommended a dental hygiene cleaning, there was no documentation of follow-up or that the resident was seen by a dental hygienist.
Two residents did not receive timely dental services as required. One resident with significant dental needs was not seen by the dental hygienist as recommended, and their name was omitted from follow-up lists. Another resident with dental prosthetic issues missed two dental consults and had not been seen by a dentist, with staff confirming these missed appointments did not meet expectations.
Multiple residents reported that food was served cold, tasted bad, or was unpalatable. Observations showed staff did not take food temperatures before service, and a test tray revealed overcooked and flavorless items. Resident Council records and surveys reflected ongoing concerns about food quality, and staff confirmed that temperature checks were not performed as expected.
The facility did not post the actual hours worked for nursing staff on a daily basis, instead displaying 0.00 hours for each discipline and shift over several days. Staff confirmed that while actual hours were tracked internally, they were not made available as required, and the administrator was unaware of the lapse.
The facility failed to accurately assess two residents, leading to potential risks in their care. One resident's MDS inaccurately indicated no PASRR level two and no dental issues, despite previous documentation and consultations. Another resident's MDS inaccurately showed adequate vision, despite having cataracts and blurred vision.
The facility failed to maintain sanitary conditions in resident refrigerators, with observations revealing outdated and improperly labeled food items. Both the Dietary Supervisor and the Administrator acknowledged the deficiency, noting that resident food should be labeled and discarded after three days.
The facility failed to provide and accurately complete required forms regarding potential liability for payment related to Medicare services ending for a resident. The resident's forms lacked proper documentation and signatures, diminishing their ability to make informed financial and care decisions.
The facility failed to ensure a PASRR assessment was accurately completed for a resident with depression and adjustment disorder with anxiety. The initial PASRR assessment did not document these diagnoses, and no subsequent PASRR was completed. Staff confirmed the deficiency and the need for another assessment.
The facility failed to meet professional standards of practice for two residents. One resident did not have proper measurements of their PICC line recorded before IV antibiotic administration, and another resident experienced a 30-day delay in obtaining a urology referral despite a provider's order and ongoing symptoms.
The facility failed to obtain provider orders, complete assessments, and update the care plan for a resident using a transfer pole and bed mobility bar, placing the resident at risk of improper use.
The facility failed to ensure enteral nutrition was administered according to provider orders for a resident with a feeding tube, leading to a significant weight loss. The care plan was not followed, and discrepancies in documentation and communication were identified.
The facility failed to provide timely dental assistance to two residents. One resident reported a missing denture in October 2023 and required a tooth extraction and new denture by January 2024, which had not been done by May 2024. Another resident with only four teeth had a care plan initiated in December 2023 for a dental referral, which had not been acted upon by May 2024. Staff confirmed that these services should have been provided promptly.
Failure to Conduct Thorough Investigations into Abuse, Neglect, and Significant Injury
Penalty
Summary
The facility failed to implement its abuse prohibition policy for two residents by not conducting thorough investigations into incidents of abuse, neglect, and significant injury. For one resident, after a fall resulting in a broken arm and hip, the facility's investigation did not include statements from all relevant staff, such as those who delivered and picked up the resident's lunch, the nursing assistant assigned to the resident, or the student who found the resident. The investigation also failed to address the period between the last staff contact and the discovery of the fall, and did not consider whether the resident received lunch or if pain medication was effective. Additionally, the resident was not receiving oxygen at the physician-ordered rate at the time of the fall, and the incident was not reported in the abuse reporting logs as required for substantial injury related to a fall. In the case of the same resident's unexpected death, the facility did not thoroughly investigate the possibility of choking, despite multiple indications that choking may have been involved. Staff interviews and documentation revealed inconsistencies regarding the location of the meal tray and the events leading up to the resident being found unresponsive. The police report and statements from the resident's representative indicated that the resident had a history of choking and that food was found in the airway during the autopsy. The facility's investigation did not include all relevant witness statements or consider the choking hazard, even though the death certificate listed choking on a food bolus as the cause of death. For another resident with severely impaired vision and a history of falls, the facility's investigation into an unwitnessed fall was incomplete. The resident, who required extensive assistance and one-on-one staff support for meals, was found on the floor after not being seen by staff for over two hours. The investigation did not address why the resident was left unattended for such a period or include statements from all staff involved in the resident's care. The facility's actions did not align with its own policies for investigating abuse, neglect, and significant injuries, as required by regulation.
Failure to Provide Safe and Appropriate Respiratory Care per Physician Orders
Penalty
Summary
The facility failed to provide respiratory care and services in accordance with physician orders and accepted professional standards for four out of five residents reviewed for respiratory services. For one resident with chronic hypoxic respiratory failure and COPD, there were multiple inconsistencies in oxygen administration, including titrating oxygen below the ordered rate, not documenting the actual flow rate delivered, and delays in providing prescribed respiratory equipment such as CPAP and BiPAP machines. Documentation showed that staff did not consistently follow or document the specific oxygen flow rates as ordered, and there were periods when the resident did not have access to required respiratory equipment, resulting in repeated hospitalizations for respiratory complications. Another resident with COPD was observed receiving oxygen at a rate that was not documented in the medical record, and staff failed to record the oxygen flow rate or corresponding oxygen saturation as required by physician orders. Orders for changing nasal cannulas and oxygen tubing were inconsistently documented, and staff interviews confirmed that documentation practices did not align with facility policy or physician directives. Additionally, there was confusion among staff regarding the necessity and frequency of changing respiratory equipment, with some orders being redundant or unclear. For two other residents with COPD, observations revealed improper use of humidification with oxygen therapy, lack of documentation regarding whether oxygen saturation was measured with or without supplemental oxygen, and discrepancies between observed oxygen flow rates and those ordered by the provider. Staff interviews further revealed a lack of clarity and consistency in following and documenting respiratory care orders, including the administration of oxygen at the correct flow rates and the timely replacement of respiratory equipment such as humidifier bottles and tubing.
Failure to Provide Social Services for Resident Refusing Respiratory Care
Penalty
Summary
The facility failed to provide medically-related social services for a resident who was reviewed for respiratory services. Despite multiple documented instances of the resident refusing essential care, such as oxygen therapy, BiPAP/CPAP use, fluid restrictions, and showers, there was no evidence that the facility's social services department was involved to address these refusals. Nursing notes and care manager documentation repeatedly described the resident as noncompliant with prescribed treatments and care recommendations, and the resident's representative was informed of these refusals. However, the social services director confirmed they were unaware of the resident's ongoing refusals and had not been notified by nursing staff. Additionally, the care plan did not include any interventions to address the resident's refusal behaviors, and there was no documentation of social services exploring the reasons for the refusals or participating in care conferences regarding these issues. The resident's representative had requested to be notified of refusals so they could intervene, but reported not receiving further communication from the facility. The lack of social services involvement and absence of a behavior-focused care plan contributed to the deficiency, as the resident continued to refuse necessary care up until their passing.
Failure to Address Resident Council Concerns Regarding Staff Responsiveness
Penalty
Summary
The facility failed to follow up on concerns raised by residents during three consecutive resident council meetings, as documented in the minutes from November and December 2024, and January 2025. Residents expressed issues regarding staff on the evening and night shifts, specifically noting that staff were chatting at the nurse's station, using cell phones, and not responding promptly to call lights, resulting in long wait times. Despite these concerns being documented in the council meeting minutes, there was no corresponding documentation in the grievance log, and no grievances were initiated related to these issues. The Activities Supervisor confirmed that grievances were not initiated for concerns raised in resident council meetings and indicated that residents should seek assistance from social services if they wished to file a grievance. The Administrator acknowledged that it was not their expectation for such concerns to go unaddressed.
Failure to Follow Medication Orders and Document Non-Pharmacological Interventions
Penalty
Summary
The facility failed to ensure that provider orders for medication administration were consistently followed and that non-pharmacological interventions (NPI) were initiated prior to administering as needed (PRN) pain medications. For one resident with multiple diagnoses including heart, lung, and kidney disease, and hypertension, the provider's order specified that midodrine should be held if the systolic blood pressure was greater than 120. However, review of the medication administration records over several months showed that licensed nurses administered midodrine multiple times when the resident's systolic blood pressure exceeded the specified parameter. Both a Licensed Practical Nurse and the Director of Nursing Services confirmed that the expectation was to hold the medication as ordered, but this was not done. Additionally, three other residents with various diagnoses, including depression, diabetes, bipolar disorder, osteomyelitis, pressure ulcer, heart failure, fractures, and acute kidney failure, were administered PRN pain medications such as acetaminophen and oxycodone without documentation that NPIs were offered or provided beforehand. Medication administration records for these residents showed repeated instances where pain medications were given without any record of NPIs being attempted or documented, as required by facility policy. Interviews with nursing staff and the Director of Nursing Services confirmed that NPIs should have been offered and documented prior to administering PRN pain medications, but this was not consistently done. The facility's own policy required licensed nurses to be familiar with medications, especially those with boxed warnings, and to monitor and document appropriate parameters and interventions. The lack of adherence to these policies and provider orders resulted in residents receiving medications without proper justification or prior use of alternative interventions, as evidenced by the documentation and staff interviews.
Failure to Date Food Items and Monitor Meal Temperatures
Penalty
Summary
The facility failed to ensure that food items were properly dated and that meals and beverages were served at appropriate temperatures, as required by professional standards. During an initial kitchen tour, multiple flavored syrups and large containers of seasonings, including parsley, paprika, taco seasoning, ground pepper, thyme, and ginger, were observed to be undated. On a subsequent observation of the tray line, a cook placed all entrees and side items for the lunch meal on the steam table, but there were no observations of temperatures being taken prior to service. Review of the lunch meal temperature log showed temperatures for all items, including cold beverages, but it was later confirmed by the dietary manager that beverage temperatures were not taken and that food temperatures were taken out of view. Both the dietary manager and the administrator acknowledged that these actions did not meet facility expectations or regulatory requirements.
Inaccurate Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that informed consent for the use of a psychotropic medication was accurately completed prior to administration for one resident. The resident, who had diagnoses of depression and bipolar disorder, was prescribed olanzapine for delirium with agitation. However, the informed consent form indicated the medication was prescribed for a psychotic disorder, a diagnosis not present in the resident's medical record. Interviews with facility staff confirmed that the informed consent form was not accurately filled out, as the resident did not have a diagnosis of psychotic disorder. Both the LPN Supervisor and the Director of Nursing Services acknowledged that the documentation did not meet expectations, as the consent form did not reflect the resident's actual diagnoses or the correct indication for the medication.
Failure to Obtain and Document Advance Directive for Resident
Penalty
Summary
The facility failed to obtain and document an advance directive (AD) for one resident, despite multiple indications in the resident's records that an AD was either in place or should have been reviewed. The electronic health record (EHR) for the resident, who was admitted with diagnoses including heart failure and diabetes, did not show an AD on file. The resident believed that an AD had been completed and that the facility had the paperwork. Care plan documentation referenced an AD and indicated that education was provided and that staff would review healthcare directives with the resident at least quarterly. However, upon review, the admission record did not show an AD, and the Social Services Director confirmed that no AD was in place at the time. The Social Services Director also acknowledged that a discussion about the AD should have been documented upon the resident's readmission, but this did not occur. The Administrator stated that ADs were to be reviewed upon admission and quarterly, and documented in the EHR, but was unable to locate the AD for this resident, confirming that documentation did not meet expectations.
Failure to Identify and Report Allegations of Abuse
Penalty
Summary
The facility failed to identify and report allegations of abuse for two residents. For one resident with a history of fracture, diabetes, insomnia, and chronic pain, a verbal altercation with a roommate was documented in the incident log. Although the incident report indicated it was reported to the state hotline, there was no documentation to confirm this, and the Director of Nursing Services could not provide evidence that the report was made to the state agency. In another case, a grievance was filed by a resident who reported that a staff member acted inappropriately during care, including grinning, singing, and winking while the resident was undressed. The facility's investigation was limited to providing customer service training to the staff member and did not include interviews with other residents or a formal investigation to rule out abuse. The Director of Nursing Services acknowledged that no investigation was conducted for this allegation, and the Administrator was not present during the time of the grievance.
Failure to Investigate Resident Altercation and Rule Out Abuse
Penalty
Summary
The facility failed to thoroughly investigate an incident involving an altercation between two residents, one of whom had a history of a right humerus fracture, type 2 diabetes, insomnia, and chronic pain syndrome, and was able to communicate needs. The incident occurred when one resident, using an electric scooter, bumped another resident's chair, causing it to spin. Following the event, staff observed the affected resident with their head down and moved them to another area to relax. The incident report indicated that the plan was to remove the electric scooter from the resident who caused the incident. However, a review of records showed that no investigation was conducted or documented regarding the altercation, and no interventions were recorded for the resident operating the scooter after the occurrence. The facility's policy required identification and interviews of all involved parties and thorough documentation to determine if abuse had occurred. During an interview, the DON stated that investigations are typically conducted for such incidents but was unsure why it did not happen in this case, attributing the lapse to a new staff member who needed more training.
Failure to Consistently Monitor and Implement Accident Prevention Interventions
Penalty
Summary
The facility failed to consistently monitor and address risk factors to minimize accident hazards for two residents. One resident, with diagnoses including dementia, substance abuse, and severe cognitive impairment (BIMS score of 5/15), was identified as high risk for elopement. Despite a care plan requiring one-on-one supervision during day and evening shifts and 15-minute checks at night, there was no documentation of the required 15-minute checks during the night shift. The resident exhibited ongoing exit-seeking behaviors, including being found in the parking lot attempting to leave the facility, and staff documented continued attempts to leave and poor safety awareness. Another resident, with a history of depression, diabetes, and bipolar disorder, was identified as a fall risk and had experienced multiple falls. The care plan included interventions such as a 'CALL DON'T FALL' sign and keeping the bed in the lowest position when unattended. Observations revealed that the sign was not posted in the resident's room during multiple visits, and the resident was found alone on a bed in the highest position while being partially dressed. The CNA assisting the resident was unfamiliar with the resident's fall risk status and left the resident unattended, contrary to the care plan interventions. Interviews with staff confirmed lapses in following care plan interventions for both residents. The Director of Nursing Services acknowledged that the required monitoring and documentation for the resident at risk of elopement were not completed as expected. Similarly, staff confirmed that the fall prevention interventions for the other resident were not consistently implemented, and the absence of the required signage and supervision did not meet facility expectations.
Failure to Monitor and Document Indwelling Catheter Function
Penalty
Summary
A deficiency occurred when the facility failed to properly monitor and document the use and function of an indwelling urinary catheter for a resident with multiple diagnoses, including neurogenic bladder and a history of urinary tract infection. The resident's care plan and physician orders required licensed nurses to check catheter functionality and monitor for complications every shift, including observing for signs of infection, catheter occlusion, and changes in urine output or appearance. Despite these requirements, observations over several days revealed the resident's catheter drainage bag contained sediment, dark cloudy urine, and later, a scant amount of dark blood-tinged urine. The resident also exhibited increased anxiety, a distended abdomen, and an increased respiratory rate, but there was no documentation of these findings or any action taken to address the catheter's function during this period. The resident reported feeling the urge to urinate and abdominal discomfort, which had persisted since the previous evening. Staff interviews confirmed that the LPN was unaware of the abnormal urine output and had not notified the provider until prompted. Upon assessment by the provider, a bladder scan revealed significant urine retention, leading to the immediate replacement of the non-functioning catheter, which resulted in prompt relief of the resident's symptoms. The lack of timely assessment, documentation, and intervention regarding the resident's catheter and urinary output constituted a failure to provide appropriate catheter care as required by facility policy and professional standards.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to provide respiratory care in accordance with professional standards for one resident who required continuous oxygen therapy. The resident, who had a history of heart and kidney disease, neurogenic bladder, urinary tract infection, and chronic respiratory failure with COPD, had a provider's order for oxygen at 3 liters per minute (LPM) via nasal cannula every shift. The resident's care plan also specified continuous oxygen therapy at the ordered rate, with licensed nurses responsible for administering oxygen as ordered. Despite these orders, observations on multiple occasions showed the resident receiving oxygen at a flow rate of 4.5 LPM, which exceeded the provider's order. During interviews, an LPN acknowledged that the oxygen flow rate had been increased without a provider's order and stated they would return it to the prescribed 3 LPM. The DON confirmed that the expectation was for staff to follow the provider's order and not change the oxygen setting without authorization. This failure to adhere to the ordered oxygen flow rate constituted a deficiency in providing safe and appropriate respiratory care.
Failure to Provide Dental Services Following Recommendation
Penalty
Summary
The facility failed to provide dental services for one resident who was admitted with chronic kidney disease and diabetes and was able to communicate their needs. Observation revealed that the resident had broken and missing bottom teeth and reported waiting to see the dental hygienist. A prior oral exam had recommended a dental hygiene cleaning, but review of the electronic health record showed no documentation of follow-up on this recommendation. During an interview, the Social Services Director confirmed that there was no documentation indicating the resident had been seen by the dental hygienist, despite the recommendation.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide prompt dental services for two residents. One resident, who had a history of heart failure, anxiety disorder, and depression, was identified as having obvious or likely cavities, broken natural teeth, inflamed or bleeding gums, or loose natural teeth during a significant change in condition assessment. The care plan included a referral to a dentist or dental hygienist, and a dental prophylaxis report recommended a six-month follow-up for maintenance. However, there was no documentation that this maintenance was conducted as recommended, and the resident's name was not included on the dental exam list for subsequent visits. Staff interviews confirmed that the resident was not seen by the dental hygienist as scheduled, and communication with the dental scheduler was delayed. Another resident, admitted with a fracture, type two diabetes, insomnia, and chronic pain syndrome, reported not having an upper denture and an ill-fitting lower denture. This resident had not seen the dentist and was unaware of any plans for a dental visit. Dental consult records showed that the resident was not seen on two separate occasions due to not being present in the room. Staff acknowledged that missing these appointments did not meet expectations.
Failure to Serve Palatable Food at Safe Temperatures
Penalty
Summary
The facility failed to ensure that food was served at proper temperatures and with palatable taste, as evidenced by multiple resident interviews and direct observations. Residents reported that food was served cold, tasted bad, and was described as horrible. Observations showed that staff did not take food temperatures prior to service, and a test tray revealed overcooked and unpalatable food items. Review of Resident Council Minutes and questionnaires indicated ongoing dietary concerns and poor ratings for food quality. Staff interviews confirmed that the lack of temperature checks did not meet facility expectations.
Failure to Post Actual Nurse Staffing Hours Daily
Penalty
Summary
The facility failed to post the actual hours worked for nursing staff each day over a five-day survey period. Observations on multiple days showed that the posted nurse staffing information listed 0.00 actual hours worked for each discipline on each shift. Interviews with the staff schedule coordinator and the human resources specialist confirmed that while actual hours worked were tracked in the computer system, they were not posted as required. The administrator was unaware that the postings were not being updated with actual hours worked, despite the expectation that this information be updated at the beginning of each shift. This failure prevented residents, family members, and visitors from accessing accurate information about the number of available nursing staff in the facility during the survey period.
Inaccurate Resident Assessments
Penalty
Summary
The facility failed to accurately assess two residents, leading to potential risks in their care. Resident 2's annual minimum data set (MDS) inaccurately indicated no pre-admission screening and resident review (PASRR) level two and no dental issues. However, the resident had a PASRR level two completed previously and had reported losing their denture months earlier. Despite a denture consultation recommending new dentures, the MDS was not updated to reflect these dental issues. Staff interviews confirmed the oversight in coding the PASRR and dental issues accurately. Resident 68's quarterly MDS inaccurately showed adequate vision without corrective lenses, despite the resident having cataracts and blurred vision. The resident's care plan noted impaired vision due to cataracts, but this was not reflected in the MDS. Staff interviews revealed that the resident's vision issues were not mentioned during the assessment, leading to incorrect coding. The Director of Nursing Services acknowledged the inaccuracies in the PASRR section for Resident 2 and the need for re-assessment of Resident 68's vision issues.
Failure to Maintain Sanitary Conditions in Resident Refrigerators
Penalty
Summary
The facility failed to maintain resident refrigerators in sanitary conditions, as observed on 05/07/2024. The resident refrigerator's freezer contained a severely freezer burnt hotdog in a plastic container without a date label and a box of yogurt sticks with a best by date of November 2023. The refrigerator section had a brown paper bag dated 04/26/2024 with artichoke dip and antipasto salad with sell-through dates of 04/29/2024, an original cardboard pizza box with a date of 04/26/2024 with dried, curled slices of pizza, a small cake without name or date, a plastic bag with a hamburger wrapped in paper with no name or date, and a bag with cut fruit with a sell-through date of 04/22/2024. During interviews, both the Dietary Supervisor and the Administrator acknowledged that the resident refrigerator did not meet the expected sanitary food storage standards, with the Administrator noting that resident food should be marked with a name and date label and discarded after three days.
Failure to Provide and Complete Required Medicare Coverage Forms
Penalty
Summary
The facility failed to provide and accurately complete the required forms regarding potential liability for payment related to Medicare services ending for Resident 14. Resident 14, who was admitted with diagnoses including pneumonia and weakness, was their own responsible party and did not have a durable power of attorney. The electronic health record did not show documentation that Resident 14 was provided the Notice of Medicare Non-Coverage (NOMNC) or the Skilled Nursing Facility (SNF) Advanced Beneficiary Notice (ABN). The NOMNC form indicated that coverage would end on 03/07/2024, but lacked the resident's or representative's signature. Similarly, the SNF ABN form was undated and unsigned, with only a handwritten note indicating a phone call, but no further documentation or signatures were present. During interviews, Staff C, the Business Office Manager, acknowledged that they should have documented additional information and attempts to obtain signatures on the forms. The Administrator, Staff A, also reviewed the forms and confirmed that they did not meet expectations. The lack of proper documentation and signatures on these forms diminished Resident 14's ability to make informed financial and care decisions related to their continued stay.
Incomplete PASRR Assessment for Resident
Penalty
Summary
The facility failed to ensure a Pre-Admission Screening and Resident Review (PASRR) assessment was accurately completed upon or prior to admission for one resident reviewed for unnecessary medications. Resident 76 was admitted with diagnoses of depression and adjustment disorder with anxiety. The quarterly minimum data set (MDS) indicated that the resident was able to make their needs known. However, the PASRR assessment completed by the hospital prior to admission did not document these serious mental illness indicators and showed no Level II evaluation was indicated. The facility's electronic health record also lacked documentation of another PASRR assessment. Interviews with the Senior Regional Social Services Director and the Director of Nursing Services confirmed that the PASRR was missing critical diagnoses and did not meet expectations, necessitating another PASRR assessment.
Failure to Meet Professional Standards of Practice
Penalty
Summary
The facility failed to ensure services provided met professional standards of practice for two residents. Resident 214, admitted with osteomyelitis and requiring long-term IV antibiotic treatment via a PICC line, did not have proper measurements of the PICC line catheter length recorded prior to administering the IV antibiotics. The medication administration record and care plan lacked directives for licensed nurses to measure the PICC line, and staff interviews confirmed that measurements were not taken or recorded as required. Resident 39, admitted with multiple diagnoses including heart disease, diabetes, and a UTI, had a provider order for a referral to a urologist due to a mass on the left kidney. Despite complaints of dysuria, there was no documentation of the urology consultation being obtained. Staff interviews revealed that the referral was not sent until 30 days after the order was made, indicating a significant delay in following the provider's order for a specialist consultation.
Failure to Ensure Proper Use of Safety Devices
Penalty
Summary
The facility failed to ensure that proper procedures were followed for the use of safety devices, specifically a transfer pole and a bed mobility bar, for Resident 11. Resident 11, who has hemiplegia affecting the left side of the body, was observed using these devices without any provider orders, safety device assessments, or consents documented in their electronic health record (EHR). Multiple observations over several days showed the transfer pole and bed mobility bar in use, but there were no markings to indicate the correct placement of the bed in relation to these devices to ensure safe transfers. Interviews with Resident 11 and staff members confirmed the lack of proper documentation and procedures. Resident 11 stated that they used the transfer pole with staff assistance and the bed mobility bar for repositioning. Staff members, including a Registered Nurse/Manager and the Director of Nursing Services, acknowledged that there should have been provider orders, assessments/consents, and care plan updates for the use of these safety devices. The absence of these critical steps placed Resident 11 at risk of improper use of the transfer pole and bed mobility bar.
Failure to Administer Enteral Nutrition per Provider Orders
Penalty
Summary
The facility failed to ensure enteral nutrition was administered in accordance with provider's orders and professional standards of practice for a resident with a feeding tube. Resident 15, who had diagnoses including stroke, hemiplegia, and dysphagia, was admitted to the facility and required tube feeding. The care plan for Resident 15 included monitoring caloric intake and following provider orders for tube feeding. However, the facility did not have a system in place to reconcile the amount of enteral formula the resident received with the amount they were ordered to receive. This led to discrepancies in the documentation of the total volume of enteral feed infused, as evidenced by multiple instances where the medication administration records (MAR) showed an 'X' instead of the actual amount infused. Consequently, Resident 15 experienced a significant weight loss of 9.8 pounds over a short period, which was not promptly addressed or communicated to the provider or registered dietician as required by the facility's protocols. Interviews with staff revealed that the weight loss was not placed into the weight loss binder to inform the registered dietician, and the resident was not re-weighed or the provider notified in a timely manner. The Assistant Director of Nursing Services (ADNS) and the Director of Nursing Services (DON) acknowledged that the enteral feed totals should have been monitored and documented per provider orders, and any significant weight loss should have been re-weighed and reported. The registered dietician also noted the absence of a designated area in the electronic health record (EHR) MAR for documenting the total volume of enteral feed infused. This lack of proper documentation and communication led to the resident's nutritional needs not being adequately met, as evidenced by the significant weight loss.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide timely dental assistance to two residents, leading to deficiencies in their care. Resident 2 reported a missing denture in October 2023, and a progress note from 10/10/2023 confirmed this. A denture consultation on 01/24/2024 recommended an x-ray, tooth extraction, and a new lower partial denture, but these actions had not been taken by the time of the interview on 05/09/2024. Resident 53, who had only four teeth, had a care plan initiated on 12/25/2023 that included a referral to a dentist/hygienist. However, by 05/09/2024, this referral had not been acted upon. Staff interviews confirmed that these dental services should have been provided promptly.
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 712 citations issued within 25 miles in the last 12 months — including the 4 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 University Place
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Birch Creek Post Acute & Rehabilitation | 1.4 mi | — | 33 | 0 |
| Orchard Park Health Care & Rehab Center | 1.5 mi | — | 4 | 0 |
| Park Rose Care Center | 3.1 mi | — | 0 | 0 |
| Alaska Gardens Health And Rehabilitation | 3.3 mi | — | 19 | 1 |
| Avamere Transitional Care Of Puget Sound | 3.4 mi | — | 56 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.